Opioids, sedatives, osmotic diuretics, hypertonic saline solutions, and barbiturates are drug classes that may be used to normalize ICP and prevent secondary injury. The nurse is caring for a patient with a traumatic brain injury.  Give one example from each class, prioritize three nursing considerations for each and prioritize the order of administration.

Class	Medication	3 Prioritized Nursing Considerations	Prioritize Order of Administration
Opioids	1.	1. 2. 3.
Sedatives	2.	1. 2. 3.
Osmotic diuretics	3.	1. 2. 3.
Hypertonic saline solutions	4.	1. 2. 3.
Barbiturates	5.	1. 2. 3.

 

 

Karen is a 40-year-old married mother of a 4 and 10-year-old. She was an unbelted passenger in a single car roll over. She was found outside the car complaining of severe head and neck pain. She is brought to the ED via EMS in C-spine precautions. She has bruising under her eyes and over the left mastoid bone. BP 165/36, HR 51, RR 24, O2sat 92% on 4 L NC. She has an 18 gauge IV in her R AC.

 

1. Prioritize your specific assessment (do not put “assess respiratory status”). Describe specifically what you will assess; chest symmetry, lung sounds, etc. of this patient in order of priority 1-10.

 

Priority	Assessment
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

 

 

1. Determine Karen’s GCS using the assessment data below:

__________ .

 

Karen’s eyes open in response to verbal stimuli
Karen is oriented to person only
Karen pulls her arm away and she moves her arm in response to a needle prick

 

 

 

1. Karen requests something for her headache. Which medication(s) are appropriate for the nurse to administer to Karen for her complaint of headache?

 

 

 

 

1. Mr. Smith is a 23-year-old male who sustained a traumatic brain injury as an

unrestrained driver in a motor vehicle crash. On admission, his blood

pressure (BP) was 158/32 mm Hg, heart rate (HR) 46 beats per minute,

respiratory rate (RR) 28 breaths per minute, and temperature 96.2° F

(35.6° C). His neurological exam reveals that his right pupil is at 6 mm and

reacts sluggishly; his left pupil is 4 mm and reacts briskly. He is nonverbal,

extends his arms bilaterally to pain, and opens his eyes minimally to pain.

 

 

1. What is the clinical significance of Mr. Smith’s blood pressure?

 

 

 

1. Determine Mr. Smith’s GCS using the assessment data above:

 

____________

 

1. What does Mr. Smith’s GCS indicate in terms of his probable outcome?

 

 

 

 

1. Joan Walkeris an 84-year-old female who has had a productivecough of green phlegm that startedfour days ago thatpersists. She wasstarted three daysago on prednisone 40 mg PO daily and azithromycin 250 mg PO x5 days by her clinic physician. She had a fever yesterday of 102.1, so she was admitted to the med-surg unit with a diagnosis of pneumonia. At 0330, the nurse hears a loud crash in Ms. Walker’s room. You rush in and find her lying on the floor. She states she fell trying to use the BSC. The patient is alert and oriented and denies pain anywhere. She says she’s fine and not hurt at all. The nurse assesses the patient and finds no evidence of injury. VS and assessment are unchanged from the earlier shift assessment.  Prioritize how the nurse should handle this situation.

 

Priority	Action
1.
2.
3.
4.
5.

 

 

 

Which of the following is not consistent with what is known about postpartum psychosis? Symptoms of postpartum psychosis can often begin within days of the delivery. B The average time of onset of symptoms of postpartum psychosis is within 2 to 3 weeks of delivery. Florid psychotic symptoms are usually preceded by prodromal signs such as O insomnia, restlessness, agitation, and mild cognitive deficits. This disorder primarily affects first-time mothers and there is very little risk of postpartum psychosis in subsequent pregnancies.

Miranda, age 43 had abdominal surgery five days ago for a ruptured appendix. Her hospital stay has been lengthened for further investigation. Yesterday, she complained of weakness and had trouble getting out of bed. She has not been eating or drinking much for the past couple of days. Earlier today, a chest X-Ray confirms that Miranda has right lobe pneumonia. She tells the nurse that she is not surprised about her test result because she has been feeling unwell since the surgery. Miranda complains of dyspnea just after coming back to the unit. She states that “quite often, I am producing thick yellowish secretions which is very hard for me to cough up.” The nurse notes that Miranda’s cough is weak, she takes a sample of Miranda’s sputum to send for culture and sensitivity testing.

The RPN just entered Miranda’s room and assessed her vital signs as follows: BP – 132/82, Temp – 38°, Heart Rate – 101, O2 Saturation – 91%, Respirations – 23. When the nurse auscultates Miranda’s posterior chest she notes decreased breath sounds and the presence of popping sounds in the right lobe. The nurse notes that the skin around Miranda’s mouth is bluish in colour. Capillary refill is less than 3 second and skin turgor is good. Miranda told the nurse that she is willing to do what she needs to so that she can go home as soon as possible.

Selection of pertinent assessment data that is relevant to the case study need (different from cluster, pattern, gap, cue & inference, norm).

► Identification of data Cluster that is present in the case study. Clear analysis what the cluster mean to the patient and the nurse.

►Identification of data Pattern that is present in the case study. Clear analysis of what the pattern mean to the patient and the nurse.

► Identification of Data Gap that is present in the case study. Clear analysis of what the data gap mean to the patient and to the nurse.

► Identification of data Norm that is present in the case study. Clear analysis of what the data norm mean to the patient and the nurse.

►Identification of Cue and inference that is present in the case study. Clear analysis of what the cue and inference mean to the patient and the nurse.

► Selection of One (1) Priority Nursing Diagnosis that reflects the data analysis

► Write Two (2) Expected Outcomes (patient goals) which reflects the priority nursing diagnosis

► Write Two (2) Nursing Interventions (nursing orders) to address and achieve the expected outcomes/patient goals

Which of the following is consistent with current perspectives on nurse practitioner competencies? The National Organization of Nurse Practitioner Faculties has developed a list of core I" competencies that all students should have upon graduation from a master’s program. B Nursing specialty organizations DO NOT publish competencies for NPs who provide I" care in specialty areas. I" C Employers DO NOT establish their own set of competencies. I" D There are national standards forjudgingfevaluating nurse practitioner competencies.