Exam 57: Nursing Management: Acute Intracranial Problems

Which assessment finding in a patient who was admitted the previous day with a basilar skull fracture is most important to report to the health care provider?

After noting that a patient with a head injury has clear nasal drainage, which action should the nurse take?

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

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

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

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

When a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter, which information obtained by the nurse is most important to communicate to the health care provider?

When admitting a patient with a possible coup-contrecoup injury after a car accident to the emergency department, the nurse obtains the following information. Which finding is most important to report to the health care provider?

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

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

Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome?

The nurse obtains these assessment findings for a patient who has a head injury. Which finding should be reported rapidly to the health care provider?

After suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 16 mm Hg. Which action should the nurse take first?

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

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 has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?

The care plan for a patient who has increased intracranial pressure and a ventriculostomy includes the following nursing actions. Which action can the nurse delegate to nursing assistive personnel (NAP) who regularly work in the intensive care unit?

When caring for a patient who has had a head injury, which assessment information requires the most rapid action by the nurse?

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 who has a head injury is diagnosed with a concussion. Which action will the nurse plan to take?