Exam 56: Acute Intracranial Problems

A 68-yr-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?

An unconscious patient with a traumatic head injury has a blood pressure of 130/76 mm Hg and an intracranial pressure (ICP)of 20 mm Hg. The nurse will calculate the cerebral perfusion pressure (CPP)as ____ mm Hg.

After having a craniectomy and left anterior fossae incision,a 64-yr-old patient has impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to

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?

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

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

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

A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L)and a decreasing level of consciousness (LOC). He is now complaining of a headache. Which prescribed interventions should the nurse implement first?

A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care?

Which is the correct point on the accompanying figure where the nurse will assess for ecchymosis when admitting a patient with a basilar skull fracture?

An unconscious patient is admitted to the emergency department (ED)with a head injury. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment being given. What action is best for the nurse to take?

A 20-yr-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?

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

Which question will the nurse ask a patient who has been admitted with a benign occipital lobe tumor to assess for functional deficits?

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

The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires rapid action by the nurse?

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?

The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?

The nurse admitting a patient who has a right frontal lobe tumor would expect the patient may have