Nokea
The nurse is admitting a patient to the emergency department (ED) who is unconscious following a head injury. The patient's partner and children are at the patient's side with many questions for the nurse regarding care. Which of the following actions is best for the nurse to take?
- A. Ask the family to stay in the waiting room until the initial assessment is completed.
- B. Allow the family to stay with the patient and briefly explain all procedures to them.
- C. Call the family's pastor or spiritual advisor to support them while initial care is given.
- D. Refer the family members to the hospital counselling service to deal with their anxiety.
Correct Answer: B
Rationale: The need for information about the diagnosis and care is very high in family members of acutely ill patients, and the nurse should allow the family to observe care and explain the procedures. A pastor or counselling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety.
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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.
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 nurse is suctioning a patient with a traumatic head injury and notes that the intracranial pressure has increased from 14 to 16 mm Hg. Which of the following actions should the nurse take first?
- A. Document the increase in intracranial pressure.
- B. Assume that the patient's neck is not in a flexed position.
- C. Notify the health care provider about the change in pressure.
- D. Increase the rate of the prescribed propofol infusion.
Correct Answer: B
Rationale: Since suctioning will cause a transient increase in intracranial pressure, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation, there is no indication that anxiety has contributed to the increase in intracranial pressure.
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.
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.