Brain Under Pressure
Restlessness, headache, nausea, and unequal pupils following a head injury should make the nurse suspect this complication.
What is increased intracranial pressure (ICP)?
A client has a complete spinal cord transection at the lumbar level. This type of paralysis is expected.
What is paraplegia?
A client brought in after fighting a house fire has hoarseness, soot around the mouth, and singed nasal hairs. This the highest priority.
What is maintaining the airway?
This inflammatory bowel disease is associated with skip lesions and can affect any part of the gastrointestinal tract.
What is Crohn's disease?
This assessment finding indicates a patient with traumatic brain injury is improving rather than deteriorating.
What is following simple commands?
A client with a cervical spinal cord injury has a blood pressure of 76/40 mmHg, heart rate of 40/min, warm dry skin, and flaccid paralysis. The nurse should suspect this condition.
What is neurogenic shock?
What is adequate urine output?
A patient with ulcerative colitis develops fatigue and anemia. This is the most likely cause.
What is chronic blood loss?
After receiving alteplase, a patient suddenly develops a severe headache, nausea, and elevated blood pressure. The nurse should suspect this complication.
What is intracranial hemorrhage?
An adolescent with a spinal cord injury says, "I catheterize myself twice a day." The nurse recognizes this places the client at greatest risk for this complication.
What is urinary tract infection?
A patient with a sulfa allergy has an order for silver sulfadiazine. The nurse should take this action first.
What is hold the medication and notify the provider?
A patient taking methotrexate reports easy bruising and a sore throat. These findings suggest this serious adverse effect.
What is bone marrow suppression?
Hypertension with widening pulse pressure, bradycardia, and irregular respirations are collectively known as this.
What is Cushing's triad?
A patient with a T4 spinal cord injury develops severe hypertension, flushing, bradycardia, and a pounding headache. This condition should be suspected immediately.
What is autonomic dysreflexia?
A client with a temperature of 105°F is ordered a cooling blanket. The nurse should monitor for this complication.
What is shivering?
A client receiving desmopressin develops weight gain, decreased urine output, and crackles in the lungs. This is the most likely cause.
What is water intoxication? (Or Fluid Overload)
A client with traumatic brain injury suddenly becomes restless, develops a unilateral fixed and dilated pupil, and no longer follows commands. The nurse should suspect this life-threatening complication.
What is brain herniation?
A nurse suspects autonomic dysreflexia in a client with a T4 spinal cord injury. After placing the client in High Fowler's position, and ensuring that the Foley catheter is draining appropriately. This is the nurse's next priority assessment.
What is assessing for fecal impaction?
Frostbitten fingers become pink and warm with capillary refill < 3 seconds after treatment. These findings indicate this.
What is tissue reperfusion?
The patient may experience positive antinuclear antibody test, fever, weakness, malaise, joint pain, erythema of the face and palms with this disease.
What is systemic lupus erythematosus (SLE)?