Nokea
The nurse is providing discharge teaching with a patient who has a concussion. Which of the following time frames should the nurse tell the patient to continue to monitor for post-concussion syndrome?
- A. Up to 2 weeks
- B. Up to 4 weeks
- C. Up to 2 months
- D. Up to 6 months
Correct Answer: C
Rationale: Post-concussion syndrome is seen anywhere from 2 weeks to 2 months after the concussion. Symptoms include persistent headache, lethargy, personality and behavioural changes, shortened attention span, decreased short-term memory, and changes in intellectual ability. This syndrome can significantly affect the patient's abilities to perform the activities of daily living.
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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 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 suctioning a patient with a traumatic head injury and notes that the intracranial pressure has increased from 14 to 16 mm Hg. Which of the following actions should the nurse take first?
- A. Document the increase in intracranial pressure.
- B. Assume that the patient's neck is not in a flexed position.
- C. Notify the health care provider about the change in pressure.
- D. Increase the rate of the prescribed propofol infusion.
Correct Answer: B
Rationale: Since suctioning will cause a transient increase in intracranial pressure, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation, there is no indication that anxiety has contributed to the increase in intracranial pressure.
The nurse is caring for a patient following a craniectomy and left anterior fossae incision who has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. Which of the following is an appropriate nursing intervention?
- A. Position the bed flat and log roll the patient.
- B. Cluster nursing activities to allow longer rest periods.
- C. Turn and reposition the patient side to side every 2 hours.
- D. Perform range-of-motion ( ROM) exercises every 4 hours.
Correct Answer: D
Rationale: ROM exercises will help to prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness.
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.