Exam 57: Nursing Management: Acute Intracranial Problems

A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L), a decreasing level of consciousness (LOC) and complains of a headache. All of the following orders have been received. Which one should the nurse accomplish first?

A patient admitted with bacterial meningitis and a temperature of 102° F has orders for all of these collaborative interventions. Which one should the nurse accomplish first?

A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial pressure of 24 mm Hg. The nurse determines that the cerebral perfusion pressure (CPP) of this patient indicates

A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. In admitting the patient, the nurse will first assess

A patient with a head injury has an arterial blood pressure is 92/50 mm Hg and an intracranial pressure of 18 mm Hg. Which action by the nurse is appropriate?

When assessing a patient with bacterial meningitis, the nurse obtains all of the following information. Which should be reported immediately to the health care provider?

A patient is brought to the emergency department (ED) after being hit in the head with a baseball during a company picnic. On admission, the patient has a headache and cannot remember being hit but has no other signs of neurologic deficit. The nurse will plan to

When the nurse applies a painful stimulus to the nailbeds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as

Which of these patients is most appropriate for the intensive care unit (ICU) charge nurse to assign to an RN who has floated from the medical unit?

A 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 remove a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as

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

A patient is admitted unconscious to the emergency department (ED) after falling and hitting the head on a rock while hiking. The patient's spouse and children stay at the patient's side and constantly ask about the treatment being given. The nurse's best approach to the patient's family is to

When caring for a patient with a right-sided intracerebral hemorrhage, the nurse suspects possible supratentorial herniation and compression of the brainstem when the

An unconscious patient has a nursing diagnosis of ineffective tissue perfusion (cerebral) related to cerebral tissue swelling. An appropriate nursing intervention for this problem is to

When a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter, which of these data obtained during the assessment is most important to communicate to the health care provider?