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The neurologic ICU nurse is admitting a patient following a craniotomy using the supratentorial approach. How should the nurse best position the patient?
- A. Position the patient supine.
- B. Maintain head of bed (HOB) elevated at 30 to 45 degrees.
- C. Position patient in prone position.
- D. Maintain bed in Trendelenberg position.
Correct Answer: B
Rationale: HOB elevation at 30-45 degrees reduces ICP in supratentorial craniotomy patients. Supine, prone, or Trendelenberg positions increase ICP risk.
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The nurse is caring for a patient with a brain tumor. What drug would the nurse expect to be ordered to reduce the edema surrounding the tumor?
- A. Solumedrol
- B. Dextromethorphan
- C. Dexamethasone
- D. Furosemide
Correct Answer: C
Rationale: Dexamethasone reduces edema around brain tumors. Solumedrol is less specific, furosemide is not ideal, and dextromethorphan is for cough suppression.
A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the ED. The physician determines the patients injury is causing increased intracranial pressure (ICP). The nurse should gauge the patients LOC on the results of what diagnostic tool?
- A. Monro-Kellie hypothesis
- B. Glasgow Coma Scale
- C. Cranial nerve function
- D. Mental status examination
Correct Answer: B
Rationale: The Glasgow Coma Scale assesses LOC via eye, verbal, and motor responses, making it ideal for monitoring ICP-related changes. Other options are not specific to LOC assessment.
The nurse caring for a patient in a persistent vegetative state is regularly assessing for potential complications. Complications of neurologic dysfunction for which the nurse should assess include which of the following? Select all that apply.
- A. Contractures
- B. Hemorrhage
- C. Pressure ulcers
- D. Venous thromboembolism
- E. Pneumonia
Correct Answer: A,C,D,E
Rationale: Immobility in a vegetative state increases risks for contractures, pressure ulcers, DVT, and pneumonia. Hemorrhage is not a common complication of decreased LOC.
A nurse is admitting a patient with a severe migraine headache and a history of acute coronary syndrome. What migraine medication would the nurse question for this patient?
- A. Rizatriptan (Maxalt)
- B. Naratriptan (Amerge)
- C. Sumatriptan succinate (Imitrex)
- D. Zolmitriptan (Zomig)
Correct Answer: C
Rationale: Sumatriptan and other triptans can cause chest pain and are contraindicated in ischemic heart disease. All listed medications are triptans, but sumatriptan is specifically noted for this risk.
The nurse is providing care for a patient who is unconscious. What nursing intervention takes highest priority?
- A. Maintaining accurate records of intake and output
- B. Maintaining a patent airway
- C. Inserting a nasogastric (NG) tube as ordered
- D. Providing appropriate pain control
Correct Answer: B
Rationale: Maintaining a patent airway is critical for an unconscious patient to ensure oxygenation and prevent aspiration. Other interventions, while important, are secondary to airway management.