Nokea
A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which of the following actions should the nurse plan to take?
- A. Administer IV furosemide
- B. Initiate high-dose barbiturate therapy
- C. Type and crossmatch for blood transfusion
- D. Prepare the patient for immediate craniotomy.
Correct Answer: D
Rationale: The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent hematoma. 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.
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The nurse is assessing a patient who is unconscious and applies a painful stimulus to the nail beds. The patient responds with internal rotation, adduction, and flexion of the arms. Which of the following terms should the nurse use when documenting the findings?
- A. Flexion withdrawal
- B. Localization of pain
- C. Decorticate posturing
- D. Decerebrate posturing
Correct Answer: C
Rationale: 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.
The nurse is admitting a patient to the emergency department (ED) who is unconscious following a head injury. The patient's partner and children are at the patient's side with many questions for the nurse regarding care. Which of the following actions 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 family's pastor or spiritual advisor to support them while initial care is given.
- D. Refer the family members to the hospital counselling service to deal with their anxiety.
Correct Answer: B
Rationale: 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 counselling 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.
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.
Family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring for a patient. Which of the following responses 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.
Correct Answer: B
Rationale: 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 member's anxiety.