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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.
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The nurse is caring for a patient who has a BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which of the following actions should the nurse take first?
- A. Elevate the head of the patient's bed to 60 degrees.
- B. Document the BP and ICP in the patient's record.
- C. Report the BP and ICP to the health care provider.
- D. Continue to monitor the patient's vital signs and ICP
Correct Answer: C
Rationale: The patient's cerebral perfusion pressure is 56 mm Hg (using the calculation CPP = MAP - ICP). This is below the normal range of 70-100 mm Hg and approaching the level of ischemia and neuronal death as a minimum of 50-60 mm Hg is necessary for adequate cerebral perfusion. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation also will be done, but they are not the first actions that the nurse should take.
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.
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.