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CC 案例研究 pg141

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乔安娜·拉米雷斯教授

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点击添加问题

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As the nurse assessing Jordan in the emergency room, which finding(s) is/are consistent with a concussion from a football injury? Select all that apply. 

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How should the nurse describe a concussion to Lakisha?

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Lakisha tells the nurse that Jordan experienced post-concussion syndrome after his concussion. Which symptoms typically support this diagnosis?

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Determine GCS Pt open eyes to painful stimuli, pupils equal but sluggish. Pt withdraws from pain stimuli and no spontaneous leg movement in lower extremities. Pt unable to respond verbally.  

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What assumptions can the nurse make, based on the GCS?

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The nurse recognizes the signs of increased intracranial pressure from the baseline assessment. Which assessment finding(s) support(s) this assumption? Select all that apply.

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The nurse has each of these medications prescribed. Which medication should the nurse hold and why?

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The nurse is reflecting on possible complications of the bolt intracranial pressure monitor. What should be the nurses highest concern?

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Calculate Jordan’s Cerebral Perfusion Pressure (MAP – ICP = CPP).  MAP 91  ICP 17  

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In what order should the nurse perform the provider’s prescriptions?

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The nurse returns to the unit with Jordan after the CT scan. The radiologist told the nurse that the scan shows a herniation of the brainstem. The prognosis is very poor. Lakisha is waiting in his room and asks the nurse what the CT scan shows. How should the nurse answer her question?

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Later that shift, Lakisha yells out to the nurse, “Something is wrong, come quick.” As the nurse enters the room, she sees that Jordan is having a clonic-tonic seizure. What observations led the nurse to think this? Select all that apply.

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What should the nurse prioritize upon entering the room?

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After the seizure is over, the nurse cleans Jordan up and changes his bedding. What should the nurse document? Select all that apply.

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