Nokea
Which of the following statements by a patient who is being discharged from the emergency department (ED) after a head injury indicates a need for intervention by the nurse?
- A. I will return if I feel dizzy or nauseated.
- B. I am going to drive home and go to bed.
- C. I do not even remember being in an accident.
- D. I can take acetaminophen for my headache.
Correct Answer: B
Rationale: Following a head injury, the patient should avoid operating heavy machinery. Retrograde amnesia is common after a concussion. The patient can take acetaminophen for headache and should return if symptoms of increased intracranial pressure such as dizziness or nausea occur.
You may also like to solve these questions
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.
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 caring for a patient with increased intracranial pressure (IICP). Which of the following are late signs of IICP? (Select all that apply.)
- A. Unilateral hemiparesis
- B. Papilledema
- C. Decorticate posturing
- D. Decerebrate posturing
- E. Hyperthermia
Correct Answer: C,D,E
Rationale: Late signs of IICP include decerebrate posturing, decorticate posturing, and hyperthermia. Unilateral hemiparesis and papilledema are early signs when the compensatory mechanism is intact.
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.
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.