Nokea
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.
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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.
Which of the following information about a patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse?
- A. Intracranial pressure of 15 mm Hg.
- B. Cerebrospinal fluid (CSF) drainage of 15 mL/hour
- C. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg.
- D. Cardiac monitor shows sinus tachycardia, with a heart rate of 126 beats/minute
Correct Answer: C
Rationale: The PbtO2 should be 20-40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20-30 mL/hour. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2.
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 caring for a patient with increased intracranial pressure (IICP). Which of the following are late signs of IICP? (Select all that apply.)
- A. Unilateral hemiparesis
- B. Papilledema
- C. Decorticate posturing
- D. Decerebrate posturing
- E. Hyperthermia
Correct Answer: C,D,E
Rationale: Late signs of IICP include decerebrate posturing, decorticate posturing, and hyperthermia. Unilateral hemiparesis and papilledema are early signs when the compensatory mechanism is intact.
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.