Nokea
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.
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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.
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 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.
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.
Which of the following assessment findings should the nurse report immediately to the health care provider when caring for a patient with increased intracranial pressure?
- A. CPP 38 mm Hg
- B. MAP 92 mm Hg
- C. PaO2 110 mm Hg
- D. BP 140/82
Correct Answer: A
Rationale: A cerebral perfusion pressure (CPP) of 38 mm Hg is critically low, below the normal range of 70-100 mm Hg, indicating inadequate cerebral perfusion and a risk of ischemia. This should be reported immediately to the health care provider. MAP, BP, and PaO2 values listed are within normal limits and do not require immediate action.