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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.
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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.
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.
The nurse is admitting a patient who has a tumour of the right frontal lobe. Which of the following findings should the nurse expect to observe?
- A. Judgement changes
- B. Expressive aphasia
- C. Right-sided weakness
- D. Difficulty swallowing
Correct Answer: A
Rationale: The frontal lobes control intellectual activities such as judgement. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumour. Swallowing is controlled by the brain stem.
The nurse is caring for a patient who is disoriented and anxious as a result of increased intracranial pressure. Which of the following nursing actions should be included in the plan of care?
- A. Encourage family members to remain at the bedside.
- B. Apply soft restraints to protect the patient from injury.
- C. Keep the room well lighted to improve patient orientation.
- D. Minimize contact with the patient to decrease sensory input
Correct Answer: A
Rationale: Patients with disorientation as a result of increased ICP will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications; the use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim.
A patient with a head injury opens his or her eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. Which of the following Glasgow Coma Scale scores should the nurse document?
- A. 9
- B. 15
- C. 13
- D. 3
Correct Answer: B
Rationale: The patient has a score of 3 for eye opening (to verbal stimulation), 3 for best verbal response (inappropriate words/cursing), and 5 for best motor response (localizes pain). Total score: 3 + 3 + 5 = 11. However, the provided options include 15, which seems incorrect based on standard Glasgow Coma Scale scoring. Assuming a possible error in the original document, the closest logical score based on the description should be calculated, but none match perfectly. The answer 'B' (15) is selected as per the document, though it may reflect an inconsistency.