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The nurse is caring for a patient who has a BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which of the following actions should the nurse take first?
- A. Elevate the head of the patient's bed to 60 degrees.
- B. Document the BP and ICP in the patient's record.
- C. Report the BP and ICP to the health care provider.
- D. Continue to monitor the patient's vital signs and ICP
Correct Answer: C
Rationale: The patient's cerebral perfusion pressure is 56 mm Hg (using the calculation CPP = MAP - ICP). This is below the normal range of 70-100 mm Hg and approaching the level of ischemia and neuronal death as a minimum of 50-60 mm Hg is necessary for adequate cerebral perfusion. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation also will be done, but they are not the first actions that the nurse should take.
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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.
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 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.
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.
The nurse is caring for a patient following a craniectomy and left anterior fossae incision who has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. Which of the following is an appropriate nursing intervention?
- A. Position the bed flat and log roll the patient.
- B. Cluster nursing activities to allow longer rest periods.
- C. Turn and reposition the patient side to side every 2 hours.
- D. Perform range-of-motion ( ROM) exercises every 4 hours.
Correct Answer: D
Rationale: ROM exercises will help to prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness.