Nokea
After receiving change of shift report, which of the following patients should the nurse assess first?
- 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
Correct Answer: D
Rationale: The patient that should be seen first is the one that requires the closest monitoringâ??the patient with ICP and receiving hyperventilation therapy. The postcraniotomy patient, patient with an ICP monitor, and the patient on IV antibiotics should be assessed as well but the priority would be the most critically ill patients.
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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.
A patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which of the following nursing interventions should 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.
Correct Answer: A
Rationale: 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.
The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which of the following nursing actions is most important?
- A. Vaccinate 11- and 12-year-old children against Haemophilus influenzae.
- B. Emphasize the importance of handwashing to prevent spread of infection.
- C. Immunize adolescents and postsecondary students against Neisseria meningitidis.
- D. Encourage adolescents and young adults to avoid crowded areas in the winter.
Correct Answer: C
Rationale: The Neisseria meningitidis vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and postsecondary students. Handwashing 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.
The nurse is caring for a patient who is disoriented and anxious as a result of increased intracranial pressure. Which of the following nursing actions should 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
Correct Answer: A
Rationale: Patients with disorientation as a result of increased ICP 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.
The nurse is admitting a patient with a basal skull fracture and notes clear drainage from the patient's 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.
Correct Answer: A
Rationale: 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 packs are appropriate orders.