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Which of the following assessment findings in a patient who was admitted the previous day with a basilar skull fracture is most important to report to the health care provider?
- A. Bruising under both eyes
- B. Complaint of severe headache
- C. Large ecchymosis behind one ear
- D. Temperature of 38.6°C (101.5°F)
Correct Answer: D
Rationale: Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to the health care provider. The other findings are typical of a patient with a basilar skull fracture.
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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 caring for a patient with a head injury who has clear nasal drainage. Which of the following actions should the nurse take?
- A. Have the patient blow the nose.
- B. Check the nasal drainage for glucose.
- C. Assure the patient that rhinorrhea is normal after a head injury.
- D. Obtain a specimen of the fluid to send for culture and sensitivity.
Correct Answer: B
Rationale: Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.
Which of the following assessment findings should the nurse report immediately to the health care provider when caring for a patient with increased intracranial pressure?
- A. CPP 38 mm Hg
- B. MAP 92 mm Hg
- C. PaO2 110 mm Hg
- D. BP 140/82
Correct Answer: A
Rationale: A cerebral perfusion pressure (CPP) of 38 mm Hg is critically low, below the normal range of 70-100 mm Hg, indicating inadequate cerebral perfusion and a risk of ischemia. This should be reported immediately to the health care provider. MAP, BP, and PaO2 values listed are within normal limits and do not require immediate action.
The nurse is caring for a patient who has a head injury and is diagnosed with a concussion. Which of the following actions should the nurse plan to take?
- A. Coordinate the transfer of the patient to the operating room.
- B. Provide discharge instructions about monitoring neurological status.
- C. Transport the patient to radiology for magnetic resonance imaging (MRI) of the brain.
- D. Arrange to admit the patient to the neurological unit for observation for 24 hours.
Correct Answer: B
Rationale: A patient with a minor head trauma is usually discharged with instructions about neurological monitoring and the need to return if neurological status deteriorates. MRI, hospital admission, or surgery is not indicated in a patient with a concussion.
Which of the following information about a patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse?
- A. Intracranial pressure of 15 mm Hg.
- B. Cerebrospinal fluid (CSF) drainage of 15 mL/hour
- C. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg.
- D. Cardiac monitor shows sinus tachycardia, with a heart rate of 126 beats/minute
Correct Answer: C
Rationale: The PbtO2 should be 20-40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20-30 mL/hour. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2.