Question

Which of the following findings require immediate nursing interventions related to the assessment of 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. Non-reactive pupils

d. Respiratory rate of 10 breaths per minute

Answer 1

Immediate nursing interventions for a patient with traumatic brain injury include addressing low mean arterial pressure, non-reactive pupils, and low respiratory rate.

Step-by-step explanation:

The findings that require immediate nursing interventions related to the assessment of a patient with a traumatic brain injury are:

• Mean arterial pressure 48 mm Hg - A mean arterial pressure of 48 mm Hg is considered low and indicates poor perfusion to the brain. Immediate nursing interventions may include administering fluids or medications to increase blood pressure and improve cerebral perfusion.
• Non-reactive pupils - Non-reactive pupils can indicate increased intracranial pressure or damage to the brainstem. Immediate nursing interventions may include notifying the healthcare provider, maintaining a patent airway, and monitoring neurological status.
• Respiratory rate of 10 breaths per minute - A respiratory rate of 10 breaths per minute is considered low and may indicate impending respiratory failure. Immediate nursing interventions may include providing supplemental oxygen, monitoring oxygen saturation, and assisting with ventilation if necessary.