10. The nurse is caring for a patient with a head injury. Over a time span of 30 minutes, the nurse observes the following vital signs changes: temperature from 97° to 98° F; pulse from 86 to 78 beats/min; respirations from 18 to 14 breaths/min; and blood pressure from 140/86 to 150/82. Which action is most important for the nurse to take? a. Notify the physician immediately.b. Document the findings.c. Determine the patient’s Glasgow Coma Scale (GCS) score.d. Observe pupils for size, equality, and reactivity.ANS: A An increasing temperature, decreasing pulse and respirations, and a widening pulse pressure are indicative of increasing intracranial pressure (ICP). Any identified change must be reported to the provider promptly. The nurse should also observe the pupils for any changes, determine the patient’s GCS score, and document the findings. PTS: 1 DIF: Cognitive Level: Analysis REF: 485 OBJ: 6 (theory) TOP: Increasing ICP KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. The patient is caring for a patient who spontaneously opens his eyes, localizes pain, and carries out confused conversation. The nurse correctly documents which Glasgow Coma Scale (GCS) rating for this patient? PTS: 1 DIF: Cognitive Level: Application REF: 486, Table 21-7 OBJ: 3 (clinical) TOP: GCS KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. The nurse is caring for a patient who requires neurologic checks. When performing an assessment, how should the nurse best evaluate the patient’s thinking?
PTS: 1 DIF: Cognitive Level: Application REF: 486 OBJ: 5 (theory) TOP: Assessment of Thinking KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
You've reached the end of your free preview.
Want to read all 10 pages?
- Fall '18
- Nursing Process Step, Med Surg Neuro