A nurse is caring for an older adult patient in the emergency department who sustained a head injury due to a fall. Which of the following are common causes of head injuries in older adults?

Choice A rationale
Swelling of the optic nerve, also known as papilledema, can be a sign of increased intracranial pressure (ICP). However, it is not a direct indicator of a worsening neurological condition.
Choice B rationale
The Glasgow Coma Scale (GCS) is a clinical tool used to assess a patient’s level of consciousness and neurological functioning. A decreasing GCS score indicates a worsening neurological condition, which could be due to increasing ICP12. Therefore, a decreasing GCS score is a direct indicator of a worsening neurological condition.
Choice C rationale
A blood pressure of 108/76 mm Hg is within the normal range and does not directly indicate a worsening neurological condition. However, drastic changes in blood pressure could potentially indicate a problem.
Choice D rationale

Changes in pupil size and shape can be a sign of increased ICP, but these changes are not specific to a worsening neurological condition. They could be due to various factors, including medication effects or damage to the cranial nerves.
Choice E rationale
A respiratory rate of 12/min is within the normal range for adults. Changes in respiratory patterns could potentially indicate a worsening neurological condition, but a rate of 12/min does not directly indicate this.

Choice A rationale: The nurse should prepare to administer tissue plasminogen activator (tPA). This medication is used to dissolve blood clots that have formed in the blood vessels of the brain. The client’s CT scan shows a large area of decreased attenuation in the left hemisphere, which is indicative of a stroke. The administration of tPA is time-sensitive and should be initiated as soon as possible after the onset of symptoms if there is no evidence of hemorrhage on the CT scan.

Choice B rationale: Positioning the client on his right side is not necessarily beneficial in this situation. The client is experiencing symptoms of a stroke, and positioning will not alleviate these symptoms. It is more important to focus on interventions that can potentially reverse the effects of the stroke, such as the administration of tPA.

Choice C rationale: There is no indication that the client requires a bolus of 50% dextrose. The client’s blood glucose levels are within normal limits, and hypoglycemia is not a concern at this time. Administering a bolus of 50% dextrose without indication could potentially lead to hyperglycemia.

Choice D rationale: The nurse should anticipate the need for endotracheal intubation. The client’s condition is deteriorating, and he is now unresponsive to verbal stimuli and only responds to painful stimuli. This indicates a decreased level of consciousness, which can compromise the client’s airway. Endotracheal intubation may be necessary to protect the client’s airway and ensure adequate ventilation.

Choice E rationale: The nurse should prepare to administer antihypertensive medication. The client’s blood pressure is significantly elevated, which can further exacerbate the damage caused by a stroke. Antihypertensive medication can help to lower the client’s blood pressure and reduce the risk of further complications.

Choice F rationale: The nurse should use a calm and reassuring approach when interacting with the client. This can help to reduce anxiety and promote a sense of safety. It is important to remember that the client may be scared and confused due to his symptoms, and a calm and reassuring approach can help to alleviate these feelings.

Choice G rationale: Restricting all fluids and sodium intake is not indicated in this situation. While fluid and sodium balance is important in stroke patients, there is no indication that the client is fluid overloaded or has a condition that would require sodium restriction. Furthermore, the client has been prescribed IV fluids, indicating that fluid restriction is not appropriate at this time.