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The nurse is caring for a patient who sustained a moderate head injury following a bicycle accident. The nurses most recent assessment reveals that the patients respiratory effort has increased. What is the nurses most appropriate response?
- A. Inform the care team and assess for further signs of possible increased ICP.
- B. Administer bronchodilators as ordered and monitor the patients LOC.
- C. Increase the patients bed height and reassess in 30 minutes.
- D. Administer a bolus of normal saline as ordered.
Correct Answer: A
Rationale: Increased respiratory effort may indicate rising ICP, requiring immediate team notification and further assessment. Bronchodilators, bed elevation, or saline are inappropriate initial actions.
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The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of deficient fluid volume related to fluid restriction and osmotic diuretic use. What would be an appropriate intervention for this diagnosis?
- A. Change the patients position as indicated.
- B. Monitor serum electrolytes.
- C. Maintain NPO status.
- D. Monitor arterial blood gas (ABG) values.
Correct Answer: B
Rationale: Monitoring serum electrolytes adjusts fluid and electrolyte therapy in patients with deficient fluid volume post-craniotomy. Positioning, NPO status, and ABG monitoring do not directly address this diagnosis.
The nurse is admitting a patient to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this patients admission orders? Select all that apply.
- A. Transcranial Doppler flow study
- B. Cerebral angiography
- C. MRI
- D. Cranial radiography
- E. Electromyelography
Correct Answer: A,B,C
Rationale: CT, MRI, cerebral angiography, and transcranial Doppler assess brain masses. Cranial radiography and EMG are not diagnostic for intracranial masses.
What should the nurse suspect when hourly assessment of urine output on a patient postcraniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours?
- A. Cushing syndrome
- B. Syndrome of inappropriate antidiuretic hormone (SIADH)
- C. Adrenal crisis
- D. Diabetes insipidus
Correct Answer: D
Rationale: High urine output post-craniotomy suggests diabetes insipidus, common after brain surgery. Cushing syndrome and SIADH cause fluid retention, and adrenal crisis causes hypovolemia.
A patient with increased ICP has a ventriculostomy for monitoring ICP. The nurses most recent assessment reveals that the patient is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication?
- A. Encephalitis
- B. CSF leak
- C. Meningitis
- D. Catheter occlusion
Correct Answer: C
Rationale: Nuchal rigidity and photophobia are signs of meningitis, a potential ventriculostomy complication. Encephalitis, CSF leak, and catheter occlusion present differently.
The nurse is caring for a patient who is in status epilepticus. What medication does the nurse know may be given to halt the seizure immediately?
- A. Intravenous phenobarbital (Luminal)
- B. Intravenous diazepam (Valium)
- C. Oral lorazepam (Ativan)
- D. Oral phenytoin (Dilantin)
Correct Answer: B
Rationale: IV diazepam is used to stop status epilepticus immediately. Phenobarbital and phenytoin are for maintenance, and oral medications are inappropriate during active seizures.