Neurological Question #17

Question

A client is admitted for observation following a motor vehicle accident that occurred on the way to the client’s daughter’s wedding. The next morning, instead of asking about the wedding, the client tells the nurse “I have to leave now since the wedding is in a few minutes.” The client then becomes agitated when the nurse re-orients and states the actual date (which is the day following the wedding). What should the nurse do next?

Answers

  1. Change the date on the hospital room whiteboard to yesterday’s date.
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  2. Perform neurological assessment and assess pupillary response.
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  3. Administer Valium 40 mg IV since the client is about to have a seizure.
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  4. Call the family to see if the wedding can be repeated.
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Overview

Explanation

The nurse needs to perform a neuro assessment to determine pupillary response, ask if a headache is present, take vital signs, and contact the health care provider. The client may be exhibiting subtle signs of increased intracranial pressure which includes restlessness, agitation, headache, and pupil changes.

Learning Outcomes

Test Taking Tip

Video Rationale