Scenario J.R. is a 28-year-old man who was doing home repairs. He…

Question Scenario J.R. is a 28-year-old man who was doing home repairs. He…                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  ScenarioJ.R. is a 28-year-old man who was doing home repairs. He fell from the top of a 6-foot stepladder, striking his head on a large rock. He experienced a momentary loss of consciousness. By the time his neighbor got to him, he was conscious but bleeding profusely from a laceration over the right temporal area. The neighbor drove him to the emergency department of your hospital. As the nurse, you immediately apply a cervical collar, lay him on a stretcher, and take J.R. to a treatment room.1. Differentiate between a primary and secondary head injury.2. What steps will you take to assess J.R.?3. List at least five components of a neurologic examination. 6 Emergency4. What is the most sensitive indicator of neurologic change?5. What are the next actions you will take?You find that J.R. has become unresponsive to verbal stimuli and responds to painful stimuli by abnormally flexing his extremities (decorticate movement). He has no verbal response. The right pupil is larger than the left and does not respond to light.6.  What is J.R.’s GCS score at this time? Indicate what this means.7.  You summon the physician. Based on the GCS score, what are the next steps you will take?8.  What is a normal intracranial pressure (ICP), and why is increased ICP so clinically important?9.  Identify at least five signs and symptoms of increased ICP.10.The physician orders a 25% mannitol solution IV. What is mannitol, and why is it being administered to J.R.?J.R. is transported to radiology for a CT, where he is found to have a large epidural hematoma on the right with a hemispheric shift to the left. He will be taken straight to the operating room (OR) for evacuation of the hematoma. While enroute from the CT scan  to  the  OR,  the  physician  instructs  the  respiratory  therapist  to  initiate hyperventilation of the patient to “blow off more CO2.”11.What is the rationale for this action?12.While he is in surgery, J.R.’s family arrives at the ED with their faith healer. They ask that their faith healer anoint J.R. and pray over him. What should the nurse say?After J.R.’s surgery he is admitted to the neurological intensive care unit (NICU).13.What assessment indicators will be closely monitored in J.R.?14.J.R. has ICP monitoring in place with an intraventricular catheter. Nursing interventions related to J.R.’s care while the catheter is in place include: (Select all that apply.)A]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               Health Science Science Nursing NURS 104 Share QuestionEmailCopy link Comments (0)