A patient is admitted to the critical care unit with an acute head injury after a motor vehicle accident. The patient has a Glasgow Coma Scale score of 6
The patient is intubated and ventilated, and a ventriculostomy is placed with physician orders to keep the ICP less than 15 mm Hg. The patient's ICP continues to rise despite aggressive intervention. Which of the following is an advantage of a ventriculostomy ICP monitoring system? a. Lower risk of infection
b. Ease of insertion
c. No penetration of brain
d. Access for cerebrospinal fluid drainage and sampling
D
Advantages of a ventriculostomy include access for cerebrospinal fluid drainage and sampling, access for determination of volume-pressure curves, direct measurement of pressure, and access for medication instillation.
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The nurse, assisting in developing a nursing care plan for the patient in shock, would include evaluation criteria for the goal of increased cerebral blood flow, which would be:
1. reduced expressions of fear, improved cerebral blood flow, as evaluated by better LOC. 2. unchanged LOC, as expressed by verbal expressions, improved respirations. 3. decreased cerebral blood flow, because it is being shunted to other vital organs. 4. improved cardiac output, resulting in decreased renal vascular blood flow.
A client is admitted with complaints of right upper quadrant pain, nausea, and vomiting. The nurse recognizes these symptoms correlate with which of the following physical changes in the elder adult?
A) a greater risk to develop gallstones B) an increased gag reflex C) decreased sense of smell D) increased stomach emptying
The key to achieving the goals of Health for All in the 21st Century (HEALTH21) is the world-wide:
a. cure of communicable disease. b. technological development of all nations. c. availability of health care insurance. d. implementation of primary health care.
Nurses working in hospice and home care settings need to be knowledgeable of health policy to
a. Provide safe nursing care. b. Prevent elder abuse. c. Receive payment for the services provided. d. Influence future legislation.