Nokea
A nurse is providing care for an unconscious patient with a head injury prescribed IV mannitol. Which of the following parameters is best for the nurse to monitor to determine if the mannitol has been effective?
- A. Hematocrit
- B. Blood pressure
- C. Oxygen saturation
- D. Intracranial pressure
Correct Answer: D
Rationale: 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.
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The nurse is assessing a patient with a head injury. Which of the following assessments should the nurse complete first?
- A. Obtain oxygen saturation.
- B. Check pupil reaction to light.
- C. Palpate the head for hematoma.
- D. Assess Glasgow Coma Scale (GCS).
Correct Answer: A
Rationale: Airway patency and breathing are the most vital functions and should be assessed first. The neurological assessments should be accomplished next and the health and medication history last.
Which of the following assessment findings 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 38.6°C (101.5°F)
Correct Answer: D
Rationale: 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.
The nurse is caring for a patient who has a head injury and is diagnosed with a concussion. Which of the following actions should the nurse plan to take?
- A. Coordinate the transfer of the patient to the operating room.
- B. Provide discharge instructions about monitoring neurological status.
- C. Transport the patient to radiology for magnetic resonance imaging (MRI) of the brain.
- D. Arrange to admit the patient to the neurological unit for observation for 24 hours.
Correct Answer: B
Rationale: A patient with a minor head trauma is usually discharged with instructions about neurological monitoring and the need to return if neurological status deteriorates. MRI, hospital admission, or surgery is not indicated in a patient with a concussion.
The nurse is suctioning a patient with a traumatic head injury and notes that the intracranial pressure has increased from 14 to 16 mm Hg. Which of the following actions should the nurse take first?
- A. Document the increase in intracranial pressure.
- B. Assume that the patient's 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 infusion.
Correct Answer: B
Rationale: 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.
The nurse is caring for a patient admitted with bacterial meningitis who has a temperature of 38.9°C (102°F) and has prescriptions for all of the following collaborative interventions. Which action should the nurse take first?
- A. Administer ceftriaxone 1 g IV.
- B. Use a cooling blanket to lower temperature.
- C. Swab the nasopharyngeal mucosa for cultures.
- D. Give acetaminophen 650 mg PO.
Correct Answer: C
Rationale: 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.