Chapter 57: Nursing Management: Acute Intracranial Problems My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 57: Nursing Management: Acute Intracranial Problems

Test Bank

MULTIPLE CHOICE

1. When family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring for a patient, which response by the nurse is best?

a.

This type of monitoring system is complex and highly skilled staff are needed.

b.

The monitoring system helps show whether blood flow to the brain is adequate.

c.

The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure.

d.

This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage.

ANS: B

Short and simple explanations should be given to patients and family members. The other explanations are either too complicated to be easily understood or may increase the family members anxiety.

DIF: Cognitive Level: Application REF: 1438

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

2. A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?

a.

Blood pressure 156/60, pulse 55, respirations 12

b.

Blood pressure 130/72, pulse 90, respirations 32

c.

Blood pressure 148/78, pulse 112, respirations 28

d.

Blood pressure 110/70, pulse 120, respirations 30

ANS: A

Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushings triad and indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.

DIF: Cognitive Level: Application REF: 1429-1430

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

3. When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as

a.

flexion withdrawal.

b.

localization of pain.

c.

decorticate posturing.

d.

decerebrate posturing.

ANS: C

Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.

DIF: Cognitive Level: Comprehension REF: 1429-1430

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

4. Which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol (Osmitrol) has been effective for an unconscious patient?

a.

Hematocrit

b.

Blood pressure

c.

Oxygen saturation

d.

Intracranial pressure

ANS: D

Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. Oxygen saturation will not directly improve as a result of mannitol administration.

DIF: Cognitive Level: Application REF: 1432-1433 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

5. A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. The nurse records the patients Glasgow Coma Scale score as

a.

9.

b.

11.

c.

13.

d.

15.

ANS: B

The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.

DIF: Cognitive Level: Application REF: 1434

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

6. Following a head injury, an unconscious 32-year-old patient is admitted to the emergency department (ED). The patients spouse and children stay at the patients side and constantly ask about the treatment being given. What action is best for the nurse to take?

a.

Ask the family to stay in the waiting room until the initial assessment is completed.

b.

Allow the family to stay with the patient and briefly explain all procedures to them.

c.

Call the familys pastor or spiritual advisor to support them while initial care is given.

d.

Refer the family members to the hospital counseling service to deal with their anxiety.

ANS: B

The need for information about the diagnosis and care is very high in family members of acutely ill patients, and the nurse should allow the family to observe care and explain the procedures. A pastor or counseling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety.

DIF: Cognitive Level: Application REF: 1438

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

7. An unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care?

a.

Keep the head of the bed elevated to 30 degrees.

b.

Position the patient with the knees and hips flexed.

c.

Encourage coughing and deep breathing to improve oxygenation.

d.

Cluster nursing interventions to provide uninterrupted rest periods.

ANS: A

The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.

DIF: Cognitive Level: Application REF: 1436-1437

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

8. After noting that a patient with a head injury has clear nasal drainage, which action should the nurse take?

a.

Have the patient blow the nose.

b.

Check the nasal drainage for glucose.

c.

Assure the patient that rhinorrhea is normal after a head injury.

d.

Obtain a specimen of the fluid to send for culture and sensitivity.

ANS: B

Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.

DIF: Cognitive Level: Application REF: 1438-1439

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

9. A patient who has a head injury is diagnosed with a concussion. Which action will the nurse plan to take?

a.

Coordinate the transfer of the patient to the operating room.

b.

Provide discharge instructions about monitoring neurologic status.

c.

Transport the patient to radiology for magnetic resonance imaging (MRI) of the brain.

d.

Arrange to admit the patient to the neurologic unit for observation for 24 hours.

ANS: B

A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need to return if neurologic status deteriorates. MRI, hospital admission, or surgery are not indicated in a patient with a concussion.

DIF: Cognitive Level: Application REF: 1440 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

10. A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take?

a.

Administer IV furosemide (Lasix).

b.

Initiate high-dose barbiturate therapy.

c.

Type and crossmatch for blood transfusion.

d.

Prepare the patient for immediate craniotomy.

ANS: D

The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary.

DIF: Cognitive Level: Application REF: 1440-1441 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

11. While admitting a patient with a basal skull fracture, the nurse notes clear drainage from the patients nose. Which of these admission orders should the nurse question?

a.

Insert nasogastric tube.

b.

Turn patient every 2 hours.

c.

Keep the head of bed elevated.

d.

Apply cold packs for facial bruising.

ANS: A

Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage, and insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold pack are appropriate orders.

DIF: Cognitive Level: Application REF: 1440

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

12. Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome?

a.

Muscle resistance

b.

Short-term memory

c.

Glasgow coma scale

d.

Pupil reaction to light

ANS: B

Decreased short-term memory is one indication of postconcussion syndrome. The other data may be assessed but are not indications of postconcussion syndrome.

DIF: Cognitive Level: Application REF: 1440

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

13. When admitting a patient who has a tumor of the right frontal lobe, the nurse would expect to find

a.

judgment changes.

b.

expressive aphasia.

c.

right-sided weakness.

d.

difficulty swallowing.

ANS: A

The frontal lobes control intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem.

DIF: Cognitive Level: Application REF: 1447 | 1448

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

14. Which statement by a patient who is being discharged from the emergency department (ED) after a head injury indicates a need for intervention by the nurse?

a.

I will return if I feel dizzy or nauseated.

b.

I am going to drive home and go to bed.

c.

I do not even remember being in an accident.

d.

I can take acetaminophen (Tylenol) for my headache.

ANS: B

Following a head injury, the patient should avoid operating heavy machinery. Retrograde amnesia is common after a concussion. The patient can take acetaminophen for headache and should return if symptoms of increased intracranial pressure such as dizziness or nausea occur.

DIF: Cognitive Level: Application REF: 1444

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

15. After having a craniectomy and left anterior fossae incision, a patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to

a.

position the bed flat and log roll the patient.

b.

cluster nursing activities to allow longer rest periods.

c.

turn and reposition the patient side to side every 2 hours.

d.

perform range-of-motion (ROM) exercises every 4 hours.

ANS: D

ROM exercises will help to prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness.

DIF: Cognitive Level: Application REF: 1450-1451

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

16. A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care?

a.

Encourage family members to remain at the bedside.

b.

Apply soft restraints to protect the patient from injury.

c.

Keep the room well-lighted to improve patient orientation.

d.

Minimize contact with the patient to decrease sensory input.

ANS: A

Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications; the use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim.

DIF: Cognitive Level: Application REF: 1453-1455 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

17. The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which nursing action is most important?

a.

Vaccinate 11- and 12-year-old children against Haemophilus influenzae.

b.

Emphasize the importance of hand washing to prevent spread of infection.

c.

Immunize adolescents and college freshman against Neisseria meningitides.

d.

Encourage adolescents and young adults to avoid crowded areas in the winter.

ANS: C

The Neisseria meningitides vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria, but it is not as effective as immunization. Vaccination with Haemophilus influenzae is for infants and toddlers. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic.

DIF: Cognitive Level: Application REF: 1453-1455

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

18. While caring for a patient who has just been admitted with meningococcal meningitis, the RN observes all of the following. Which one requires action by the RN?

a.

The bedrails at the head and foot of the bed are both elevated.

b.

The patient receives a regular diet from the dietary department.

c.

The nursing assistant goes into the patients room without a mask.

d.

The lights in the patients room are turned off and the blinds are shut.

ANS: C

Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the food and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis.

DIF: Cognitive Level: Application REF: 1453-1455

TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

19. When assessing a patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider?

a.

The patient has a positive Kernigs sign.

b.

The patient complains of having a stiff neck.

c.

The patients temperature is 101 F (38.3 C).

d.

The patients blood pressure is 86/42 mm Hg.

ANS: D

Shock is a serious complication of meningitis, and the patients low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernigs sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension.

DIF: Cognitive Level: Application REF: 1452-1453

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

20. A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?

a.

Elevate the head of the patients bed to 60 degrees.

b.

Document the BP and ICP in the patients record.

c.

Report the BP and ICP to the health care provider.

d.

Continue to monitor the patients vital signs and ICP.

ANS: C

The patients cerebral perfusion pressure is 56 mm Hg, below the normal of 60 to 100 mm Hg and approaching the level of ischemia and neuronal death. Immediate changes in the patients therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation also will be done, but they are not the first actions that the nurse should take.

DIF: Cognitive Level: Analysis REF: 1426

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

21. After suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 16 mm Hg. Which action should the nurse take first?

a.

Document the increase in intracranial pressure.

b.

Assure that the patients neck is not in a flexed position.

c.

Notify the health care provider about the change in pressure.

d.

Increase the rate of the prescribed propofol (Diprovan) infusion.

ANS: B

Since suctioning will cause a transient increase in intracranial pressure, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation; there is no indication that anxiety has contributed to the increase in intracranial pressure.

DIF: Cognitive Level: Application REF: 1426 | 1435-1437 | 1436-1437

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

22. Which of these patients is most appropriate for the intensive care unit (ICU) charge nurse to assign to an RN who has floated from the medical unit?

a.

A 44-year-old receiving IV antibiotics for meningococcal meningitis

b.

A 23-year-old who had a skull fracture and craniotomy the previous day

c.

A 30-year-old who has an intracranial pressure (ICP) monitor in place after a head injury a week ago

d.

A 61-year-old who has increased ICP and is receiving hyperventilation therapy

ANS: A

An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The postcraniotomy patient, patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critically ill patients.

DIF: Cognitive Level: Application REF: 1435-1438

OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

23. A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L) and a decreasing level of consciousness (LOC) and complains of a headache. Which of these prescribed interventions should the nurse implement first?

a.

Draw blood for arterial blood gases (ABGs).

b.

Administer 5% hypertonic saline intravenously.

c.

Administer acetaminophen (Tylenol) 650 mg orally.

d.

Send patient for computed tomography (CT) of the head.

ANS: B

The patients low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurses first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased intra-cranial pressure (ICP). Drawing ABGs and obtaining a CT scan may add some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.

DIF: Cognitive Level: Application REF: 1452-1455

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

24. After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first?

a.

A patient whose cranial x-ray shows a linear skull fracture

b.

A patient who has an initial Glasgow Coma Scale score of 13

c.

A patient who lost consciousness for a few seconds after a fall

d.

A patient whose right pupil is 10 mm and unresponsive to light

ANS: D

The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure. The other patients are not at immediate risk for complications such as herniation.

DIF: Cognitive Level: Analysis REF: 1432-1433 | 1437-1438

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Safe and Effective Care Environment

25. Which assessment finding in a patient who was admitted the previous day with a basilar skull fracture is most important to report to the health care provider?

a.

Bruising under both eyes

b.

Complaint of severe headache

c.

Large ecchymosis behind one ear

d.

Temperature of 101.5 F (38.6 C)

ANS: D

Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to the health care provider. The other findings are typical of a patient with a basilar skull fracture.

DIF: Cognitive Level: Application REF: 1440

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

26. When a patients intracranial pressure (ICP) is being monitored with an intraventricular catheter, which information obtained by the nurse is most important to communicate to the health care provider?

a.

Oral temperature 101.6 F

b.

Apical pulse 102 beats/min

c.

Intracranial pressure 15 mm Hg

d.

Mean arterial pressure 90 mm Hg

ANS: A

Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse are all borderline high but require only ongoing monitoring at this time.

DIF: Cognitive Level: Application REF: 1438-1440

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

27. The charge nurse observes an inexperienced staff nurse who is caring for a patient who has had a craniotomy for a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?

a.

The staff nurse suctions the patient every 2 hours.

b.

The staff nurse assesses neurologic status every hour.

c.

The staff nurse elevates the head of the bed to 30 degrees.

d.

The staff nurse administers a mild analgesic before turning the patient.

ANS: A

Suctioning increases intracranial pressure and is done only when the patients respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate.

DIF: Cognitive Level: Application REF: 1430-1431

OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

MSC: NCLEX: Safe and Effective Care Environment

28. A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first?

a.

Obtain oxygen saturation.

b.

Check pupil reaction to light.

c.

Palpate the head for hematoma.

d.

Assess Glasgow Coma Scale (GCS).

ANS: A

Airway patency and breathing are the most vital functions and should be assessed first. The neurologic assessments should be accomplished next and the health and medication history last.

DIF: Cognitive Level: Application REF: 1435-1437

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

29. The care plan for a patient who has increased intracranial pressure and a ventriculostomy includes the following nursing actions. Which action can the nurse delegate to nursing assistive personnel (NAP) who regularly work in the intensive care unit?

a.

Monitor cerebrospinal fluid color hourly.

b.

Document intracranial pressure every hour.

c.

Turn and reposition the patient every 2 hours.

d.

Check capillary blood glucose level every 6 hours.

ANS: D

Experienced NAP can obtain capillary blood glucose levels when they have been trained and evaluated in the skill. Monitoring and documentation of cerebrospinal fluid (CSF) color and intracranial pressure (ICP) require RN-level education and scope of practice. Although repositioning patients is frequently delegated to NAP, repositioning a patient with a ventriculostomy is complex and should be done by the RN.

DIF: Cognitive Level: Application REF: 1442

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

30. Which information about a patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse?

a.

Intracranial pressure of 15 mm Hg

b.

Cerebrospinal fluid (CSF) drainage of 15 mL/hour

c.

Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg

d.

Cardiac monitor shows sinus tachycardia, with a heart rate of 126 beats/min

ANS: C

The PbtO2 should be 20 to 40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20 to 30 mL/hour. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2.

DIF: Cognitive Level: Application REF: 1430-1432

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

31. When caring for a patient who has had a head injury, which assessment information requires the most rapid action by the nurse?

a.

The patient is more difficult to arouse.

b.

The patients pulse is slightly irregular.

c.

The patients blood pressure increases from 120/54 to 136/62 mm Hg.

d.

The patient complains of a headache at pain level 5 of a 10-point scale.

ANS: A

The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache is not unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual.

DIF: Cognitive Level: Application REF: 1431-1433

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

32. The nurse obtains these assessment findings for a patient who has a head injury. Which finding should be reported rapidly to the health care provider?

a.

Urine output of 800 mL in the last hour

b.

Intracranial pressure of 16 mm Hg when patient is turned

c.

Ventriculostomy drains 10 mL of cerebrospinal fluid per hour

d.

LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg

ANS: A

The high urine output indicates that diabetes insipidus may be developing and interventions to prevent dehydration need to be rapidly implemented. The other data do not indicate a need for any change in therapy.

DIF: Cognitive Level: Application REF: 1434-1435

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

33. When admitting a patient with a possible coup-contracoup injury after a car accident to the emergency department, the nurse obtains the following information. Which finding is most important to report to the health care provider?

a.

The patient takes warfarin (Coumadin) daily.

b.

The patients blood pressure is 162/94 mm Hg.

c.

The patient is unable to remember the accident.

d.

The patient complains of a severe dull headache.

ANS: A

The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported. The other information would not be unusual in a patient with a head injury who had just arrived to the ED.

DIF: Cognitive Level: Application REF: 1437-1438

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

34. A patient admitted with bacterial meningitis and a temperature of 102 F (38.8 C) has orders for all of these collaborative interventions. Which action should the nurse take first?

a.

Administer ceftizoxime (Cefizox) 1 g IV.

b.

Use a cooling blanket to lower temperature.

c.

Swap the nasopharyngeal mucosa for cultures.

d.

Give acetaminophen (Tylenol) 650 mg PO.

ANS: C

Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented.

DIF: Cognitive Level: Application REF: 1440-1441

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

COMPLETION

1. An unconscious patient with a traumatic head injury has a blood pressure of 126/72 mm Hg, and an intracranial pressure of 18 mm Hg. The nurse will calculate the cerebral perfusion pressure as ____________________.

ANS:

72 mm Hg

The formula for calculation of cerebral perfusion pressure is [(Systolic pressure + Diastolic blood pressure 2)/3] = intracranial pressure.

DIF: Cognitive Level: Application REF: 1452-1453

OBJ: Special Questions: Alternate Item Format

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

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