Nokea
The nurse is caring for a patient with a head injury and has admission vital signs of blood pressure 128/68 mm Hg, pulse 110 beats/minute, and respirations 26/minute. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
- A. Blood pressure 156/60, pulse 55, respirations 12
- B. Blood pressure 130/72, pulse 90, respirations 32
- C. Blood pressure 148/78, pulse 112, respirations 28
- D. Blood pressure 110/70, pulse 120, respirations 30
Correct Answer: A
Rationale: Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.
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The nurse is assessing a patient with bacterial meningitis and obtains the following data. Which of the following findings should be reported immediately to the health care provider?
- A. The patient has a positive Kernig's sign.
- B. The patient complains of having a stiff neck.
- C. The patient's temperature is 38.3°C (100.9°F).
- D. The patient's blood pressure is 86/42 mm Hg.
Correct Answer: D
Rationale: Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life-threatening as the hypotension.
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 assessing a patient with a head injury. Which of the following assessments should the nurse complete first?
- A. Obtain oxygen saturation.
- B. Check pupil reaction to light.
- C. Palpate the head for hematoma.
- D. Assess Glasgow Coma Scale (GCS).
Correct Answer: A
Rationale: Airway patency and breathing are the most vital functions and should be assessed first. The neurological assessments should be accomplished next and the health and medication history last.
The nurse is caring for a patient who is unconscious with a traumatic head injury and has a blood pressure of 72 mm Hg, and an intracranial pressure of 22 mm Hg. What is the cerebral perfusion pressure (CPP)?
- A. 50 mm Hg
- B. 94 mm Hg
- C. 72 mm Hg
- D. 22 mm Hg
Correct Answer: A
Rationale: The formula for cerebral perfusion pressure (CPP) is CPP = MAP - ICP, where MAP (mean arterial pressure) is calculated as (SBP + 2*DBP)/3. Given BP of 72 mm Hg (assuming this is the MAP as the question implies a single value), and ICP of 22 mm Hg, CPP = 72 - 22 = 50 mm Hg.
A nurse is providing care for an unconscious patient with a head injury prescribed IV mannitol. Which of the following parameters is best for the nurse to monitor to determine if the mannitol has been effective?
- A. Hematocrit
- B. Blood pressure
- C. Oxygen saturation
- D. Intracranial pressure
Correct Answer: D
Rationale: Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. Oxygen saturation will not directly improve as a result of mannitol administration.