Which assessment finding(s) require(s) immediate attention? Select all that apply.
Arousable only by painful stimuli
Does not follow commands
Temperature 98.4°F (36.9° C)
Blood pressure 136/81 mm Hg
Laceration left foot that is 2.4" (6 cm) long
Pupils are 6 mm and sluggish
Correct Answer : A,B,F
Rationale:
A. Arousable only by painful stimuli: Reduced level of consciousness in a client with a subarachnoid hemorrhage indicates potential increased intracranial pressure (ICP) or neurological deterioration. Immediate monitoring and intervention are critical to prevent further brain injury.
B. Does not follow commands: The inability to follow commands reflects altered neurologic status and may indicate worsening cerebral perfusion or progressing neurological compromise. This finding requires urgent assessment and continuous monitoring.
C. Temperature 98.4°F (36.9° C): This is within normal limits and does not pose immediate risk. Mild temperature variations are not acutely concerning in the context of neurological compromise.
D. Blood pressure 136/81 mm Hg: Although slightly elevated, this blood pressure is not immediately life-threatening. Continuous monitoring is indicated due to the risk of rebleeding or increased ICP, but it is not the most urgent concern at this time.
E. Laceration left foot that is 2.4" (6 cm) long: While it requires wound care, this laceration is not life-threatening compared with the client’s acute neurological status. Immediate attention focuses on stabilizing intracranial pathology first.
F. Pupils are 6 mm and sluggish: Dilated, sluggish pupils indicate possible increased ICP or impending brain herniation. This is a critical neurologic finding that requires immediate assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["120"]
Explanation
Calculation:
- Identify the prescribed rate and IV concentration
Prescribed Rate: 4 mg/min
IV Concentration: 1 gram in 500 mL
1 gram = 1,000 mg
- Convert the prescribed rate to mg/hr
4 mg/min × 60 min = 240 mg/hr
- Calculate the infusion rate in mL/hr
Infusion Rate (mL/hr) = (Prescribed Dose per hour ÷ Total Dose in Bag) × Total Volume
Infusion Rate = (240 ÷ 1,000) × 500
Infusion Rate = 0.24 × 500
Infusion Rate = 120 mL/hr
Correct Answer is A
Explanation
Rationale:
A. Epinephrine: Epinephrine is the first-line medication for asystole and pulseless electrical activity (PEA) during CPR. It acts as a potent vasoconstrictor, increasing coronary and cerebral perfusion pressure, which improves the chances of return of spontaneous circulation (ROSC). It should be administered as soon as possible via IV or intraosseous route.
B. Amiodarone: Amiodarone is an antiarrhythmic used primarily for shockable rhythms such as ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). It is not indicated for asystole because there is no organized electrical activity to treat.
C. Adenosine: Adenosine is used to treat supraventricular tachycardia by temporarily blocking AV nodal conduction. It has no role in asystole or pulseless cardiac arrest and is not part of CPR protocols for non-shockable rhythms.
D. Lidocaine: Lidocaine is an antiarrhythmic alternative for VF or pulseless VT when amiodarone is unavailable. It does not improve outcomes in asystole and is not recommended for non-shockable rhythms during CPR.
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