A nurse is caring for four patients in the neurologic intensive care unit. After receiving the hand-off report, which patient does the nurse see first?

Patient with a Glasgow Coma Scale score that was 9 and is now 12.

Patient who is requesting pain medication for a new onset headache.

Patient with a Glasgow Coma Scale score that was 10 and is now 8.

Patient with a moderate brain injury who is amnesic for the event.

Answer and Explanation

The Correct Answer is C

Choice A reason:

A Glasgow Coma Scale (GCS) score that improves from 9 to 12 indicates a positive trend in the patient's neurological status. While monitoring is still required, this patient is not the highest priority.

Choice B reason:

A patient requesting pain medication for a new onset headache needs attention, but this is not as urgent as a significant decline in the Glasgow Coma Scale score, which can indicate a deterioration in neurological function.

Choice C reason:

A Glasgow Coma Scale score that drops from 10 to 8 signifies a significant decline in the patient's neurological status, indicating potential worsening of the condition. This patient requires immediate assessment and intervention to identify and address the cause of the deterioration.

Choice D reason:

A patient with a moderate brain injury who is amnesic for the event needs ongoing monitoring, but this is not as urgent as addressing a significant drop in the Glasgow Coma Scale score.

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Correct Answer is D

Explanation

Choice A reason:

Administering fluids is important for maintaining hemodynamic stability, but it is not the immediate priority for a patient with compromised respiration and low oxygen saturation.

Choice B reason:

Giving pain medications is necessary for patient comfort but is not the priority in a situation where the patient's respiratory status is severely compromised.

Choice C reason:

Preparing the patient for a CT scan can help assess internal injuries but is not the immediate priority when the patient is cyanotic and has low oxygen saturation. Immediate respiratory support is required first.

Choice D reason:

Preparing to assist with intubation is the priority action. The patient's oxygen saturation is critically low, and the chest wall is not moving normally, indicating potential respiratory failure. Intubation and mechanical ventilation are necessary to secure the airway and provide adequate oxygenation.

A. Encourage patient to deep breathe and use incentive spirometer B. Offer the patient medication for sedation C. Assess patient's ability to speak D. Assess vital signs and effort of breathing

Correct Answer is D

Explanation

Choice A reason:

Encouraging the patient to deep breathe and use an incentive spirometer is important for lung expansion and preventing atelectasis. However, it is not the most immediate action following extubation.

Choice B reason:

Offering the patient medication for sedation is not appropriate immediately following extubation, as it could depress respiratory function and interfere with the patient's ability to clear secretions and maintain an open airway.

Choice C reason:

Assessing the patient's ability to speak is important to ensure that the vocal cords were not damaged during the intubation process. However, this is secondary to ensuring that the patient is breathing effectively and maintaining adequate oxygenation.

Choice D reason:

Assessing vital signs and effort of breathing is the most immediate and important action following extubation. Monitoring the patient’s respiratory status ensures that they are maintaining a patent airway, breathing effectively, and not experiencing respiratory distress or failure.

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A nurse is caring for four patients in the neurologic intensive care unit. After receiving the hand-off report, which patient does the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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