A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?
a. Elevate the head of the patient's bed to 60 degrees.
b. Document the BP and ICP in the patient's record.
c. Report the BP and ICP to the health care provider.
d. Continue to monitor the patient's vital signs and ICP.
Answer: c. Report the BP and ICP to the health care provider.
You might also like to view...
A woman who is 28 weeks pregnant is admitted to the high-risk OB unit with preterm premature rupture of the membranes. Four hours after admission, the nurse notes the following:
temperature: 38.5 °C (101.5 °F), maternal pulse: 122 beats/minute, and white blood cell count: 23,000 mm3. Which action by the nurse takes priority? A. Document the findings and notify the health-care provider. B. Facilitate fern testing or Nitrazine testing on vaginal fluid. C. Prepare to administer a prn dose of acetaminophen (Tylenol). D. Reassure the woman that these are expected findings.
A survey by the National Center for Complementary and Alternative Medicine showed that 62% of Americans used prayer within the preceding 12 months for health issues
Indicate whether the statement is true or false
The NANDA-I classification is a:
a. standardized classification of patient/client outcomes. b. set of nursing diagnoses of actual problems, risks, and health enhancement needs. c. standardized classification of interventions. d. unified nursing language system into which nursing terminologies can be cross-mapped.
What condition can result from the bone demineralization associated with immobility?
a. Osteoporosis b. Pooling of blood c. Urinary retention d. Susceptibility to infection