Upgrade to remove ads
Only $35.99/year

MedSurg Ch. 57-TBI-Found on NCLEX

Terms in this set (37)

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?
a.
"This type of monitoring system is complex and it is managed by skilled staff."
b.
"The monitoring system helps show whether blood flow to the brain is adequate."
c.
"The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure."
d.
"This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage."
b. "the monitoring system helps show whether blood flow to the brain is adequate"
Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
a.
Blood pressure 154/68, pulse 56, respirations 12
b.
Blood pressure 134/72, pulse 90, respirations 32
c.
Blood pressure 148/78, pulse 112, respirations 28
d.
Blood pressure 110/70, pulse 120, respirations 30
a. blood pressure 154/68, pulse 56, respirations 12
When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as
a.
flexion withdrawal.
b.
localization of pain.
c.
decorticate posturing.
d.
decerebrate posturing.
c. decorticate posturing
The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness?
a.
Blood pressure
b.
Oxygen saturation
c.
Intracranial pressure
d.
Hemoglobin and hematocrit
c. intracranial pressure
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
a.
9.
b.
11.
c.
13.
d.
15.
b. 11
An unconscious 39-year-old male patient is admitted to the emergency department (ED) with a head injury. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment being given. What action is best for the nurse to take?
a.
Ask the family to stay in the waiting room until the initial assessment is completed.
b.
Allow the family to stay with the patient and briefly explain all procedures to them.
c.
Refer the family members to the hospital counseling service to deal with their anxiety.
d.
Call the family's pastor or spiritual advisor to take them to the chapel while care is given.
b. allow the family to stay with the patient and briefly explain the procedures to them
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?
a.
Encourage coughing and deep breathing.
b.
Position the patient with knees and hips flexed.
c.
Keep the head of the bed elevated to 30 degrees.
d.
Cluster nursing interventions to provide rest periods.
c. keep the head of the bed elevated to 30 degrees
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?
a.
Have the patient gently blow the nose.
b.
Check the drainage for glucose content.
c.
Teach the patient that rhinorrhea is expected after a head injury.
d.
Obtain a specimen of the fluid to send for culture and sensitivity.
b. check the drainage for glucose content
Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness?
a.
Coordinate the transfer of the patient to the operating room.
b.
Provide discharge instructions about monitoring neurologic status.
c.
Transport the patient to radiology for magnetic resonance imaging (MRI).
d.
Arrange to admit the patient to the neurologic unit for 24 hours of observation.
b. provide discharge instructions about monitoring neurologic status
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?
a.
Administer IV furosemide (Lasix).
b.
Prepare the patient for craniotomy.
c.
Initiate high-dose barbiturate therapy.
d.
Type and crossmatch for blood transfusion.
b. prepare the patient for craniotomy
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.
Keep the head of bed elevated.
b.
Insert nasogastric tube to low suction.
c.
Turn patient side to side every 2 hours
d.
Apply cold packs intermittently to face.
b. insert nasogastric tube to low suction
A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome?
a.
Short-term memory
b.
Muscle coordination
c.
Glasgow Coma Scale
d.
Pupil reaction to light
a. short term memory
The nurse admitting a patient who has a right frontal lobe tumor would expect the patient may have
a.
expressive aphasia.
b.
impaired judgment.
c.
right-sided weakness.
d.
difficulty swallowing.
b. impaired judgement
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?
a.
"I will return if I feel dizzy or nauseated."
b.
"I am going to drive home and go to bed."
c.
"I do not even remember being in an accident."
d.
"I can take acetaminophen (Tylenol) for my headache."
b. i am going to drive home and go to bed
After having a craniectomy and left anterior fossae incision, a 64-year-old patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to
a.
cluster nursing activities to allow longer rest periods.
b.
turn and reposition the patient side to side every 2 hours.
c.
position the bed flat and log roll to reposition the patient.
d.
perform range-of-motion (ROM) exercises every 4 hours.
d. perform ROM exercises every 4 hours
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.
Encourage family members to remain at the bedside.
b.
Apply soft restraints to protect the patient from injury.
c.
Keep the room well-lighted to improve patient orientation.
d.
Minimize contact with the patient to decrease sensory input.
a. encourage family members to remain at the beside
The public health nurse is planning a program to decrease the incidence of meningitis in adolescents and young adults. Which action is most important?
a.
Encourage adolescents and young adults to avoid crowds in the winter.
b.
Vaccinate 11- and 12-year-old children against Haemophilus influenzae.
c.
Immunize adolescents and college freshman against Neisseria meningitides.
d.
Emphasize the importance of hand washing to prevent the spread of infection.
c. immunize adolescents and college freshmen against Neisseria meningtides
A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action?
a.
The bedrails at the head and foot of the bed are both elevated.
b.
The patient receives a regular diet from the dietary department.
c.
The lights in the patient's room are turned off and the blinds are shut.
d.
Unlicensed assistive personnel enter the patient's room without a mask.
d. UAP assistive personnel enter the patient's room without a mask
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.
The patient exhibits nuchal rigidity.
b.
The patient has a positive Kernig's sign.
c.
The patient's temperature is 101° F (38.3° C).
d.
The patient's blood pressure is 88/42 mm Hg.
d. the patient's blood pressure is 88/42 mm Hg
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.
Document the BP and ICP in the patient's record.
b.
Report the BP and ICP to the health care provider.
c.
Elevate the head of the patient's bed to 60 degrees.
d.
Continue to monitor the patient's vital signs and ICP
b. resport the bp and icp to the health care provider
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?
a.
Document the increase in intracranial pressure.
b.
Ensure that the patient's neck is in neutral position.
c.
Notify the health care provider about the change in pressure.
d.
Increase the rate of the prescribed propofol (Diprivan) infusion.
b. ensure that the patient's neck is in neutral position
Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit?
a.
A 45-year-old receiving IV antibiotics for meningococcal meningitis
b.
A 25-year-old admitted with a skull fracture and craniotomy the previous day
c.
A 55-year-old who has increased intracranial pressure (ICP) and is receiving hyperventilation therapy
d.
A 35-year-old with ICP monitoring after a head injury last week
a. a 45 y.o. receiving IV antibiotics for meningococcal meningitis
A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now complaining of a headache. Which prescribed interventions should the nurse implement first?
a.
Administer IV 5% hypertonic saline.
b.
Draw blood for arterial blood gases (ABGs).
c.
Send patient for computed tomography (CT).
d.
Administer acetaminophen (Tylenol) 650 mg orally.
a. administer IV 5% hypertonic saline
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?
a.
A 20-year-old patient whose cranial x-ray shows a linear skull fracture
b.
A 30-year-old patient who has an initial Glasgow Coma Scale score of 13
c.
A 40-year-old patient who lost consciousness for a few seconds after a fall
d.
A 50-year-old patient whose right pupil is 10 mm and unresponsive to light
d. a 50 y.o. patient whose right pupil is 10 mm and unresponsive to light
The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding is most important to report to the health care provider?
a.
Complaint of severe headache
b.
Large contusion behind left ear
c.
Bilateral periorbital ecchymosis
d.
Temperature of 101.4° F (38.6° C)
d. temperature of 101.4
After evacuation of an epidural hematoma, 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?
a.
Pulse 102 beats/min
b.
Temperature 101.6° F
c.
Intracranial pressure 15 mm Hg
d.
Mean arterial pressure 90 mm Hg
b. temperature 101.6
The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?
a.
The staff nurse assesses neurologic status every hour.
b.
The staff nurse elevates the head of the bed to 30 degrees.
c.
The staff nurse suctions the patient routinely every 2 hours.
d.
The staff nurse administers an analgesic before turning the patient.
c. the staff nurse suctions the patient routinely every 2 hours
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.
Check oxygen saturation.
b.
Assess pupil reaction to light.
c.
Verify Glasgow Coma Scale (GCS) score.
d.
Palpate the head for hematoma or bony irregularities.
a. check oxygen saturation
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?
a.
Document intracranial pressure every hour.
b.
Turn and reposition the patient every 2 hours.
c.
Check capillary blood glucose level every 6 hours.
d.
Monitor cerebrospinal fluid color and volume hourly.
c. check capillary blood glucose level every 6 hours
Which information about a 30-year-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse?
a.
Intracranial pressure of 15 mm Hg
b.
Cerebrospinal fluid (CSF) drainage of 25 mL/hour
c.
Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg
d.
Cardiac monitor shows sinus tachycardia at 128 beats/minute
c. pressure of oxygen in brain tissue is 14 mm Hg
The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires the most rapid action by the nurse?
a.
The apical pulse is slightly irregular.
b.
The patient complains of a headache.
c.
The patient is more difficult to arouse.
d.
The blood pressure (BP) increases to 140/62 mm Hg.
c. the patient is more difficult arouse
Which finding for a patient who has a head injury should the nurse report immediately to the health care provider?
a.
Intracranial pressure is 16 mm Hg when patient is turned.
b.
Pale yellow urine output is 1200 mL over the last 2 hours.
c.
LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.
d.
Ventriculostomy drained 40 mL of cerebrospinal fluid in the last 2 hours.
b. pale yellow urine output is 1200 mL over the last 2 hours
When admitting a 42-year-old patient with a possible brain injury after a car accident to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider?
a.
The patient takes warfarin (Coumadin) daily.
b.
The patient's blood pressure is 162/94 mm Hg.
c.
The patient is unable to remember the accident.
d.
The patient complains of a severe dull headache.
a. the patient takes wafarin daily
A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order for collaborative intervention should the nurse implement first?
a.
Administer ceftizoxime (Cefizox) 1 g IV.
b.
Give acetaminophen (Tylenol) 650 mg PO.
c.
Use a cooling blanket to lower temperature.
d.
Swab the nasopharyngeal mucosa for cultures.
d. swab the nasopharyngeal mucosa for cultures
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?
a.
Elevate the head of the bed 20 degrees.
b.
Restrict oral fluids to 1000 mL daily.
c.
Administer ceftriaxone (Rocephin) 1 g IV every 12 hours.
d.
Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache.
b. restrict oral fluids to 1000 mL daily
Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community?
a.
Encourage the use of effective insect repellents during mosquito season.
b.
Remind patients that most cases of viral encephalitis can be cared for at home.
c.
Teach about the importance of prophylactic antibiotics after exposure to encephalitis.
d.
Arrange for screening of school-age children for West Nile virus during the school year.
a. encourage the use of effective insect repellents during mosquito season
To assess for functional deficits, which question will the nurse ask a patient who has been admitted for treatment of a benign occipital lobe tumor?
a.
"Do you have difficulty in hearing?"
b.
"Are you experiencing visual problems?"
c.
"Are you having any trouble with your balance?"
d.
"Have you developed any weakness on one side?"
b. are you experiencing visual problems?
Students also viewed