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A patient has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the patients ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following?
- A. Hemiplegia
- B. Dry mucous membranes
- C. Signs of internal bleeding
- D. Loss of brain stem reflexes
Correct Answer: D
Rationale: Loss of brain stem reflexes (e.g., pupillary, corneal) signals impending death in severe head injury. Hemiplegia, dry membranes, and bleeding are not specific to this outcome.
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A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the ED. The physician determines the patients injury is causing increased intracranial pressure (ICP). The nurse should gauge the patients LOC on the results of what diagnostic tool?
- A. Monro-Kellie hypothesis
- B. Glasgow Coma Scale
- C. Cranial nerve function
- D. Mental status examination
Correct Answer: B
Rationale: The Glasgow Coma Scale assesses LOC via eye, verbal, and motor responses, making it ideal for monitoring ICP-related changes. Other options are not specific to LOC assessment.
A patient is postoperative day 1 following intracranial surgery. The nurses assessment reveals that the patients LOC is slightly decreased compared with the day of surgery. What is the nurses best response to this assessment finding?
- A. Recognize that this may represent the peak of post-surgical cerebral edema.
- B. Alert the surgeon to the possibility of an intracranial hemorrhage.
- C. Understand that the surgery may have been unsuccessful.
- D. Recognize the need to refer the patient to the palliative care team.
Correct Answer: A
Rationale: Cerebral edema peaks 24-36 hours post-surgery, often causing decreased LOC. Hemorrhage is not confirmed, surgery success is premature to judge, and palliative care is not indicated.
The nurse has created a plan of care for a patient who is at risk for increased ICP. The patients care plan should specify monitoring for what early sign of increased ICP?
- A. Disorientation and restlessness
- B. Decreased pulse and respirations
- C. Projectile vomiting
- D. Loss of corneal reflex
Correct Answer: A
Rationale: Disorientation and restlessness are early signs of increased ICP. Decreased pulse, vomiting, and loss of reflexes are later manifestations.
A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects the patients safety?
- A. Place the patient in a side-lying position.
- B. Pad the patients bed rails.
- C. Administer antianxiety medications as ordered.
- D. Reassure the patient and family members.
Correct Answer: B
Rationale: A side-lying position prevents aspiration of secretions post-seizure. Padding rails, antianxiety drugs, or reassurance are secondary to airway safety.
A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the patients plan of care?
- A. Monitoring of pulse oximetry
- B. Administration of a low-protein diet
- C. Administration of thorough oral hygiene
- D. Fluid restriction as ordered
Correct Answer: C
Rationale: Phenytoin can cause gingival hyperplasia, making thorough oral hygiene essential. Pulse oximetry, low-protein diet, and fluid restriction are not related to phenytoin's adverse effects.