A patient with IICP has a sodium level of 128 mEq/L. The physician orders 3% hypertonic saline. What is the primary goal of this intervention?

A. You auscultate the site of anastomosis with your stethoscope and listen for a rushing sound is incorrect because this describes assessing for a bruit, which is the auditory evaluation of blood flow through the AV fistula. While listening for a bruit is important to evaluate patency, it does not assess the thrill, which is a tactilefinding.

B. You place a blood pressure cuff on the arm of the AV fistula to look for pulsations at the site is incorrect because using a blood pressure cuff in this way is not part of standard assessment for thrill and may actually compromise the fistula if pressure is applied inappropriately. Cuffs are used for blood pressure measurement but not for evaluating fistula patency.

C. You want to palpate the site of anastomosis for a buzzing sensation is correct because a thrillis a palpable vibrationfelt over the AV fistula, usually at the site of the anastomosis between the artery and vein. The thrill is produced by turbulent blood flowthrough the fistula and indicates that the access is patent and functioning properly. Nurses assess the thrill by gently placing the fingertips over the fistula; a strong, continuous vibration is expected in a healthy, mature fistula ready for hemodialysis.

D. You check for capillary refill distal from the site of anastomosis is incorrect because capillary refill evaluates peripheral perfusion to the handbut does not provide information about fistula patency or flow. Although distal perfusion is important to assess (to ensure adequate circulation and avoid ischemia), it does not substitute for palpating the thrill or auscultating the bruit.

A. Subdural hematoma is correctbecause older adults are at high risk for subdural hematomas following head trauma, even with minor injuries. Brain atrophy in the elderly causes stretching of bridging veins, increasing the likelihood of bleeding. Symptoms can be subtle, delayed, or mistaken for baseline confusion or dementia. A change in mental status after a head injury should always prompt concern for intracranial bleeding, making this the priority and most serious potential complication.

B. Delirium related to being in the hospital is incorrectbecause although hospitalization can cause delirium in elderly patients, this explanation should not be assumed when there is a recent head injury. Intracranial bleeding must be ruled out first, as it is life-threatening and requires urgent intervention.

C. Diabetes is incorrectbecause there is no information provided indicating hypoglycemia or hyperglycemia, and diabetes would not be the most immediate concern related to confusion following a head injury. While glucose abnormalities can cause altered mental status, they are not the highest-priority concern in this scenario.

D. Scalp laceration is incorrectbecause scalp injuries can cause significant bleeding but do not typically cause changes in mental status. The presence of confusion after head trauma raises concern for deeper intracranial injury rather than a superficial wound.