The nurse is caring for several patients in the Intensive Care Unit. Which of the following patients is at greatest risk of anoxic brain injury? A patient who:

was found facedown in water for unknown length of time.

has had multiple concussions in a short period of time.

was in an assault resulting in a basilar skull fracture.

suffered an epidural hematoma.

Answer and Explanation

The Correct Answer is A

A. A patient found facedown in water is at high risk of anoxic brain injury due to potential prolonged oxygen deprivation, which is directly associated with lack of oxygen to the brain.

B. Multiple concussions can lead to other types of brain injury but are less associated with anoxic injury than prolonged oxygen deprivation.

C. A basilar skull fracture can cause complications such as CSF leaks but does not directly cause an anoxic brain injury.

D. An epidural hematoma may increase ICP, but with timely intervention, anoxic injury may be avoided; anoxic brain injury is more directly related to oxygen deprivation.

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Correct Answer is A

Explanation

A. Standard precautions should be used for all patients, including those with AIDS, as they are designed to prevent the transmission of infections regardless of the patient's diagnosis. This includes the use of gloves, hand hygiene, and proper disposal of sharps.

B. Droplet precautions are specific to diseases that are spread through respiratory droplets, which is not the primary concern in AIDS management.

C. Contact precautions are used for infections that can be transmitted through direct contact with the patient or contaminated surfaces, but are not routinely required for AIDS patients unless they have co-infections.

D. Behavioral precautions are not a recognized category for infection control in clinical settings.

A. Drug dependence B. Cardiac rhythm C. Pulse oximetry D. Pain level

Correct Answer is C

Explanation

A. While drug dependence can be a concern with long-term use, it is not the immediate priority in an emergency setting where the goal is to stabilize the patient in status epilepticus.

B. Cardiac rhythm monitoring is important when administering certain medications, but lorazepam primarily affects the central nervous system and respiratory system, making oxygen saturation monitoring more critical.

C. Pulse oximetry is the priority assessment as IV lorazepam can depress the respiratory system, leading to hypoxia. Monitoring oxygen saturation helps ensure the patient maintains adequate respiratory function during administration.

D. Assessing pain is important in patient care, but it is not the priority in managing a patient in status epilepticus, where stabilization is essential.

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The nurse is caring for several patients in the Intensive Care Unit. Which of the following patients is at greatest risk of anoxic brain injury? A patient who:

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Naxlex Comprehensive Predictor Exams

A nurse is assigned a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Which type of precaution should be used when providing direct care?

Correct Answer is A

Explanation

The healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?

Correct Answer is C

Explanation

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