Nokea
A patient with a head injury opens his or her eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. Which of the following Glasgow Coma Scale scores should the nurse document?
- A. 9
- B. 15
- C. 13
- D. 3
Correct Answer: B
Rationale: The patient has a score of 3 for eye opening (to verbal stimulation), 3 for best verbal response (inappropriate words/cursing), and 5 for best motor response (localizes pain). Total score: 3 + 3 + 5 = 11. However, the provided options include 15, which seems incorrect based on standard Glasgow Coma Scale scoring. Assuming a possible error in the original document, the closest logical score based on the description should be calculated, but none match perfectly. The answer 'B' (15) is selected as per the document, though it may reflect an inconsistency.
You may also like to solve these questions
The nurse is caring for a patient who is unconscious with a traumatic head injury and has a blood pressure of 72 mm Hg, and an intracranial pressure of 22 mm Hg. What is the cerebral perfusion pressure (CPP)?
- A. 50 mm Hg
- B. 94 mm Hg
- C. 72 mm Hg
- D. 22 mm Hg
Correct Answer: A
Rationale: The formula for cerebral perfusion pressure (CPP) is CPP = MAP - ICP, where MAP (mean arterial pressure) is calculated as (SBP + 2*DBP)/3. Given BP of 72 mm Hg (assuming this is the MAP as the question implies a single value), and ICP of 22 mm Hg, CPP = 72 - 22 = 50 mm Hg.
The nurse is caring for a patient with increased intracranial pressure (IICP). Which of the following are late signs of IICP? (Select all that apply.)
- A. Unilateral hemiparesis
- B. Papilledema
- C. Decorticate posturing
- D. Decerebrate posturing
- E. Hyperthermia
Correct Answer: C,D,E
Rationale: Late signs of IICP include decerebrate posturing, decorticate posturing, and hyperthermia. Unilateral hemiparesis and papilledema are early signs when the compensatory mechanism is intact.
Which of the following assessment information should the nurse collect to determine whether a patient is developing post-concussion syndrome?
- A. Muscle resistance
- B. Short-term memory
- C. Glasgow Coma Scale
- D. Pupil reaction to light
Correct Answer: B
Rationale: Decreased short-term memory is one indication of post-concussion syndrome. The other data may be assessed but are not indications of post-concussion syndrome.
The nurse is caring for a patient with a head injury. Which of the following findings 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 (CSF) per hour
- D. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.
Correct Answer: A
Rationale: 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.
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 radiograph 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
Correct Answer: D
Rationale: The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage, brain herniation, and increased intracranial pressure. The other patients are not at immediate risk for complications such as herniation.