Exam 57: Nursing Management: Acute Intracranial Problems

The public health nurse is planning a program to decrease the incidence of meningitis in adolescents and young adults.Which action is most important?

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness?

Which finding for a patient who has a head injury should the nurse report immediately to the health care provider?

The nurse is admitting a patient with a basal skull fracture.The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose.Which admission order should the nurse question?

During change-of-shift report,the nurse learns that a patient with a head injury has decorticate posturing to noxious stimulation.Which positioning shown in the accompanying figure will the nurse expect to observe?

A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling.Which nursing intervention will be included in the plan of care?

After endotracheal suctioning,the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 17 mm Hg.Which action should the nurse take first?

A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C)and a severe headache.Which order for collaborative intervention should the nurse implement first?

Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community?

The nurse has administered prescribed IV mannitol (Osmitrol)to an unconscious patient.Which parameter should the nurse monitor to determine the medication's effectiveness?

When a brain-injured patient responds to nail bed pressure with internal rotation,adduction,and flexion of the arms,the nurse reports the response as

A 20-year-old male patient is admitted with a head injury after a collision while playing football.After noting that the patient has developed clear nasal drainage,which action should the nurse take?

A 46-year-old patient with a head injury opens the eyes to verbal stimulation,curses when stimulated,and does not respond to a verbal command to move but attempts to push away a painful stimulus.The nurse records the patient's Glasgow Coma Scale score as

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries,which patient should the nurse assess first?

A 68-year-old male patient is brought to the emergency department (ED)by ambulance after being found unconscious on the bathroom floor by his spouse.Which action will the nurse take first?

A 42-year-old patient who has bacterial meningitis is disoriented and anxious.Which nursing action will be included in the plan of care?

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP)of 106/52 mm Hg and an intracranial pressure (ICP)of 14 mm Hg.Which action should the nurse take first?

A 23-year-old patient who is suspected of having an epidural hematoma is admitted to the emergency department.Which action will the nurse plan to take?

When assessing a 53-year-old patient with bacterial meningitis,the nurse obtains the following data.Which finding should be reported immediately to the health care provider?

To assess for functional deficits,which question will the nurse ask a patient who has been admitted for treatment of a benign occipital lobe tumor?