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When caring for a patient with increased ICP the nurse knows the importance of monitoring for possible secondary complications, including syndrome of inappropriate antidiuretic hormone (SIADH). What nursing interventions would the nurse most likely initiate if the patient developed SIADH?
- A. Fluid restriction
- B. Transfusion of platelets
- C. Transfusion of fresh frozen plasma (FFP)
- D. Electrolyte restriction
Correct Answer: A
Rationale: SIADH causes fluid overload, requiring fluid restriction and electrolyte monitoring. Platelet or plasma transfusions and electrolyte restriction are not indicated.
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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.
A patient has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication?
- A. Vigilant monitoring of fluid balance
- B. Continuous BP monitoring
- C. Serial arterial blood gases (ABGs)
- D. Monitoring of the patients airway for patency
Correct Answer: A
Rationale: Diabetes insipidus causes extreme polyuria, requiring close fluid balance monitoring. BP, ABGs, and airway monitoring are less directly related.
While completing a health history on a patient who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state?
- A. Epileptic cry
- B. Confusion
- C. Urinary incontinence
- D. Body rigidity
Correct Answer: B
Rationale: Confusion is typical in the postictal state after a seizure. Epileptic cry, incontinence, and rigidity occur during the seizure, not afterward.
A nurse is caring for a patient who experiences debilitating cluster headaches. The patient should be taught to take appropriate medications at what point in the course of a new headache?
- A. As soon as the pain becomes unbearable
- B. As soon as the patient senses the onset of symptoms
- C. Twenty to thirty minutes after the onset of symptoms
- D. When the patient senses his or her symptoms peaking
Correct Answer: B
Rationale: Early administration of medication at symptom onset aborts cluster headaches effectively. Delaying treatment prolongs pain unnecessarily.
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.