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A patient admits to intravenous (IV) drug use and presents with red and severely painful right eye, floaters, photophobia and decreased visual acuity. The nurse explains to the patient and family that the plan of care will be as follows:

Surgery to remove the eye

Referral for drug rehabilitation program

Admission for IV and intravitreal antibiotics

Follow up with eye specialist outpatient

Answer and Explanation

The Correct Answer is C

A. Surgery to remove the eye is not the immediate course of action and is only considered in severe cases where infection cannot be managed.

B. Referral for a drug rehabilitation program is beneficial for the patient's long-term health but is not the priority in this case where there is an active eye infection.

C. Admission for IV and intravitreal antibiotics is necessary to treat a possible severe eye infection, which can be sight-threatening, especially in immunocompromised patients, such as those with a history of IV drug use.

D. An outpatient follow-up with an eye specialist may be part of ongoing care but does not address the acute need for immediate antibiotic therapy to prevent further complications.

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A. after the client has an electroencephalogram (EEG)." B. due to having minimal risk for infection." C. by threading it through the femoral artery to the brain." D. to monitor intracranial pressure (ICP) and drain the cerebral spinal fluid."

Correct Answer is D

Explanation

A. EEG is a monitoring tool for brain activity, but it is not a prerequisite for ventriculostomy placement.

B. While the procedure is carefully managed to reduce infection risk, ventriculostomy does have an infection risk due to its invasive nature.

C. Ventriculostomy is not inserted via the femoral artery; it is placed directly in the brain’s ventricles.

D. A ventriculostomy is used to monitor ICP and allows for the drainage of cerebrospinal fluid, which helps in managing elevated ICP in patients with brain injuries.

A. Suction the patient to minimize secretions B. Continue with the assessment and document the finding C. Notify the physician and raise HOB to 35-45 degrees D. Lower the head of the bed and pad the side rails

Correct Answer is C

Explanation

A. Suctioning can increase ICP due to the Valsalva response and should only be done if absolutely necessary.

B. Documenting without intervention could lead to worsening of the patient's condition.

C. Notifying the physician and raising the head of the bed helps to reduce ICP by promoting venous drainage. An ICP of 30 mmHg is critically high, requiring immediate intervention to prevent further damage.

D. Lowering the head of the bed can increase ICP further; head elevation is recommended to improve cerebral drainage.

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A patient admits to intravenous (IV) drug use and presents with red and severely painful right eye, floaters, photophobia and decreased visual acuity. The nurse explains to the patient and family that the plan of care will be as follows:

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Correct Answer is D

Explanation

Correct Answer is C

Explanation

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Take full exam for free A patient admits to intravenous (IV) drug use and presents with red and severely painful right eye, floaters, photophobia and decreased visual acuity. The nurse explains to the patient and family that the plan of care will be as follows:

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The nurse is educating on the placement of a ventriculostomy (intraventricular catheter) to the patient diagnosed with a brain injury and their family. The nurse states, "The ventriculostomy is placed:

Correct Answer is D

Explanation

The nurse is caring for a patient in the ICU with a diagnosis of acute closed head injury whose intracranial pressure (ICP) is 30mmHg. What is the priority action by the nurse?

Correct Answer is C

Explanation

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A patient admits to intravenous (IV) drug use and presents with red and severely painful right eye, floaters, photophobia and decreased visual acuity. The nurse explains to the patient and family that the plan of care will be as follows: