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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When caring for a child with coarctation of the aorta, the nurse assesses for the most common clinical manifestation, which is:
a. clubbing of the digits. b. upper extremity hypertension. c. pedal edema and portal congestion. d. loud systolic ejection murmur.
A nurse wants to provide opportunities for a patient to try out new, more assertive behaviors. Which technique should the nurse use?
a. Clarifying b. Role-playing c. Giving feedback d. Encouraging evaluation
A client says to the admitting nurse, "Why do you need to know the names of all the over-the-counter supplements I take? They aren't drugs." Which responses by the nurse are the most appropriate?
1. "The admitting physician needs to know everything you are taking." 2. "You're right. I'm not sure why the admitting paperwork asks for this information. Would you mind listing them anyway?" 3. "The law requires us to keep a list of over-the-counter drugs and supplements that you are taking." 4. "It is true that supplements are not considered drugs; however, some of these products can cause adverse effects with prescribed drugs." 5. "We need to know if you are having an allergic reaction to one of them."
A nurse is preparing to administer a dose of gentamicin to a patient who is receiving the drug 3 times daily. The nurse will monitor _____ levels
a. peak b. peak and trough c. serum drug d. trough