Exam 57: Nursing Management: Acute Intracranial Problems

A patient who has bacterial meningitis and is disoriented and anxious has a nursing diagnosis of disturbed sensory perception related to decreased level of consciousness. An appropriate nursing intervention is to

A patient with a severe head injury has been maintained on IV fluids of 5% dextrose in water (D₅W) at 50 ml/hr for 3 days. The nurse will anticipate the need to

The health care provider prescribes IV mannitol (Osmitrol) for an unconscious patient. The nurse will determine that the medication is effective if

While admitting a patient with a basal skull fracture, the nurse notes clear drainage from the patient's nose. Which of these admission orders should the nurse question?

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

A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?

When caring for a patient who has had a head injury, which assessment information is of most concern to the nurse?

When assessing a patient with a head injury, the nurse recognizes that the earliest indication of increased intracranial pressure (ICP) is

Following a craniotomy with a craniectomy and left anterior fossae incision, the patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness (LOC) and weakness. An appropriate nursing intervention is to

The nurse identifies a nursing diagnosis of ineffective breathing pattern related to loss of central nervous system (CNS) integrative function for a patient who has posttraumatic brain swelling, based on the finding of

When admitting a patient who has a tumor of the right frontal lobe, the nurse would expect to find

In planning discharge for the patient following brain trauma, the nurse includes teaching and support for the family, primarily because

Family members are optimistic about a comatose patient's recovery because the patient's eyes open and the patient appears to be awake at times. Which statement by the nurse to the family is appropriate?

A patient with a brain tumor is receiving radiation after having had a craniotomy. The nurse will explain that the purpose of the ordered methylprednisolone (Solu-Medrol) is to

The nurse notes that a patient with a head injury has a clear nasal drainage. The most appropriate nursing action for this finding is to

Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a head injury. To evaluate the effectiveness of the therapy, the nurse should

Four days after a patient has undergone a craniotomy to remove an astrocytoma of the temporal lobe, the dressing is removed and the nurse finds the patient crying. The patient tells the nurse, "I look awful and feel even worse." The most appropriate nursing diagnosis for the patient is

A patient with increasing headaches who is having diagnostic testing for a brain tumor asks the nurse what type of treatment will be used if a tumor is discovered. Which response by the nurse is most appropriate?

A victim of an automobile accident was found unconscious at the scene of the accident but briefly regained consciousness during transport to the hospital. On admission, the Glasgow Coma Scale score is 8, and an acute epidural hematoma is suspected. The nurse will anticipate the need to

While caring for a patient who has just been admitted with meningococcal meningitis, the RN observes all of the following. Which one requires action by the RN?