NEURO EMERGENCIES
A 24-year-old patient is admitted after a motor vehicle crash with a severe TBI. Over the last hour, the nurse notes increasing restlessness, repeated attempts to pull at the IV, and complaints of worsening headache. ICP has increased from 14 mm Hg to 20 mm Hg. The family says, “He just seems more agitated than before.” Based on this presentation, what is the nurse’s priority interpretation and action?
The patient is showing early signs of increasing ICP. The priority is to reduce stimulation and optimize positioning, including keeping the head midline and HOB elevated 30 degrees.
A patient 12 hours after pituitary surgery has a urine output of 1200 mL in 3 hours, intense thirst, serum sodium of 155 mEq/L, and urine specific gravity of 1.001. Which disorder should the nurse suspect?
Diabetes insipidus.
A patient with cirrhosis is brought in by family for confusion, irritability, and “acting unlike himself.” The nurse notes asterixis and difficulty following commands. Which complication is most likely occurring?
Hepatic encephalopathy.
A patient receiving chemotherapy for leukemia develops a temperature of 101.3°F and ANC of 300. The patient says, “I just thought I was coming down with something minor.” What is the nurse’s priority interpretation?
This is neutropenic fever, an oncologic emergency.
A patient with increased ICP is prescribed 0.45% sodium chloride at 100 mL/hr. Why should the nurse question this order?
Hypotonic fluids can worsen cerebral edema and increase ICP.
Which patient should the nurse assess first:
A patient with bacterial meningitis who now requires louder verbal stimulation to awaken, a patient with pancreatitis reporting pain of 9/10 despite morphine 1 hour ago, a patient with SIADH whose sodium is 126 mEq/L and asking for water, or a patient with prostate cancer who has not voided in 6 hours and feels bladder pressure?
The patient with bacterial meningitis who now requires louder verbal stimulation to awaken, because decreasing level of consciousness is an early sign of neurologic deterioration and possible increasing ICP.
Which patient should the nurse assess first:
A patient with DI who has urine output of 900 mL over 2 hours and sodium of 153 mEq/L, a patient with SIADH who is suddenly nauseated and reports a headache with sodium of 119 mEq/L, a patient with prostate cancer with continuous bladder irrigation and pink urine output, or a patient with chronic liver disease with 2+ edema and fatigue?
The patient with SIADH who is suddenly nauseated and reports a headache with sodium of 119 mEq/L, because acute neurologic symptoms in severe hyponatremia may precede seizures and cerebral edema.
A patient admitted with bacterial meningitis has fever, nuchal rigidity, and photophobia. Two hours later, the nurse notes the patient is increasingly lethargic, difficult to arouse, and now has unequal pupils. What complication should the nurse suspect?
Increased ICP with possible brain herniation.
A patient with small-cell lung cancer becomes progressively confused and then has a seizure. Labs show sodium 117 mEq/L, low serum osmolality, and concentrated urine. Which syndrome is most likely causing this event?
SIADH causing severe hyponatremia.
A patient with liver failure is prescribed lactulose. Twelve hours later, the patient has had three loose stools and is more alert. What does this indicate about the medication?
It is working as intended by reducing ammonia and improving encephalopathy.
A patient receiving doxorubicin for breast cancer reports increasing fatigue, palpitations, and shortness of breath with activity. Which serious adverse effect should the nurse suspect?
Cardiotoxicity.
A patient with TBI is receiving mannitol. During assessment, the nurse notes crackles in the lung bases and increasing respiratory effort. Why is this finding concerning?
It may indicate fluid overload or pulmonary edema related to osmotic fluid shifts.
Which patient should the nurse see first:
A stroke patient with new slurred speech 45 minutes after arrival to the unit, a leukemia patient with platelets of 18,000 and petechiae, a cirrhosis patient with ammonia of 88 and mild confusion, or a patient with chronic pancreatitis asking when pancreatic enzymes should be taken?
The stroke patient with new slurred speech, because an acute neurologic change may indicate evolving stroke or worsening cerebral perfusion and is immediately time-sensitive.
Which patient should the nurse see first:
A seizure patient who has been sleeping for 20 minutes after an event and has an oxygen saturation of 89% on room air, a meningitis patient with temperature 102.9°F and photophobia, a patient with cirrhosis with abdominal girth increased by 2 cm since yesterday, or a breast cancer patient asking whether filgrastim causes hair loss?
The seizure patient who has been sleeping for 20 minutes after an event and has an oxygen saturation of 89% on room air, because airway and oxygenation are the priority; postictal hypoventilation or obstruction may be occurring.
A 68-year-old patient arrives with right-sided weakness and aphasia. CT is negative for bleeding, and symptom onset was 90 minutes ago. Alteplase is started. 20 minutes later, the patient begins vomiting and becomes less responsive. What is the nurse’s priority action?
Stop the alteplase and notify the provider immediately because the patient may be experiencing intracranial hemorrhage.
A patient with SIADH is increasingly lethargic and has sodium of 119 mEq/L. The provider enters an order for maintenance IV fluids at 125 mL/hr. Why should the nurse question this order?
Additional fluids can worsen dilutional hyponatremia and increase the risk of cerebral edema and seizures.
A patient with cirrhosis suddenly vomits a large amount of bright red blood. BP is dropping and HR is rising. Which complication is most likely responsible?
Ruptured esophageal varices.
A patient with colorectal cancer reports abdominal distention, vomiting, no bowel movement for 2 days, and inability to pass flatus. Which complication should the nurse suspect?
Bowel obstruction.
A patient with seizures receives lorazepam and then phenytoin. Why are both medications used?
Lorazepam stops the active seizure, while phenytoin helps prevent recurrence.
Which patient should the nurse assess first:
A lung cancer patient with facial swelling and new hoarseness, a patient with SIADH and sodium of 118 mEq/L who is now increasingly restless, a post-mastectomy patient with 75 mL of serosanguinous drainage in 8 hours, or a patient with seizures who wants to know when they can drive again?
The lung cancer patient with facial swelling and new hoarseness, because this may indicate worsening superior vena cava syndrome or airway compromise, and airway threats take priority.
Which patient should the nurse assess first:
A patient 1 hour after alteplase who reports a sudden severe headache, a patient with spinal cord injury who has goosebumps and nasal stuffiness during catheter irrigation, a patient with pancreatitis whose calcium is 7.6 mg/dL and reports tingling around the mouth, or a leukemia patient with hemoglobin 7.0 g/dL and fatigue?
The patient 1 hour after alteplase who reports a sudden severe headache, because this may signal intracranial hemorrhage, a life-threatening complication of thrombolytic therapy.
A patient with a history of seizure disorder is found actively seizing in bed. Tonic-clonic movements continue for more than 5 minutes despite oxygen and safety measures. What medication does the nurse expect to administer first, and why?
Lorazepam, because it is the priority first-line medication for stopping active prolonged seizure activity or status epilepticus.
A patient with DI has been receiving treatment for 6 hours. Which assessment finding best indicates therapy is working: sodium 156 mEq/L, urine output decreasing, urine specific gravity 1.001, or continued intense thirst?
Urine output decreasing.
A patient with ascites is lying flat and reports increasing shortness of breath. The abdomen is tense and distended. What is the nurse’s priority intervention?
Place the patient in high Fowler’s position to improve breathing.
A patient with lung cancer develops facial swelling, distended neck veins, and worsening dyspnea when lying down. Which complication is most likely occurring?
Superior vena cava syndrome.
A patient with cirrhosis is receiving spironolactone and furosemide. Which lab value requires the most immediate follow-up: sodium 135 mEq/L, potassium 6.0 mEq/L, glucose 98 mg/dL, or hemoglobin 11.1 g/dL?
Potassium 6.0 mEq/L, because spironolactone can cause dangerous hyperkalemia.
Which patient should the nurse see first:
A patient with TBI whose ICP rose from 18 to 22 mm Hg over 30 minutes and is now pulling at the linens, a patient with autonomic dysreflexia whose BP is 198/96 after being sat upright, a patient with colorectal cancer whose hemoglobin dropped from 9.2 to 8.5, or a patient with meningitis requesting pain medication for headache?
The patient with autonomic dysreflexia whose BP remains 198/96 after being sat upright, because severe ongoing hypertension places the patient at immediate risk for stroke, seizure, or intracranial hemorrhage and indicates the trigger has not yet been relieved.
Which patient should the nurse see first:
A neutropenic leukemia patient with temp 100.7°F and chills, a TBI patient with ICP now 23 mm Hg and increasing agitation, an SCI patient with BP 206/102 and severe headache during bowel care, or a stroke patient 2 hours after alteplase with bleeding gums?
The stroke patient 2 hours after alteplase with bleeding gums is concerning, but the SCI patient with BP 206/102 and severe headache during bowel care should be seen first, because active autonomic dysreflexia with severe hypertension can cause immediate stroke, seizure, or death within minutes if the trigger is not removed.
A patient with a spinal cord injury at T6 suddenly reports a pounding headache and blurred vision during a routine bowel program. BP is 220/108, HR is 46, and the patient is flushed above the level of injury. What is happening, and what is the first nursing action?
The patient is experiencing autonomic dysreflexia. The first action is to sit the patient upright to reduce blood pressure.
A patient with severe hyponatremia from SIADH is receiving hypertonic saline. Why must sodium correction be closely monitored and not corrected too rapidly?
Rapid sodium correction can cause osmotic demyelination syndrome.
A patient with acute pancreatitis has severe epigastric pain radiating to the back, tachycardia, hypotension, and low urine output. Why is aggressive IV fluid resuscitation such a priority in this patient?
Because pancreatitis causes major third-spacing and hypovolemia, which can lead to shock and organ hypoperfusion.
A patient with prostate cancer reports new low back pain, progressive leg weakness, and difficulty walking. Why is this finding especially concerning?
It may indicate spinal cord compression from metastatic disease.
A patient taking vincristine reports numbness and tingling in the hands and feet. Which adverse effect is the nurse identifying?
Peripheral neuropathy.
Which patient should the nurse assess first:
A patient with hepatic encephalopathy who has not had a bowel movement in 24 hours and is now more drowsy, a patient with pancreatitis with BP 92/58 and urine output of 20 mL/hr for the last 2 hours, a patient with leukemia and ANC 400 who has an oral temperature of 100.8°F, or a stroke patient who failed a swallow screen and is asking for ice chips?
The patient with leukemia and ANC 400 who has an oral temperature of 100.8°F, because neutropenic fever is an oncologic emergency and can progress rapidly to sepsis and shock, even if the blood pressure is not yet severely abnormal.
Which patient should the nurse assess first:
A patient with pancreatitis and BP 88/54 after a drop in pain level, a patient with SIADH and sodium 117 mEq/L who just vomited, a patient with lung cancer and stridor, or a patient with liver failure who is newly combative and confused?
The patient with lung cancer and stridor, because stridor indicates upper airway obstruction and airway always takes priority over other unstable findings.