Nursing Actions and Patient Care in Traumatic Brain Injury, Exams of Nursing

Download Nursing Actions and Patient Care in Traumatic Brain Injury and more Exams Nursing in PDF only on Docsity! Chapter 14 Bank and Evolve examination test 2024 with correct  The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5°. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patient's plan of care? o Frequent neurological assessments o Side to side position changes o Range of motion to extremities o Frequent oropharyngeal suctioning - AnswersA  A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. Her blood pressure is 144/90 mm Hg, and her mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)? o 54 mm Hg o 72 mm Hg o 90 mm Hg o 126 mm Hg - AnswersC  While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse? o Both pressures are high. o Both pressures are low. o ICP is high; CPP is normal. o ICP is high; CPP is low. - AnswersC  The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse? o Hyperoxygenate during endotracheal suctioning. o Elevate the patient's head of the bed 30 degrees. o Apply bilateral heel protectors after repositioning. o Provide rest periods between nursing interventions. - AnswersD  While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient's left naris. What is the best nursing action? o Have the patient blow the nose until clear. o Insert bilateral cotton nasal packing. o Place a nasal drip pad under the nose. o Suction the left nares until the drainage clears. - AnswersC  The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action? o Stimulate the patient hourly. o Continue to monitor the patient. o Elevate the head of the bed. o Notify the physician immediately. - AnswersD  The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse requires further action? o ICP of 10 mm Hg o CPP of 70 mm Hg o GCS score of 5 o CVP of 2 mm Hg - AnswersD  The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow? o Altered cerebral spinal fluid production and reabsorption o Decreased cerebral blood volume due to vessel constriction o Increased cerebral blood volume due to vessel dilation o No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal) - AnswersC  The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action? o Monitor the patient's airway patency. o Elevate the head of the patient's bed.  The physician has opted to treat a patient with a complete spinal cord injury with glucocorticoids. The physician orders 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/min for 23 hours. What is the total 24-hour dose for the 70-kg patient? o 2478 mg o 5000 mg o 10,794 mg o 12,750 mg - AnswersC  The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which physician order should the nurse institute first? o Mannitol 1 g intravenous o Portable chest x-ray o Seizure precautions o Ancef 1 g intravenous - AnswersA  The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5° F. Which physician order should the nurse institute first? o Blood cultures (2 specimens) for temperature > 101° F o Acetaminophen (Tylenol) 650 mg per rectum o 500 mL albumin infusion intravenously o Decadron 20 mg intravenous push every 4 hours - AnswersC  The nurse, caring for a patient following a subarachnoid hemorrhage, begins a nicardipine (Cardene) infusion. Baseline blood pressure assessed by the nurse is 170/100 mm Hg. Five minutes after beginning the infusion at 5 mg/hr, the nurse assesses the patient's blood pressure to be 160/90 mm Hg. What is the best action by the nurse? o Stop the infusion for 5 minutes. o Increase the dose by 2.5 mg/hr. o Notify the physician of the BP. o Begin weaning the infusion. - AnswersB  The nurse is preparing to administer a routine dose of phenytoin (Dilantin). The physician orders phenytoin (Dilantin) 500 mg intravenous every 6 hours. What is the best action by the nurse? o Administer over 2 minutes. o Administer with 0.9% normal saline intravenous. o Contact the physician. o Assess cardiac rhythm. - AnswersC  The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an intravenous (IV) line, which order by the physician should the nurse implement first? o Obtain stat serum electrolytes. o Administer lorazepam (Ativan). o Obtain stat portable chest x-ray. o Administer phenytoin (Dilantin). - AnswersB  The physician orders fosphenytoin (Cerebyx), 1.5 g intravenous (IV) loading dose for a 75-kg patient in status epilepticus. What is the most important action by the nurse? o Contact the admitting physician. o Administer drug over 10 minutes. o Mix medication with 0.9% normal saline. o Administer via central line. - AnswersB  The nurse is to administer 100 mg phenytoin (Dilantin) intravenous (IV). Vital signs assessed by the nurse include blood pressure 90/60 mm Hg, heart rate 52 beats/min, respiratory rate 18 breaths/min, and oxygen saturation (SpO2) 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the best action by the nurse? o Administer over 2 minutes. o Administer over 5 minutes. o Mix medication with 0.9% normal saline. o Administer via central line. - AnswersB  The nurse is preparing to administer 100 mg of phenytoin (Dilantin) to a patient in status epilepticus. To prevent patient complications, what is the best action by the nurse? o Ensure patency of intravenous (IV) line. o Mix drug with 0.9% normal saline. o Evaluate serum K+ level. o Obtain an IV infusion pump. - AnswersA  The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm. Assessment by the nurse notes blood pressure 90/60 mm Hg, heart rate 115 beats/min, respiratory rate 28 breaths/min, oxygen saturation (SpO2) 99% on supplemental oxygen at 3L/min by cannula, a Glasgow Coma Score of 4, and a central venous pressure (CVP) of 2 mm Hg. After reviewing the physician orders, which order is of the highest priority? o Lasix 20 mg intravenous push as needed o 500 mL albumin intravenous infusion o Decadron 10 mg intravenous push o Dilantin 50 mg intravenous push - AnswersB  After receiving the hand-off report from the day shift charge nurse, which patient should the evening charge nurse assess first? o A patient with meningitis complaining of photophobia o A mechanically ventilated patient with a GCS of 6 o A patient with bacterial meningitis on droplet precautions o A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104° F - AnswersD  The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse? o Implement droplet precautions upon admission. o Wash hands thoroughly before leaving the room. o Scrub the hub of all central line ports prior to use. o Dispose of all bloody dressings in biohazard bags. - AnswersA  The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min, oxygen saturation (SpO2) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5° F. What is the priority nursing action? o Elevate the head of the bed 30 degrees. o Keep lights dim at all times. o Implement seizure precautions. o Maintain bedrest at all times. - AnswersC  The nurse is preparing to monitor intracranial pressure (ICP) with a fluid-filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.) o Use of a heparin flush solution ventriculostomy system is blood tinged. What is the best interpretation of this finding by the nurse?  Cerebral aneurysms commonly rupture in the subarachnoid space.  This assessment finding is indicative of developing cerebral meningitis.  Patient movement has resulted in dislodgement of the catheter.  Normal cerebral spinal fluid contains a small amount of visible blood. - AnswersA  The nurse is caring for a patient admitted with a spinal cord injury. Upon assessment, the nurse notes a complete loss of motor and sensory function below the patients nipple line. What is the best understanding of this assessment finding by the nurse?  Anterior cord lesion  Central cord lesion.  Complete cord lesion.  Brown-Séquard syndrome - AnswersC  The nurse is preparing to admit a patient from the ED who has sustained a complete spinal cord lesion at the C5 level. When planning the patients care, which nursing intervention is most important?  Perform hourly incentive spirometry.  warming devices as needed.  Give small, frequent feedings.  with passive range of motion. - AnswersA  The nurse is caring for a patient with an assessed Glasgow Coma Scale score of 3. What is the best understanding of this finding?  Coma scale score is a direct result of dysfunction of the cerebellum.  Damage to the patient's corpus callosum has led to a comatose state.  A Glasgow Coma Scale score of less than 3 indicates a semi- comatose state.  There is impairment of the reticular activating system (RAS), resulting in coma. - AnswersD  Autonomic dysreflexia is characterized by an exaggerated response of the sympathetic nervous system to a variety of stimuli. Common causes of autonomic dysreflexia include: (Select all that apply.)  bladder distention.  fecal impaction.  sinus bradycardia.  urinary tract infection. - AnswersA, B  Which statements best represent optimal fluid administration for the management of increased intracranial pressure? (Select all that apply.)  Normal saline (0.9%) is recommended for fluid volume resuscitation.  The goal is to keep serum osmolality greater than 320 mOsm/L.  0.45% saline solution is acceptable for fluid volume resuscitation.  Hypotonic solutions are avoided to prevent an increase in cerebral edema. - AnswersA, D