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The nurse is caring for a patient who has a head injury and is diagnosed with a concussion. Which of the following actions should the nurse plan to take?
- A. Coordinate the transfer of the patient to the operating room.
- B. Provide discharge instructions about monitoring neurological status.
- C. Transport the patient to radiology for magnetic resonance imaging (MRI) of the brain.
- D. Arrange to admit the patient to the neurological unit for observation for 24 hours.
Correct Answer: B
Rationale: A patient with a minor head trauma is usually discharged with instructions about neurological monitoring and the need to return if neurological status deteriorates. MRI, hospital admission, or surgery is not indicated in a patient with a concussion.
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The nurse is caring for a patient with a head injury who has clear nasal drainage. Which of the following actions should the nurse take?
- A. Have the patient blow the nose.
- B. Check the nasal drainage for glucose.
- C. Assure the patient that rhinorrhea is normal after a head injury.
- D. Obtain a specimen of the fluid to send for culture and sensitivity.
Correct Answer: B
Rationale: Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.
A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which of the following actions should the nurse plan to take?
- A. Administer IV furosemide
- B. Initiate high-dose barbiturate therapy
- C. Type and crossmatch for blood transfusion
- D. Prepare the patient for immediate craniotomy.
Correct Answer: D
Rationale: The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent hematoma. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary.
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 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 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.