Exam 57: Nursing Management: Acute Intracranial Problems

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?

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?

An unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care?

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?

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

An unconscious patient with a traumatic head injury has a blood pressure of 126/72 mm Hg, and an intracranial pressure of 18 mm Hg. The nurse will calculate the cerebral perfusion pressure as ____________________.

Following a head injury, an unconscious 32-year-old patient is admitted to the emergency department ( ED ). The patient's spouse and children stay at the patient's side and constantly ask about the treatment being given. What action is best for the nurse to take?

When family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring for a patient, which response by the nurse is best?

A patient with possible cerebral edema has a serum sodium level of 115 mEq/L ( 115 mmol/L ) and a decreasing level of consciousness ( LOC ) and complains of a headache. Which of these prescribed interventions should the nurse implement first?

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?

Which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol (Osmitrol) has been effective for an unconscious patient?

A patient with a head injury has admission vital signs of 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?

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

A patient is brought to the emergency department ( ED ) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first?

A patient admitted with bacterial meningitis and a temperature of 102° F ( 38.8° C ) has orders for all of these collaborative interventions. Which action should the nurse take first?