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The nurse is caring for a patient who is disoriented and anxious as a result of increased intracranial pressure. Which of the following nursing actions should be included in the plan of care?
- A. Encourage family members to remain at the bedside.
- B. Apply soft restraints to protect the patient from injury.
- C. Keep the room well lighted to improve patient orientation.
- D. Minimize contact with the patient to decrease sensory input
Correct Answer: A
Rationale: Patients with disorientation as a result of increased ICP will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications; the use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim.
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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.
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.
After receiving change of shift report, which of the following patients should the nurse assess first?
- A. A 44-year-old receiving IV antibiotics for meningococcal meningitis
- B. A 23-year-old who had a skull fracture and craniotomy the previous day
- C. A 30-year-old who has an intracranial pressure (ICP) monitor in place after a head injury a week ago
- D. A 61-year-old who has increased ICP and is receiving hyperventilation therapy
Correct Answer: D
Rationale: The patient that should be seen first is the one that requires the closest monitoringâ??the patient with ICP and receiving hyperventilation therapy. The postcraniotomy patient, patient with an ICP monitor, and the patient on IV antibiotics should be assessed as well but the priority would be the most critically ill patients.
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.
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.