When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/min, respirations 24 breaths/min, which subsequent vital signs would the nurse report immediately to the health care provider?

BP 126/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min

BP 112/56 mm Hg, pulse 98 beats/min, respirations 28 breaths/min

BP 129/65 mm Hg, pulse 60 beats/min, respirations 20 breaths/min

BP 172/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min

Answer and Explanation

The Correct Answer is D

A.   BP 126/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min - While the low pulse and respirations should be assessed, this blood pressure isn't as concerning.
B.   BP 112/56 mm Hg, pulse 98 beats/min, respirations 28 breaths/min - These vital signs are within a safer range compared to the critical changes in D.
C.   BP 129/65 mm Hg, pulse 60 beats/min, respirations 20 breaths/min - These are stable vital signs.
D.   The BP of 172/54 mm Hg, combined with bradycardia (pulse of 58 beats/min) and hypoventilation (respirations of 10 breaths/min), is indicative of Cushing's triad, a late sign of increased intracranial pressure, which is an emergency requiring immediate attention.

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Correct Answer is D

Explanation

A. A ventriculostomy involves inserting a catheter into the ventricles of the brain to monitor ICP, not a procedure for instilling drugs.
B. A ventriculostomy involves the insertion of a catheter to monitor ICP, not an internal transducer.
C. Cerebrospinal fluid (CSF) samples can be taken via ventriculostomy; the procedure does not prevent this.
D. A ventriculostomy measures the pressure within the brain’s ventricles to monitor intracranial
pressure, which is the correct understanding.

A. "tPA should be administered within 12 hrs of the onset of a stroke." B. "tPA is administered by intraarterial infusion." C. "tPA is administered IV." D. "PA requires BP monitoring during and 24 hrs after the treatment."

Correct Answer is A

Explanation

A. tPA (tissue plasminogen activator) should be administered within 3 to 4.5 hours of the onset of ischemic stroke symptoms, not 12 hours. Administering it after this window increases the risk of complications such as bleeding.
B. tPA is administered by intraarterial infusion is true, but it refers to a specific technique for certain stroke types.
C. tPA is administered IV is correct for intravenous administration in many cases of ischemic stroke.

D. tPA requires BP monitoring during and 24 hrs after the treatment is accurate as blood pressure control is critical when administering tPA.

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When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/min, respirations 24 breaths/min, which subsequent vital signs would the nurse report immediately to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After receiving pre procedural instructions, which patient statement demonstrates an understanding of a scheduled ventriculostomy?

Correct Answer is D

Explanation

An RN is teaching a student nurse about tissue plasminogen activator (tPA) administration in a patient with ischemic stroke. Which statement made by the student nurse indicates a need for further teaching?

Correct Answer is A

Explanation

For the patient who wears contact lenses, which intervention would the nurse teach the patient when diagnoses with bacterial conjunctivitis?

Which term would the nurse use to document a patient who is comatose from a head injury and display flexion of the arms, wrists, and fingers, as well as adduction of the upper extremities?

Cellulitis of the right lower extremity may present with which assessment finding?

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?

Which medical condition places a patient at a higher risk for an embolic stroke?

Which laboratory result would the nurse anticipate when reviewing the cerebrospinal fluid analysis of a patient with bacterial meningitis?

Which method of measurement is the gold standard for obtaining intracranial pressures?

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?