Question

The nurse is caring for a patient who is experiencing tachypnea followed by periods of apnea. Assessment findings include nonreactive pupils and an abnormal protrusion of the brainstem into other brain tissue. The nurse identifies that the patient is experiencing what complication?

a) Cerebral edema
b) Neurogenic pulmonary edema
c) Brainstem herniation
d) Seizures

Answer 1

The patient with tachypnea, apnea, nonreactive pupils, and protrusion of the brainstem is likely experiencing brainstem herniation, a severe condition requiring immediate attention.

Step-by-step explanation:

The nurse is caring for a patient who is experiencing tachypnea followed by periods of apnea, alongside nonreactive pupils and an abnormal protrusion of the brainstem into other brain tissue. These symptoms suggest that the patient is experiencing brainstem herniation, which is a serious life-threatening condition that occurs when there is a pressure shift within the skull that causes the brainstem to move downward. The abnormal protrusion of brain tissue is indicative of this type of herniation. It is a neurological emergency and can lead to compression of vital structures, loss of brainstem reflexes, and changes in breathing patterns as seen in this patient.