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:

Mechanical ventilation is not typically required for patients with rib fractures unless there is severe respiratory compromise or other underlying issues that necessitate ventilatory support.

Choice B reason:

Preparing for a chest tube is not generally required for isolated rib fractures unless there is an associated pneumothorax or hemothorax. Chest tubes are used to manage complications that involve air or blood in the pleural space.

Choice C reason:

Needle decompression is performed in emergencies to relieve tension pneumothorax. This procedure is not indicated for simple rib fractures without evidence of a tension pneumothorax.

Choice D reason:

An intercostal nerve block for pain management is an appropriate intervention for a patient with rib fractures. It helps control pain, allowing the patient to breathe deeply and cough effectively, which is important for preventing complications such as pneumonia.

A. Arterial Blood Gas (ABG) B. Blood pressure C. Capillary refill D. Heart rate

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.

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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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Explanation

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