Which of the following findings require immediate nursing interventions in a patient with a traumatic brain injury? (Select all that apply.)
A) Mean arterial pressure 48 mm Hg
B) Elevated serum blood alcohol level
C) Nonreactive pupils
D) Respiratory rate of 10 breaths/min
E) Open skull fracture

Question

Quizplus · Accepted Answer

Rapid assessment of patients with neurological injury is vital to the treatment of patients with traumatic brain injury.Preventing hypotension (mean arterial pressure less than 50 mm Hg)is essential to maintain cerebral perfusion; nonreactive pupils are an abnormal finding and require immediate attention to evaluate the cause.Adequate oxygenation and ventilation are necessary to deliver oxygen to the brain; thus,a respiratory rate of 10 requires further evaluation.An open skull fracture leaves the patient extremely vulnerable to infection in the brain.An elevated blood alcohol level interferes with the ability to conduct a neurological examination but does not require immediate intervention.

Which of the Following Findings Require Immediate Nursing Interventions in a Patient