Exam 53: Nursing Management: Acute Intracranial Problems

Which finding for a patient who has a head injury should the nurse report immediately to the health care provider?

The nurse is admitting a patient with a basal skull fracture.The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose.Which admission order should the nurse question?

A 68-year-old male patient is brought to the emergency department (ED)by ambulance after being found unconscious on the bathroom floor by his spouse.Which action will the nurse take first?

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP)of 106/52 mm Hg and an intracranial pressure (ICP)of 14 mm Hg.Which action should the nurse take first?

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department.Which action prescribed by the health care provider should the nurse question?

The nurse has administered prescribed IV mannitol (Osmitrol)to an unconscious patient.Which parameter should the nurse monitor to determine the medication's effectiveness?

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring.Which response by the nurse is best?

The nurse admitting a patient who has a right frontal lobe tumor would expect the patient may have

A patient has increased intracranial pressure and a ventriculostomy after a head injury.Which action can the nurse delegate to unlicensed assistive personnel (UAP)who regularly work in the intensive care unit?

An unconscious patient with a traumatic head injury has a blood pressure of 130/76 mm Hg,and an intracranial pressure (ICP)of 20 mm Hg.The nurse will calculate the cerebral perfusion pressure (CPP)as ____ mm Hg.

A 42-year-old patient who has bacterial meningitis is disoriented and anxious.Which nursing action will be included in the plan of care?

A 46-year-old 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 push away a painful stimulus.The nurse records the patient's Glasgow Coma Scale score as

After endotracheal suctioning,the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 17 mm Hg.Which action should the nurse take first?

When assessing a 53-year-old patient with bacterial meningitis,the nurse obtains the following data.Which finding should be reported immediately to the health care provider?

A 23-year-old patient who is suspected of having an epidural hematoma is admitted to the emergency department.Which action will the nurse plan to take?

During change-of-shift report,the nurse learns that a patient with a head injury has decorticate posturing to noxious stimulation.Which positioning shown in the accompanying figure will the nurse expect to observe?

A 41-year-old patient who is unconscious 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?

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness?

A 20-year-old male patient is admitted with a head injury after a collision while playing football.After noting that the patient has developed clear nasal drainage,which action should the nurse take?

Which statement by a 40-year-old patient who is being discharged from the emergency department (ED)after a concussion indicates a need for intervention by the nurse?