Nokea
The nurse is caring for a patient with a head injury. Which of the following findings should be reported rapidly to the health care provider?
- A. Urine output of 800 mL in the last hour
- B. Intracranial pressure of 16 mm Hg when patient is turned
- C. Ventriculostomy drains 10 mL of cerebrospinal fluid (CSF) per hour
- D. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.
Correct Answer: A
Rationale: The high urine output indicates that diabetes insipidus may be developing and interventions to prevent dehydration need to be rapidly implemented. The other data do not indicate a need for any change in therapy.
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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.
The nurse is caring for a patient with possible cerebral edema who has a serum sodium level of 115 mmol/L, a decreasing level of consciousness (LOC), and has a headache. Which of the following prescribed interventions should the nurse implement first?
- A. Draw blood for arterial blood gases (ABGs).
- B. Administer 5% hypertonic saline intravenously.
- C. Administer acetaminophen 650 mg orally.
- D. Send patient for computed tomography (CT) of the head.
Correct Answer: B
Rationale: The patient's low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse's first action should be to correct the low sodium level. Acetaminophen will have minimal effect on the headache because it is caused by cerebral edema and increased intracranial pressure (ICP). Drawing ABGs and obtaining a CT scan may add some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.
Which of the following statements by a patient who is being discharged from the emergency department (ED) after a head injury indicates a need for intervention by the nurse?
- A. I will return if I feel dizzy or nauseated.
- B. I am going to drive home and go to bed.
- C. I do not even remember being in an accident.
- D. I can take acetaminophen for my headache.
Correct Answer: B
Rationale: Following a head injury, the patient should avoid operating heavy machinery. Retrograde amnesia is common after a concussion. The patient can take acetaminophen for headache and should return if symptoms of increased intracranial pressure such as dizziness or nausea occur.
The nurse is caring for a patient who has had a head injury. Which of the following assessment information requires the most rapid action by the nurse?
- A. The patient is more difficult to arouse.
- B. The patient's pulse is slightly irregular.
- C. The patient's blood pressure increases from 120/54 to 136/62 mm Hg.
- D. The patient indicates a headache at pain level 5 of a 10-point scale.
Correct Answer: A
Rationale: The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache is not unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual.
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.