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The nurse is admitting a patient with a basal skull fracture. The nurse notes
ecchymoses around both
eyes and clear drainage from the patients 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.ANS:
B
Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage.
Insertion of a nasogastric
tube will increase the risk for infections such as meningitis. Turning
the patient, elevating the head, andapplying cold packs are
appropriate orders.
2. 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 lightANS: A
Decreased short-term memory is one indication of postconcussion
syndrome. The other data may be
assessed but are not indications of postconcussion syndrome.
3. 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.
ANS: B
The frontal lobe controls intellectual activities such as judgment. Speech is
controlled in the parietal lobe.
Weakness and hemiplegia occur on the contralateral side from
the tumor. Swallowing is controlled by thebrainstem.
4. 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.ANS: B
Following a head injury, the patient should avoid driving and operating heavy
machinery.
Retrograde
amnesia is common after a concussion. The patient can take
acetaminophen for headache and shouldreturn if symptoms of
increased intracranial pressure such as dizziness or nausea occur.
5. 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.ANS: D
ROM exercises will help prevent the complications of immobility. Patients with
anterior craniotomies are
positioned with the head elevated. The patient with a craniectomy
should not be turned to the operativeside. When the patient is weak,