NR 464 Acute Intracranial Problems Questions With
Complete Solutions
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, what action should the nurse
take? Correct Answers Check the drainage for glucose content.
Clear nasal drainage in a patient with a head injury suggests a
dural tear and cerebrospinal fluid (CSF) leakage. If the drainage
is CSF, it will test positive for glucose.
A 23-year-old patient who is suspected of having an epidural
hematoma is admitted to the emergency department. What
action will the nurse plan to take? Correct Answers Prepare
the patient for craniotomy.
RATIONAL: The principal treatment for epidural hematoma is
rapid surgery to remove the hematoma and prevent herniation.
A 41-year-old patient who is unconscious has a nursing
diagnosis of ineffective cerebral tissue perfusion related to
cerebral tissue swelling. How should the nurse position the bed?
Correct Answers Keep the head of the bed elevated to 30
degrees.
The patient with increased intracranial pressure (ICP) should be
maintained in the head-up position to help reduce ICP.
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 Correct Answers 11
The patient has a score of 3 for eye opening, 3 for best verbal
response, and 5 for best motor response.
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. What 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. Correct
Answers Check OxygenAirway patency and breathing are the
most vital functions, and should be assessed first. The
neurologic assessments should be accomplished next and
additional assessment after that.
DIF: Cognitive Level: Apply (application) REF: 1372
OBJ: Special Questions: Prioritization TOP: Nursing Process:
Assessment
MSC: NCLEX: Physiological Integrity
A college athlete is seen in the clinic 6 weeks after a concussion.
What assessment information will the nurse collect to determine
whether a patient is developing postconcussion syndrome?
Complete Solutions
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, what action should the nurse
take? Correct Answers Check the drainage for glucose content.
Clear nasal drainage in a patient with a head injury suggests a
dural tear and cerebrospinal fluid (CSF) leakage. If the drainage
is CSF, it will test positive for glucose.
A 23-year-old patient who is suspected of having an epidural
hematoma is admitted to the emergency department. What
action will the nurse plan to take? Correct Answers Prepare
the patient for craniotomy.
RATIONAL: The principal treatment for epidural hematoma is
rapid surgery to remove the hematoma and prevent herniation.
A 41-year-old patient who is unconscious has a nursing
diagnosis of ineffective cerebral tissue perfusion related to
cerebral tissue swelling. How should the nurse position the bed?
Correct Answers Keep the head of the bed elevated to 30
degrees.
The patient with increased intracranial pressure (ICP) should be
maintained in the head-up position to help reduce ICP.
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 Correct Answers 11
The patient has a score of 3 for eye opening, 3 for best verbal
response, and 5 for best motor response.
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. What 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. Correct
Answers Check OxygenAirway patency and breathing are the
most vital functions, and should be assessed first. The
neurologic assessments should be accomplished next and
additional assessment after that.
DIF: Cognitive Level: Apply (application) REF: 1372
OBJ: Special Questions: Prioritization TOP: Nursing Process:
Assessment
MSC: NCLEX: Physiological Integrity
A college athlete is seen in the clinic 6 weeks after a concussion.
What assessment information will the nurse collect to determine
whether a patient is developing postconcussion syndrome?
