NEUROLOGY
HEMIPARESIS
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Question
[CLICK ON ANY CHOICE TO KNOW THE RIGHT ANSWER]
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A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client’s care plan?
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Risk for injury
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Disturbed sensory perception (visual)
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Dressing or grooming self-care deficit
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Impaired verbal communication
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Explanation:
Detailed explanation-1: -First, you should get into a sitting position or elevate your head as much as possible. Changing position can drop your blood pressure. Since bladder issues are the most common cause of AD, you or a caregiver should check your bladder.
Detailed explanation-2: -The answer is C. A ventriculostomy is a catheter inserted in the area of the lateral ventricle to assess ICP. It will help drain CSF during increase pressure readings and measure ICP. The nurse must monitor for ICP levels greater than 20 mmHg and report it to the doctor.
Detailed explanation-3: -Initiate CPR or rescue breathing as needed. Look for uncontrolled bleeding, identify the source, and apply pressure to the source.
There is 1 question to complete.