Medications
client who experienced a 20 minute episode of tinnitus, diplopia, unilateral facial droop, and dysarthria with symptoms improving within the 20 minutes
Low-dose aspirin therapy
unresponsive terminally ill client who has low pulse ox reading, irregular breating pattern with periods of apnea and gurgling sounds in the back of their throat
Cheyne-Stokes respirations.
conscious client with a cervical cord injury. Which immediate assessments should the nurse be watching for?
Blood pressure
GI assessment
gag reflex
client with left-sided weakness that started 60 minutes earlier who is admitted to the emergency department and diagnostic tests are ordered. What Radiology test will be ordered?
CT scan of the Head
what is assistive coughing (quad cough)
Place your hands below the client's diaphragm and pushes upward with exhalation.
Reduce cerebral edema in spinal cord injury patients
dexamethasone
end of life with a history of severe traumatic brain injury is experiencing severe myoclonic jerks. what medication would the nurse given
Ativan (lorazepam)
client with a basal skull fracture and the nurse notes ecchymosis around both eyes and clear drainage from the client's nose. what the orders the RN would question?
Head of bed at 90 degrees.
NG Tube Placement
C6 spinal cord injury priority assessment?
Breathing and respiratory
client with a severe traumatic brain injury with seizure activity. The most common medication given?
phenytoin
client with a traumatic brain injury on a high dose of mannitol. What electrolyte will decrease
Sodium
A terminal client states “If my heart or breathing stop, I do not want to be resuscitated.” Which action would the nurse take first?
Call the care provider to have a DNR conversation with the client.
Client with spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. What is the first action by the nurse
high-Fowler’s position.
T3 spinal cord injury with client complaint of a pounding headache. What should the RN check first
Blood Pressure
Which is the nurse's priority action for a patient having a seizure ?
ensure client safety
The nurse is caring for a client with a subarachnoid hemorrhage. Which calcium channel blocker is often prescribed to prevent vasospasm in this condition?
Nimodipine
Which test is used to test brain stem function?
Dolls eyes movement
neurogenic shock signs
Low heart rate
Flaccid extremities
decrease Urine output
First assessment for a patient that had a head injury and now is having clear nasal drainage,
Check nasal drainage for glucose
traumatic brain injury, the client is unconscious for 5 hours so far, GCS is 9. which sign is concerning and needs urgent treatment?
decerebrate posturing
A client with a spinal cord injury is having autonomic dysreflexia. Which medication does the nurse anticipate to be given to address the hypertension in this emergency?
Nifedipine
The client requests to die at home in a familiar setting, and hospice care is initiated. Which initial action by the hospice nurse would best support family coping?
Explain the roles of all interdisciplinary team members involved in hospice.
The nurse is caring for an elderly client with hypernatremia . which sign is showing the client is NOT improving
The client is now Restlessness and agitation
Client with basilar skull fracture and has ecchymosis that extends over the mastoid
Battle's sign
A client post craniotomy who is starting their first day working with physical therapy to get into a chair. What needs to be placed on the client first?
Helmet