The healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?

Drug dependence

Cardiac rhythm

Pulse oximetry

Pain level

Answer and Explanation

The Correct Answer is C

A. While drug dependence can be a concern with long-term use, it is not the immediate priority in an emergency setting where the goal is to stabilize the patient in status epilepticus.

B. Cardiac rhythm monitoring is important when administering certain medications, but lorazepam primarily affects the central nervous system and respiratory system, making oxygen saturation monitoring more critical.

C. Pulse oximetry is the priority assessment as IV lorazepam can depress the respiratory system, leading to hypoxia. Monitoring oxygen saturation helps ensure the patient maintains adequate respiratory function during administration.

D. Assessing pain is important in patient care, but it is not the priority in managing a patient in status epilepticus, where stabilization is essential.

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Correct Answer is C

Explanation

A. Chronic head injury patients often struggle with processing multiple pieces of information simultaneously due to cognitive limitations.

B. Activities requiring complex strategy, like chess, are typically challenging shortly after admission and not a realistic expectation.

C. Difficulty with planning and organizing thoughts and behaviors is a common cognitive deficit in patients with chronic head injury due to impaired executive function, often resulting from damage to the frontal lobe.

D. While non-compliance can occur, it is less predictable and may not be directly linked to chronic head injury itself.

A. T 92.5 F (33.6 C), BP 90/64, HR 80, RR 14, 02 Sat 97% Room Air B. T 98.7 F (36.4 C), BP 220/46, HR 30, RR 6, O2 Sat 98% Room Air C. T 98.6 F (37 C), BP 200/94, HR 90, RR 18, 02 Sat 100% Room Air D. T 103.1 F (39.5 C), BP 82/50, HR 132, RR 30, O2 Sat 99% Room Air

Correct Answer is B

Explanation

A. The low blood pressure (90/64) may indicate hypovolemia or shock but is not specific for ICP concerns.

B. This set of vital signs is concerning due to the extremely high blood pressure (220/46) combined with a very low heart rate (30) and low respiratory rate (6), which can indicate an autonomic response to increased ICP, potentially leading to Cushing's triad (hypertension, bradycardia, and irregular respirations).

C. Although the blood pressure is high (200/94), the heart rate is normal and the respiratory rate is stable, making this less alarming compared to option B.

D. The elevated temperature and abnormal heart rate (132) indicate potential fever and tachycardia, but the blood pressure (82/50) is low and does not directly indicate increased ICP.

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The healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which behavior(s) by the patient diagnosed with a chronic head injury would the nurse expect to find?

Correct Answer is C

Explanation

The nurse is caring for a patient with an acute brain injury. Which of the following sets of vital signs would concern the nurse about increasing intracranial pressure (ICP)?

Correct Answer is B

Explanation

The healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?

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