The physician has ordered Dopamine for a patient in the ICU who has suffered a spinal cord injury. The nurse determines that the drug is having the desired effect when the assessment findings are:

Temperature of 96.8°F

Blood pressure 110/68

Respiratory rate of 20 breaths/min

Heart rate of 70 beats/min

Answer and Explanation

The Correct Answer is B

Choice A reason:

A temperature of 96.8°F is within the normal range for a human body (97.8°F to 99.1°F). However, it does not necessarily indicate the desired effect of Dopamine. Dopamine is primarily used to improve blood flow and cardiac output, particularly in critically ill patients. Therefore, temperature alone is not a reliable indicator of its effectiveness.

Choice B reason:

Blood pressure of 110/68 mmHg suggests that the Dopamine is effectively maintaining the patient's hemodynamic stability. Dopamine is often used to support blood pressure in patients with hypotension, particularly after spinal cord injuries. Maintaining an adequate blood pressure ensures that vital organs receive sufficient blood flow, which is a key therapeutic goal of Dopamine administration.

Choice C reason:

A respiratory rate of 20 breaths/min is considered normal for an adult (12-20 breaths/min). While normal respiratory rate is a positive sign, it is not a direct measure of Dopamine's effectiveness. Dopamine's primary action is on the cardiovascular system, so a normal respiratory rate alone does not necessarily indicate that the drug is having the desired effect.

Choice D reason:

A heart rate of 70 beats/min is within the normal range for adults (60-100 beats/min). Similar to the respiratory rate, while a normal heart rate is beneficial, it is not a direct indicator of Dopamine's effectiveness. Dopamine's role in improving cardiac output and blood pressure is more critical in assessing its desired effects.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason:

Assessing the level of consciousness is the most important nursing assessment for detecting early signs of a declining condition in a patient with a severe concussion. Changes in consciousness can indicate worsening brain injury or increased intracranial pressure, and prompt recognition is crucial for timely intervention.

Choice B reason:

A focal neurological exam is important but is more specific to identifying localized neurological deficits rather than detecting general deterioration. It is essential but secondary to monitoring the overall level of consciousness.

Choice C reason:

Body posturing can indicate severe brain injury or increased intracranial pressure, but it typically occurs later in the course of deterioration. Early changes in the level of consciousness are more sensitive indicators of a declining condition.

Choice D reason:

Vital signs are important to monitor, but changes in vital signs can occur later in the progression of a declining neurological status. Early detection of changes in the level of consciousness allows for more timely intervention.

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The physician has ordered Dopamine for a patient in the ICU who has suffered a spinal cord injury. The nurse determines that the drug is having the desired effect when the assessment findings are:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a teenager recently admitted with a severe concussion from playing football. Which is the most important nursing assessment to detect early signs of a declining condition?

Correct Answer is A

Explanation

A nurse applies a painful stimulus to the nailbeds of an unconscious patient. The patient responds with extension of the arms and legs, pronation of the arms, and plantar flexion. The nurse documents this as:

Correct Answer is D

Explanation

A nurse is caring for a patient who has a closed-head injury with ICP readings ranging from 16-22 mm Hg. What actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply.

A nursing student studying spinal cord injury recognizes all of the following to be causes of secondary injuries:

The nurse is caring for a mechanically ventilated spinal cord injury patient in the ICU. To avoid the complication of autonomic dysreflexia, the nurse plans to implement the following orders:

Why does the healthcare provider prescribe a ventilator setting to maintain partial pressure of arterial carbon dioxide (PaCO2) between 35 and 38 mmHg for a patient with traumatic brain injury?

A nurse in the ED is assessing a client who is taking warfarin and experiencing rectal bleeding. Which of the following drugs should the nurse anticipate administering to the client?

You are caring for a patient in the ED who came in after a hard tackle in a football game. The x-rays show that he has a fracture of 2 ribs on the right side. Which intervention will the nurse expect for this patient?

A patient with a neck fracture at the C3 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During the initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding:

The nurse is assessing a patient with suspected traumatic cervical spine injury who just arrived to the emergency department. The nurse knows the priority actions for caring for this patient include all of the following. Place the actions in order of priority.