23.The nurse is caring for a patient whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this patient?A)Assessing the patient's verbal responseB)Assessing the patient's ability to follow complex commandsC)Assessing the patient's judgmentD)Assessing the patient's response to pain24.The nurse caring for a patient in a persistent vegetative state is regularly assessing for potential complications. Complications of neurologic dysfunction for which the nurse should assess include which of the following? Select all that apply.25.The nurse is caring for a patient with a brain tumor. What drug would the nurse expect to be ordered to reduce the edema surrounding the tumor?Page 5
26.The nurse is caring for a patient who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the patient's respiratoryeffort has increased. What is the nurse's most appropriate response?27.A patient has a poor prognosis after being involved in a motor vehicle accident resultingin a head injury. As the patient's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following?A)HemiplegiaB)Dry mucous membranesC)Signs of internal bleedingD)Loss of brain stem reflexes28.A patient has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize?29.When caring for a patient with increased ICP the nurse knows the importance of monitoring for possible secondary complications, including syndrome of inappropriate antidiuretic hormone (SIADH). What nursing interventions would the nurse most likely initiate if the patient developed SIADH?Page 6
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- Summer '15
- Intracranial pressure, Traumatic brain injury