Nokea
The nurse is assessing a patient who is unconscious and applies a painful stimulus to the nail beds. The patient responds with internal rotation, adduction, and flexion of the arms. Which of the following terms should the nurse use when documenting the findings?
- A. Flexion withdrawal
- B. Localization of pain
- C. Decorticate posturing
- D. Decerebrate posturing
Correct Answer: C
Rationale: Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.
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The nurse is assessing a patient with a head injury. Which of the following assessments should the nurse complete first?
- A. Obtain oxygen saturation.
- B. Check pupil reaction to light.
- C. Palpate the head for hematoma.
- D. Assess Glasgow Coma Scale (GCS).
Correct Answer: A
Rationale: Airway patency and breathing are the most vital functions and should be assessed first. The neurological assessments should be accomplished next and the health and medication history last.
The nurse is caring for a patient who has just been admitted with meningococcal meningitis. Which of the following observations requires the nurse to act?
- A. The bedrails at the head and foot of the bed are both elevated.
- B. The patient receives a regular diet from the dietary department.
- C. The student nurse goes into the patient's room without a mask.
- D. The lights in the patient's room are turned off and the blinds are shut.
Correct Answer: C
Rationale: Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions for at least the first 48 hours. Because the patient may be confused and weak, bedrails should be elevated at both the foot and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis.
The nurse is caring for a patient admitted with bacterial meningitis who has a temperature of 38.9°C (102°F) and has prescriptions for all of the following collaborative interventions. Which action should the nurse take first?
- A. Administer ceftriaxone 1 g IV.
- B. Use a cooling blanket to lower temperature.
- C. Swab the nasopharyngeal mucosa for cultures.
- D. Give acetaminophen 650 mg PO.
Correct Answer: C
Rationale: Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented.
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.
Which of the following assessment findings in a patient who was admitted the previous day with a basilar skull fracture is most important to report to the health care provider?
- A. Bruising under both eyes
- B. Complaint of severe headache
- C. Large ecchymosis behind one ear
- D. Temperature of 38.6°C (101.5°F)
Correct Answer: D
Rationale: Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to the health care provider. The other findings are typical of a patient with a basilar skull fracture.