Exam 56: Acute Intracranial Problems

Which information about a 30-yr-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse?

Which statement by patient who is being discharged from the emergency department (ED)after a concussion indicates a need for intervention by the nurse?

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action?

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question?

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

After evacuation of an epidural hematoma,a patient's intracranial pressure (ICP)is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider?

The public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is most likely to be effective?

When assessing a 53-yr-old patient with bacterial meningitis,the nurse obtains the following data. Which finding requires the most immediate intervention?

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best for this situation?

A patient with increased intracranial pressure after a head injury has a ventriculostomy in place. Which action can the nurse delegate to unlicensed assistive personnel (UAP)who regularly work in the intensive care unit?

Admission vital signs for a brain-injured patient are blood pressure of 128/68 mm Hg,pulse of 110 beats/min,and of respirations 26 breaths/min. Which set of vital signs,if taken 1 hour later,will be of most concern to the nurse?

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding indicates a possible complication that should be reported to the health care provider?

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether the patient is developing postconcussion syndrome?

The nurse is caring for a patient who has a head injury. Which finding,when reported to the health care provider,should the nurse expect will result in new prescribed interventions?

While admitting a 42-yr-old patient with a possible brain injury after a car accident to the emergency department (ED),the nurse obtains the following information. Which finding is most important to report to the health care provider?

A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse expect to take?

A patient with a head injury opens his 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

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?

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?

Which patient is most appropriate for the intensive care unit (ICU)charge nurse to assign to a registered nurse (RN)who has floated from the medical unit?