The nurse is caring for a 72-year-old patient brought to the ED with severe headache and decreasing level of consciousness. The nurse reviews the patient's assessment data to prepare the plan of care.

Exhibits

Complete the bowtie by dragging and dropping the condition the patient is most likely experiencing, two interventions the nurse would perform/anticipate related to the condition, and two parameters the nurse would monitor.

Answer and Explanation

The Correct Answer is []

Condition the Patient is Most Likely Experiencing:

Intracerebral Haemorrhage (ICH) : The patient presents with a severe headache, lethargy, decreased level of consciousness, and slurred, incomprehensible speech, which are common signs of a stroke or intracerebral haemorrhage. A history of hypertension and atrial fibrillation increases the risk for both ischemic and hemorrhagic strokes. The use of apixaban, an anticoagulant, suggests the patient is at risk for bleeding complications, including intracerebral haemorrhage.

Interventions to Perform/Anticipate:

Perform a CT Scan of the Head:
- Rationale: A CT scan will help determine if there is bleeding or an ischemic event in the brain. It is crucial for differentiating between ischemic and hemorrhagic stroke, guiding subsequent treatment.
Administer Intravenous Antihypertensives:
- Rationale: Controlling blood pressure is critical to reduce the risk of further bleeding in the brain. Immediate BP management is essential in the acute setting of suspected stroke.

Parameters to Monitor:

Neurological Status:
- Rationale: Monitoring changes in the patient’s level of consciousness, pupil reactions, and motor response will help assess the progression of the neurological deficit and effectiveness of interventions.
Blood Pressure:
- Rationale: Maintaining blood pressure within a safe range is essential to prevent exacerbation of the hemorrhage. Hypertension management is key to avoid further complications.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["B","D","E"]

Explanation

A. Clean pins with hydrogen peroxide four times daily. Hydrogen peroxide is not recommended for routine pin care as it can damage tissue and delay healing. Overuse can also lead to the formation of oxygen bubbles in the tissue, which may cause complications. Recommended cleaning solutions often include saline or a mild antiseptic, depending on the facility's protocol.
B. Monitor pin sites at least daily: Regular monitoring of pin sites is essential to detect early signs of infection or complications such as redness, swelling, warmth, or discharge. Early detection allows for prompt intervention, which is crucial in preventing more severe infections and complications.
C. Loosen screws holding the pins during cleaning. Loosening screws can destabilize the fixation device and disrupt the bone alignment, potentially causing injury and delaying healing. Screws and pins should remain securely tightened unless adjustments are being made by a qualified healthcare provider.
D. Use strict aseptic technique for pin care: Using strict aseptic technique helps prevent the introduction of microorganisms at the pin sites. This is critical because external fixation devices create a direct pathway for pathogens to enter the body, which can lead to serious infections like osteomyelitis.
E. Follow agency protocol for pin care: Each healthcare facility may have specific protocols and guidelines for pin care based on evidence-based practices. Following these protocols ensures that the care provided is consistent and meets the latest standards for infection control and patient safety.
F. Avoid touching the pins. While it is crucial to avoid unnecessary handling of pins to prevent contamination, touching the pins during necessary cleaning and care using aseptic technique is allowed. Completely avoiding touching the pins could result in inadequate cleaning and care.

A. Risk of infection is great. B. Replantation can occur. C. Postoperative therapy will be required. D. Prosthetic fitting is often prescribed.

Correct Answer is ["A","B","C"]

Explanation

A. Risk of infection is great.: Traumatic amputations create an open wound, increasing the risk of infection. Proper wound care and monitoring for signs of infection are critical.
B. Replantation can occur.: Depending on the severity of the injury and the viability of the amputated part, replantation is possible and is a common consideration in the plan of care.
C. Postoperative therapy will be required.: Rehabilitation, including physical therapy, is essential for restoring function and mobility in the affected limb after amputation or replantation.
D. Prosthetic fitting is often prescribed.: While prosthetics can be used for finger amputations, not all cases require them, especially if replantation is successful. This is less common compared to major limb amputations.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with an external fixation device. Which of the following actions should the nurse implement? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

The nurse is contributing to the plan of care for a patient who has a traumatic finger amputation. What should the nurse consider?

Correct Answer is ["A","B","C"]

Explanation

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