A nurse is calculating the intake of a client during the past 9 hours.

The client's intake includes:

• Lactated Ringer's IV at 150 mL/hr
• cefazolin 2 g IV intermittent bolus in 100 mL of 0.9% sodium chloride
• two units of packed RBCs of 275 mL and 250 mL
• two IV bolus infusions of 250 mL of 0.9% sodium chloride
• ranitidine 50 mg IV intermittent bolus in 50 mL of dextrose 5% in water.

How many mL of intake should the nurse record?

Choice A rationale

Basilar skull fractures can lead to cerebral injuries and CSF leaks, but do not typically cause anoxic brain injury unless they compromise oxygenation or cause cerebral edema severely reducing blood flow.

Choice B rationale

Prolonged submersion compromises oxygen delivery, leading to diffuse cerebral hypoxia or anoxia, the primary cause of brain injury in drowning victims due to interruption of arterial oxygenation over unknown durations.

Choice C rationale

Epidural or subdural hematomas elevate intracranial pressure and compress brain tissue, but they are not as immediately hypoxic as situations involving complete oxygen deprivation like submersion.

Choice D rationale

Prolonged seizures, or status epilepticus, may disrupt normal metabolic processes, potentially causing neuronal injury. However, primary hypoxia is generally less pronounced than in submersion cases.

Choice A rationale

IV fluid bolus may address hypotension but is not the first priority. Symptoms of dizziness and diaphoresis in a spinal cord injury patient suggest autonomic dysreflexia or orthostatic hypotension requiring positional changes first.

Choice B rationale

Rescheduling therapy does not address the acute symptoms the patient is experiencing. Immediate action to manage dizziness and diaphoresis, such as altering body position, is required to stabilize the patient.

Choice C rationale

Lowering the head of the bed counters orthostatic hypotension, a common issue in spinal cord injury patients. Obtaining vital signs identifies the underlying cause and guides further interventions.

Choice D rationale

Bladder distention can trigger autonomic dysreflexia, but without evidence of urinary retention, prioritizing positional adjustments is more urgent to alleviate symptoms of dizziness and stabilize hemodynamics.