After a craniotomy, the nurse assesses the patient and finds generalized edema, decreased urine output, acute confusion, and muscle weakness. The client has IV fluids running at 75 mL/hr. What action should the nurse take first?

Assess the client's serum sodium level.

Continue to monitor the client's urinary output.

Increase the rate of the IV infusion.

Administer desmopressin IV per protocol.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Assessing the client's serum sodium level is the priority action. The symptoms of generalized edema, decreased urine output, acute confusion, and muscle weakness are suggestive of possible hyponatremia or other electrolyte imbalances, which can be critical in the postoperative period following a craniotomy. Checking the serum sodium level will provide essential information to guide further treatment.

Choice B reason:

While continuing to monitor the client's urinary output is important, it does not address the immediate need to diagnose and correct a potential electrolyte imbalance. The nurse needs to take action to determine the underlying cause of the patient's symptoms.

Choice C reason:

Increasing the rate of the IV infusion could potentially worsen the patient's condition, especially if the symptoms are related to fluid overload or electrolyte imbalance. This action should only be taken based on specific clinical indications and after appropriate assessments.

Choice D reason:

Administering desmopressin IV per protocol is not appropriate as the first action without confirming the underlying cause of the symptoms. Desmopressin is used for specific conditions such as diabetes insipidus, and its administration should be based on a confirmed diagnosis.

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Correct Answer is B

Explanation

Choice A reason:

A 72-year-old client with a brain tumor, GCS of 5, and decerebrate posturing may not be an ideal candidate for organ donation due to age and underlying cancer, which can affect organ viability.

Choice B reason:

A 24-year-old client after a motor vehicle accident with a GCS of 3 and no activity on electroencephalogram is a prime candidate for organ donation. The lack of brain activity indicates brain death, and the patient's young age and otherwise healthy organs make them suitable for transplantation.

Choice C reason:

A 68-year-old male with a massive stroke and GCS of 6 has significant neurological impairment but is not necessarily brain dead. Further evaluation would be required, but this patient may not meet the criteria for brain death necessary for organ donation.

Choice D reason:

A 50-year-old female with a GCS of 12 after surgical evacuation of an epidural hematoma is not an ideal candidate for organ donation at this time as they have a higher level of consciousness and potential for recovery.

A. Decorticate posturing B. Flexion withdrawal C. Localization of pain D. Decerebrate posturing

Correct Answer is D

Explanation

Choice A reason:

Decorticate posturing involves abnormal flexion of the arms towards the chest and extension of the legs. This posture indicates damage to the corticospinal tract at the level of the diencephalon. The described response does not match decorticate posturing.

Choice B reason:

Flexion withdrawal is a response to painful stimuli where the patient pulls away or flexes the affected limb. This is a less severe response than posturing and does not match the description provided in the scenario.

Choice C reason:

Localization of pain refers to the patient's ability to purposefully move a hand to the site of a painful stimulus, indicating higher brain function. The described response of arm and leg extension with pronation does not fit this description.

Choice D reason:

Decerebrate posturing is characterized by extension of the arms and legs, pronation of the arms, and plantar flexion. This posture indicates severe brainstem damage and is consistent with the described response.

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After a craniotomy, the nurse assesses the patient and finds generalized edema, decreased urine output, acute confusion, and muscle weakness. The client has IV fluids running at 75 mL/hr. What action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is reviewing the status of patients in the critical care unit. Which patient should the charge nurse notify the organ procurement team to evaluate for possible organ donation?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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