A 58-year-old male is brought to the Emergency Room after receiving a blow to the head with a bat in a local barroom brawl.
Witnesses report that the patient was unconscious at the bar after being hit, but recovered consciousness about 5 minutes later.
Now as you assess the patient, he appears to be falling asleep and is unable to verbally reply to your sentences.
What is your PRIORITY action?
Notify MD of potential emergency, prepare for possible burr-hole procedure.
Ensure patient is receiving adequate pain medication.
Place patient on nasal cannula at 2 Lpm.
Stop patient assessment and obtain a stat EKG.
The Correct Answer is A
Choice A rationale
The patient's initial unconsciousness, followed by a lucid interval and then declining consciousness (appearing to fall asleep, unable to verbally reply), is a classic presentation of an epidural hematoma. This condition requires immediate medical attention as expanding hematomas can lead to brain herniation. Notifying the MD and preparing for a burr-hole procedure to relieve intracranial pressure is the highest priority to prevent irreversible brain damage.
Choice B rationale
While pain management is important, it is not the priority in a patient with a rapidly deteriorating neurological status. Administering pain medication without addressing the underlying intracranial pathology could mask critical neurological signs and delay life-saving interventions. The immediate concern is the potential for brain compression, not comfort.
Choice C rationale
Placing the patient on a nasal cannula at 2 Lpm for a patient with deteriorating consciousness is insufficient and potentially inappropriate. If the patient's respiratory drive is compromised due to increased intracranial pressure, more aggressive airway management, potentially intubation, might be required. Oxygenation should be assessed and managed, but it is not the initial priority without evaluating the airway and breathing comprehensively in a declining patient.
Choice D rationale
Obtaining a stat EKG is not the priority action in a patient presenting with acute neurological deterioration following head trauma. While cardiac function is important, the immediate threat to life in this scenario is neurological compromise due to potential intracranial bleeding and rising intracranial pressure. An EKG would be a secondary assessment after stabilizing the primary neurological issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Cyanosis, a bluish discoloration of the skin and mucous membranes, is a late and ominous sign of hypoxia. It becomes clinically apparent when there are approximately 5 grams per deciliter of desaturated hemoglobin. This indicates a significant reduction in oxygen saturation and severe tissue hypoxia, representing a decompensated physiological state.
Choice B rationale
Bradycardia, a slower than normal heart rate (normal range 60-100 beats per minute for adults), is typically a late sign of hypoxia, particularly in adults. Initially, the body often compensates for hypoxia with tachycardia to increase cardiac output and oxygen delivery. Profound and prolonged hypoxia can depress myocardial function, leading to bradycardia.
Choice C rationale
Hypotension, a low blood pressure (normal range systolic 90-120 mmHg, diastolic 60-80 mmHg), is generally considered a late sign of hypoxia. In the early stages, the sympathetic nervous system may initially increase blood pressure as a compensatory mechanism. However, prolonged or severe hypoxia can lead to myocardial depression and vasodilation, resulting in hypotension.
Choice D rationale
Agitation is an early neurological sign of hypoxia. As oxygen levels decrease, cerebral hypoxia affects brain function, leading to irritability, restlessness, and confusion. The brain is highly sensitive to oxygen deprivation, and these behavioral changes are often among the first indicators of inadequate oxygenation, preceding more overt physiological decompensation.
Correct Answer is C
Explanation
Choice A rationale
Reverse Trendelenburg positions the patient with the head higher than the feet. While this can reduce venous pressure in the lower extremities, it is not the optimal position for infratentorial tumor resection as it may not adequately facilitate venous drainage from the posterior fossa and could increase pressure on the incision site.
Choice B rationale
Semi-Fowlers position, with the head of the bed elevated to 30-45 degrees, is often used for supratentorial surgeries to promote venous drainage. However, for infratentorial tumor removal, this position can put undue pressure on the operative site due to gravity, potentially leading to complications such as swelling and CSF leakage.
Choice C rationale
Positioning the patient flat on their side is the recommended approach after infratentorial surgery. This position prevents pressure on the incision site and promotes optimal venous and cerebrospinal fluid drainage from the posterior fossa. It also helps to prevent complications such as tentorial herniation and brainstem compression.
Choice D rationale
High Fowlers position, with the head of the bed elevated to 60-90 degrees, is generally contraindicated after infratentorial surgery. This position significantly increases pressure on the posterior fossa incision due to gravity and can compromise cerebral venous outflow, potentially leading to increased intracranial pressure and other neurological deficits.
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