A nurse is monitoring a client who has a traumatic brain injury and a ventriculostomy drain. The nurse should report which of the following findings as a complication of this therapeutic procedure? (Select all that apply.)
Infection
Vomiting
Widening pulse pressure
Equal and reactive pupils
Intracranial pressure reading of 10 mm Hg
Correct Answer : A,B,C
Choice A Reason:
Infection is a significant complication of a ventriculostomy drain. The presence of a foreign object in the brain increases the risk of infections such as meningitis or ventriculitis. Signs of infection can include fever, redness, swelling at the insertion site, and changes in mental status.
Choice B Reason:
Vomiting can be a sign of increased intracranial pressure (ICP), which is a serious complication in clients with a traumatic brain injury and a ventriculostomy drain. Increased ICP can lead to further brain injury and requires immediate medical attention.
Choice C Reason:
Widening pulse pressure (the difference between systolic and diastolic blood pressure) can indicate increased intracranial pressure. This is a critical finding that should be reported immediately as it can signify worsening brain injury or other complications.
Choice D Reason:
Equal and reactive pupils are generally a normal finding and do not indicate a complication. This suggests that the brainstem is functioning properly and there is no significant increase in intracranial pressure affecting the cranial nerves.
Choice E Reason:
An intracranial pressure reading of 10 mm Hg is within the normal range (typically 7-15 mm Hg for adults). Therefore, this finding does not indicate a complication and does not require immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Increasing hydration is important in the postoperative period to maintain fluid balance and support recovery. However, it is not the immediate priority following pheochromocytoma removal. The primary concern is to monitor and manage hemodynamic stability, particularly blood pressure.
Choice B Reason:
Monitoring blood pressure is the priority action following pheochromocytoma removal. This surgery can lead to significant fluctuations in blood pressure due to the sudden removal of catecholamine-secreting tumors. Close monitoring is essential to detect and manage potential hypotension or hypertension, which can be life-threatening if not promptly addressed.
Choice C Reason:
Measuring urine output is important for assessing kidney function and fluid balance, but it is not the immediate priority. Blood pressure monitoring takes precedence because of the potential for severe hemodynamic instability following the removal of the tumor.
Choice D Reason:
Providing a calm environment is beneficial for the patient’s overall recovery and can help reduce stress and anxiety. However, it is not the most critical action immediately following surgery. Ensuring hemodynamic stability through blood pressure monitoring is the top priority.
Correct Answer is C
Explanation
Choice A Reason
Lidocaine is primarily used to treat ventricular arrhythmias, such as ventricular tachycardia or ventricular fibrillation. It is not typically used for bradycardia (a heart rate of 40/min) and would not be appropriate for this scenario.
Choice B Reason
Adenosine is used to treat certain types of supraventricular tachycardia (SVT) by slowing down the heart rate. It is not indicated for bradycardia and would not be suitable for a heart rate of 40/min.
Choice C Reason
Atropine is the first-line medication for treating symptomatic bradycardia. It works by blocking the effects of the vagus nerve on the heart, thereby increasing the heart rate. Given the client’s symptoms of a low heart rate, diaphoresis, and chest pain, atropine is the appropriate choice.
Choice D Reason
Verapamil is a calcium channel blocker used to treat high blood pressure, angina, and certain types of arrhythmias. However, it is not used for bradycardia and could potentially worsen the condition by further lowering the heart rate.
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