A nurse is caring for a patient with a closed head injury on mechanical ventilation. Which of the following actions is highest priority?

Provide small doses of opioid analgesia

Maintain pCO2 of 35-45

Administer an anti-anxiety agent

Monitor blood pressure every four hours

Answer and Explanation

The Correct Answer is B

Choice A reason:

Providing small doses of opioid analgesia is important for pain management, but it is not the highest priority in a patient with a closed head injury on mechanical ventilation. Pain control should be balanced with the need to monitor neurological status.

Choice B reason:

Maintaining pCO2 of 35-45 is critical for patients with a closed head injury on mechanical ventilation. Proper pCO2 levels help manage intracranial pressure (ICP) and prevent secondary brain injury. Hyperventilation to lower pCO2 can reduce ICP but must be carefully controlled to avoid cerebral ischemia.

Choice C reason:

Administering an anti-anxiety agent can help manage agitation and anxiety, but it is not the highest priority. Sedation must be used cautiously in head injury patients to avoid masking changes in neurological status.

Choice D reason:

Monitoring blood pressure every four hours is necessary for overall patient care, but continuous monitoring and immediate interventions are more critical in managing intracranial pressure and preventing secondary brain injury.

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Correct Answer is A

Explanation

Choice A reason:

Arterial Blood Gas (ABG) analysis is the best method to determine the effectiveness of treatments in a client receiving mechanical ventilation. ABGs provide direct information about the patient's oxygenation, ventilation, and acid-base status, which are critical in managing acute respiratory failure.

Choice B reason:

While blood pressure is important for overall patient monitoring, it does not provide specific information about the effectiveness of ventilation and respiratory status. It is more related to hemodynamic stability.

Choice C reason:

Capillary refill can provide some information about peripheral perfusion but is not specific enough to assess the effectiveness of mechanical ventilation or respiratory treatments.

Choice D reason:

Heart rate is a vital sign that can indicate the patient's overall condition but does not specifically assess the effectiveness of ventilation or respiratory treatments. It should be considered along with other more specific respiratory assessments.

A. Elevate the head of the bed immediately and notify the provider B. Administer PRN tylenol for the patient's headache C. Recheck all of the patient's vital signs D. Elevate the patient's knees and lower the head of the bed

Correct Answer is A

Explanation

Choice A reason:

Elevating the head of the bed and notifying the provider is the correct initial action when a patient with a spinal cord lesion at T4 experiences a significantly elevated blood pressure (190/100), headache, and flushing. These symptoms suggest autonomic dysreflexia, a potentially life-threatening condition that requires immediate intervention. Elevating the head of the bed helps to lower blood pressure, and notifying the provider ensures that further medical treatment can be administered promptly.

Choice B reason:

Administering PRN Tylenol for the patient's headache is not the appropriate first action in this scenario. While Tylenol may help with the headache, it does not address the underlying cause of the elevated blood pressure and autonomic dysreflexia. Immediate intervention to lower blood pressure is critical to prevent complications.

Choice C reason:

Rechecking all of the patient's vital signs is important but not the priority action in this situation. The nurse should first take measures to lower the blood pressure and address the symptoms of autonomic dysreflexia by elevating the head of the bed and notifying the provider. Monitoring vital signs can be done concurrently, but it should not delay the immediate intervention required.

Choice D reason:

Elevating the patient's knees and lowering the head of the bed is contraindicated in this situation. Lowering the head of the bed can further increase intracranial pressure and exacerbate symptoms of autonomic dysreflexia. The proper position to help reduce blood pressure is to elevate the head of the bed.

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A nurse is caring for a patient with a closed head injury on mechanical ventilation. Which of the following actions is highest priority?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method to determine the effectiveness of the current treatments?

Correct Answer is A

Explanation

A patient with a spinal cord lesion at T4 tells the nurse that he has a headache and feels flushed. The BP is significantly elevated to 190/100. The first action by the nurse is to:

Correct Answer is A

Explanation

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