Nokea
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.
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Which of the following statements by a patient who is being discharged from the emergency department (ED) after a head injury indicates a need for intervention by the nurse?
- A. I will return if I feel dizzy or nauseated.
- B. I am going to drive home and go to bed.
- C. I do not even remember being in an accident.
- D. I can take acetaminophen for my headache.
Correct Answer: B
Rationale: Following a head injury, the patient should avoid operating heavy machinery. Retrograde amnesia is common after a concussion. The patient can take acetaminophen for headache and should return if symptoms of increased intracranial pressure such as dizziness or nausea occur.
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 possible cerebral edema who has a serum sodium level of 115 mmol/L, a decreasing level of consciousness (LOC), and has a headache. Which of the following prescribed interventions should the nurse implement first?
- A. Draw blood for arterial blood gases (ABGs).
- B. Administer 5% hypertonic saline intravenously.
- C. Administer acetaminophen 650 mg orally.
- D. Send patient for computed tomography (CT) of the head.
Correct Answer: B
Rationale: The patient's low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse's first action should be to correct the low sodium level. Acetaminophen will have minimal effect on the headache because it is caused by cerebral edema and increased intracranial pressure (ICP). Drawing ABGs and obtaining a CT scan may add some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.
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.
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.