A patient, diagnosed with cerebral edema, has an intracranial pressure of 50 mm Hg. Which of the following nursing diagnoses would be a priority for this patient?
1. risk for injury
2. pain
3. decreased intracranial adaptive capacity
4. sensory perceptual alterations
3
Rationale: When the intracranial pressure is elevated for any reason the brain fails to compensate for increases in the pressure. The most appropriate and focused nursing diagnosis developed for this problem is decreased intracranial adaptive capacity. It is the priority for this patient. The other answer choices are all problems that need to be addressed, however they are not the initial priority for this patient.
You might also like to view...
The nurse is working in a prenatal clinic with a woman who admits to drinking a glass of wine with dinner. The nurse should teach the client that:
1. the mother could bleed during labor. 2. wine is acceptable to drink during pregnancy. 3. wine does not cause fetal anomalies. 4. the baby could experience fetal alcohol syndrome.
You are the nurse evaluating a new patient's laboratory results. Based upon the laboratory findings, what will cause the release of antidiuretic hormone (ADH)?
A) Increased serum sodium B) Decreased serum sodium C) Decrease in serum osmolality D) Decrease in thirst
African American patients seem to have a negative reaction to which of the following asthma medications?
a. Inhaled corticosteroids c. Leukotriene receptor agonist b. Long-term beta-agonist bronchodilators d. Oral corticosteroid
The subcutaneous administration route results in the most rapid drug action.
a. true b. false