Question

ques :

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?

Select one:

a. Type and crossmatch for blood transfusion.

b. Initiate high-dose barbiturate therapy.

c. Administer IV furosemide (Lasix).

d. Prepare the patient for craniotomy.

ques :

After sustaining an ABI, 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

Select one:

a. turn and reposition the patient side to side every 2 hours.

b. cluster nursing activities to allow longer rest periods.

c. perform range-of-motion (ROM) exercises every 4 hours.

d. position the bed flat and log roll to reposition the patient.

ques :

The nurse is caring for an older adult patient who was admitted to the hospital following a closed head injury that resulted in a 5-minute period of unconsciousness. The nurse most carefully monitors the patient for which change?

Select one:

a. Decreasing heart rate

b. Decreasing level of consciousness (LOC)

c. Decreasing pulse pressure

d. Increasing respiratory rate

ques :

The nurse is caring for a patient with a neurologic injury who is awake. On assessment, the patient displays mild disorientation to surroundings and time and needs additional verbal cues to stimulate response to commands. The nurse correctly documents the patient’s level of consciousness (LOC) by using which term?

Select one:

a. Confused

b. Lethargic

c. Obtunded

d. Alert

Answer 1

1. Answer is D prepare the patient for craniotomy. In Epidural hematoma, hematoma that form between dura and skull and thus result in compression of meningeal artery and leads to arterial bleeding. Due to compression of meningeal artery epidural hematoma is surgical emergency were craniotomy to be done immediately to prevent further complication.

Type and crossmatch for blood transfusion is not necessary in Epidural hematoma because blood loss is not as severe so it is not the correct answer.

Initiate high dose barbiturate therapy and administer IV furosemide is the management for increased ICP if epidural hematoma is not resolved by craniotomy it leads to a complication of increased intracranial pressure. So it is not the answer.

2. Answer is A turn and reposition the patient side to side every 2 hours. Due to decresed level of consciousness patient has impaired physical mobility to improve blood circulation, reduce pressure, prevent skin breakdown reposition every 2 hours to be done.

Cluster nursing activity to allow longer rest periods is not the correct answer because longer rest period without any passive exercise or repositioning will cause skin breakdown and bedsore due to pressure.

Perform range of motion exercise every 4 hours is not the correct answer because due to decrease level of consciousness patient can't able to perform range of motion exercise.

Position the bed flat and log roll to reposition the patient is not the correct answer because log roll done to patient with spine injury.

3. Answer is D increased respiratory rate. Closed head injury result in 5 minutes period of unconsciousness occur due to impaired cerebral tissue perfusion ( reduce arterial blood flow ) were it leads to respiratory depression. Respiratory depression leads to cerebral edema and increased intracranial pressure to prevent life threatening complication respiratory rate to to monitor carefully.

Decrease heart rate is not the answer compare to option D.

Decrease level of consciousness is not the correct answer because it is the late sign first respiratory rate to be monitored.

Decreasing pulse pressure is not the answer because widened pulse pressure is seen.

4. Answer is A confused. The term disoriented means the patient is confused.

Lethargic means drowsiness were patient aroused by moderate stimulus and get back to sleep. So it is not the answer.

Obtunded is similar as lethargy. Patient has slow response to stimulus and will sleep more than normal and sleep with drowsiness. So it is not the answer.

Alert termed as patient is well oriented to time, place.