Nokea
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.
You may also like to solve these questions
The nurse is admitting a patient who has a tumour of the right frontal lobe. Which of the following findings should the nurse expect to observe?
- A. Judgement changes
- B. Expressive aphasia
- C. Right-sided weakness
- D. Difficulty swallowing
Correct Answer: A
Rationale: The frontal lobes control intellectual activities such as judgement. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumour. Swallowing is controlled by the brain stem.
After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first?
- A. A patient whose cranial radiograph shows a linear skull fracture
- B. A patient who has an initial Glasgow Coma Scale score of 13
- C. A patient who lost consciousness for a few seconds after a fall
- D. A patient whose right pupil is 10 mm and unresponsive to light
Correct Answer: D
Rationale: The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage, brain herniation, and increased intracranial pressure. The other patients are not at immediate risk for complications such as herniation.
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.
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 caring for a patient with a head injury. Which of the following findings should be reported rapidly to the health care provider?
- A. Urine output of 800 mL in the last hour
- B. Intracranial pressure of 16 mm Hg when patient is turned
- C. Ventriculostomy drains 10 mL of cerebrospinal fluid (CSF) per hour
- D. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.
Correct Answer: A
Rationale: The high urine output indicates that diabetes insipidus may be developing and interventions to prevent dehydration need to be rapidly implemented. The other data do not indicate a need for any change in therapy.