A patient, diagnosed with a traumatic brain injury, is receiving mannitol. The nurse is implementing which of the following levels of intervention for the patient?
1. Level one
2. Level two
3. Level three
4. Level four
2
Rationale: Level two interventions to reduce intracranial pressure and optimize cerebral perfusion pressure after a traumatic brain injury include hyperosmolar therapy. Mannitol is an osmotic diuretic which will draw fluid from the intracellular and interstitial spaces resulting in an improved blood flow to the brain. Level one interventions include strategies to prevent venous constriction outflow from the brain. Level three interventions are neuromuscular blockage, hyperventilation, and hypothermia. Level four interventions include barbiturate therapy or surgical intervention to reduce the intracranial pressure.
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A 2-year-old child is scheduled for a tonsillectomy. When determining the plan of care, the nurse should:
a. Include the parents or caregivers in the plan of care b. Explain to the child that she will have a sore throat after surgery c. Tell the child that she can have her favorite foods for the first 24 hours after surgery d. Prepare the child for discharge from the hospital as soon as she is alert
Which of the following cardiac enzymes is a highly specific biomarker for myocardial damage?
a. CK-MB b. Troponin I c. Troponin T d. LDH
A client phones into the physician's office and reports an insect has flown into his ear and asks the nurse what he should do. The nurse instructs him to:
A) irrigate the ear with water to flush out the insect. B) instill mineral oil into the ear canal and try to gently remove insect with tweezers. C) attempt to remove the insect with a cotton-tipped applicator that has been dipped in hydrogen peroxide. D) apply Vaseline to smother and kill the insect.
Collecting information about a person is:
a. Assessment b. Gossip c. Implementation d. Evaluation