Exam 59: Nursing Management Acute Intracranial Problems

The charge nurse observes an inexperienced staff nurse who is caring for a client who has had a craniotomy for a brain tumour. Which of the following actions by the inexperienced nurse requires the charge nurse to intervene?

The nurse is caring for a client with a head injury. Which of the following findings should be reported rapidly to the health care provider?

The nurse is caring for a client with a head injury and has admission vital signs of blood pressure 128/68 mm Hg, pulse 110 beats/minute, and respirations 26/minute. Which of these vital signs, if taken 1 hour after admission, will be of most concern tothenurse?

The nurse is caring for a client with possible cerebral edema who has a serum sodium level of 115 mmol/L, a decreasing level of consciousness (LOC), and has a headache. Which of the following prescribed interventions should the nurse implement first?

Aclient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which of the following nursing interventions should be included in the plan of care?

The nurse is admitting a client to the emergency department (ED) who is unconscious following a head injury. The client's spouse and children stay at the client's side and constantly ask about the treatment being given. What of the following actions is bestfor the nurse to take?

The nurse is providing discharge teaching with a client who has a concussion. Which of the following time frames should the nurse tell the client to continue to monitor for post-concussion syndrome?

Which of the following parameters is best for the nurse to monitor to determine whether the prescribed IV mannitol has been effective for an unconscious client?

The nurse is admitting a client who has a tumour of the right frontal lobe. Which of the following findings should the nurse expect to observe?

The nurse is caring for a client admitted with bacterial meningitis who has atemperature of 38.9C (102F) and has prescriptions for all of the following collaborative interventions. Which action should the nurse take first?

The nurse is assessing a client who is unconscious and applies a painful stimulus to the nail beds. The client responds with internal rotation, adduction, and flexion of the arms. Which of the following terms should the nurse use when documenting the findings?

A client who is suspected of having an epidural hematoma is admitted to the emergency department. Which of the following actions should the nurse plan to take?

The nurse is admitting a client with a basal skull fracture and notes clear drainage from the client's nose. Which of these admission orders should the nurse's question?

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

The nurse is caring for a client with a head injury who has clear nasal drainage. Which of the following actions should the nurse take?

The nurse is caring for a client who has a head injury and is diagnosed with a concussion. Which of the following actions should the nurse plan to take?

Which of the following statements by a client who is being discharged from the emergency department (ED) after a head injury indicates a need for intervention by the nurse?

Aclient with a head injury opens his or her eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. Which of the following Glasgow Coma Scale scores should the nursedocument?

The nurse is monitoring a client's intracranial pressure (ICP) with an intraventricular catheter. Which of the following information obtained by the nurse is most important to communicate to the health care provider?

The nurse is caring for a client following a craniectomy and left anterior fossae incision who has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. Which of the following is an appropriate nursingintervention?