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The nurse has created a plan of care for a patient who is at risk for increased ICP. The patients care plan should specify monitoring for what early sign of increased ICP?
- A. Disorientation and restlessness
- B. Decreased pulse and respirations
- C. Projectile vomiting
- D. Loss of corneal reflex
Correct Answer: A
Rationale: Disorientation and restlessness are early signs of increased ICP. Decreased pulse, vomiting, and loss of reflexes are later manifestations.
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A patient is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this patients care, the nurse would expect to administer what priority medication?
- A. Hydrochlorothiazide (HydroDIURIL)
- B. Furosemide (Lasix)
- C. Mannitol (Osmitrol)
- D. Spirolactone (Aldactone)
Correct Answer: C
Rationale: Mannitol, an osmotic diuretic, reduces cerebral edema by dehydrating brain tissue. Other diuretics like hydrochlorothiazide, furosemide, and spirolactone are not typically used for increased ICP.
The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of deficient fluid volume related to fluid restriction and osmotic diuretic use. What would be an appropriate intervention for this diagnosis?
- A. Change the patients position as indicated.
- B. Monitor serum electrolytes.
- C. Maintain NPO status.
- D. Monitor arterial blood gas (ABG) values.
Correct Answer: B
Rationale: Monitoring serum electrolytes adjusts fluid and electrolyte therapy in patients with deficient fluid volume post-craniotomy. Positioning, NPO status, and ABG monitoring do not directly address this diagnosis.
What should the nurse suspect when hourly assessment of urine output on a patient postcraniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours?
- A. Cushing syndrome
- B. Syndrome of inappropriate antidiuretic hormone (SIADH)
- C. Adrenal crisis
- D. Diabetes insipidus
Correct Answer: D
Rationale: High urine output post-craniotomy suggests diabetes insipidus, common after brain surgery. Cushing syndrome and SIADH cause fluid retention, and adrenal crisis causes hypovolemia.
A patient is postoperative day 1 following intracranial surgery. The nurses assessment reveals that the patients LOC is slightly decreased compared with the day of surgery. What is the nurses best response to this assessment finding?
- A. Recognize that this may represent the peak of post-surgical cerebral edema.
- B. Alert the surgeon to the possibility of an intracranial hemorrhage.
- C. Understand that the surgery may have been unsuccessful.
- D. Recognize the need to refer the patient to the palliative care team.
Correct Answer: A
Rationale: Cerebral edema peaks 24-36 hours post-surgery, often causing decreased LOC. Hemorrhage is not confirmed, surgery success is premature to judge, and palliative care is not indicated.
Following a traumatic brain injury, a patient has been in a coma for several days. Which of the following statements is true of this patients current LOC?
- A. The patient occasionally makes incomprehensible sounds.
- B. The patients current LOC will likely become a permanent state.
- C. The patient may occasionally make nonpurposeful movements.
- D. The patient is incapable of spontaneous respirations.
Correct Answer: C
Rationale: Coma patients may exhibit nonpurposeful movements to stimuli. Verbal sounds are rare, comas are not permanent, and spontaneous respirations may persist.