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
Bradycardia, a slow heart rate (typically below 60 beats per minute in adults), is a key component of Cushing's triad. It results from the body's compensatory response to increased intracranial pressure, where systemic hypertension triggers a reflex vagal response, leading to a decrease in heart rate.
Choice B rationale
Widening pulse pressure, defined as an increasing difference between systolic and diastolic blood pressure, is a hallmark of Cushing's triad. This occurs as the body attempts to maintain cerebral perfusion pressure by increasing systolic pressure against a relatively stable or slightly decreased diastolic pressure due to peripheral vasodilation.
Choice C rationale
Hypertension, specifically systolic hypertension, is a crucial component of Cushing's triad. It reflects the body's physiological attempt to overcome increased intracranial pressure and maintain adequate cerebral blood flow by increasing systemic arterial pressure, ensuring perfusion to the brain.
Choice D rationale
Hypothermia, a core body temperature below 35°C (95°F), is not a recognized component of Cushing's triad. Cushing's triad specifically describes a set of physiological responses to increased intracranial pressure: bradycardia, hypertension, and widening pulse pressure, all related to cardiovascular and respiratory regulation.
Correct Answer is D
Explanation
Choice A rationale
Metabolic acidosis is characterized by a primary reduction in serum bicarbonate, typically below 22 mmol/L, which drives the pH below the normal range of 7.35. While compensation mechanisms would involve a decrease in PaCO2, the provided arterial blood gas values demonstrate an elevated pH and elevated bicarbonate, which are inconsistent with metabolic acidosis.
Choice B rationale
Respiratory acidosis is primarily defined by an increase in arterial carbon dioxide (PaCO2), above the normal range of 45 mm Hg, leading to a decrease in blood pH below 7.35. Compensation would involve an increase in bicarbonate. The given values, particularly the elevated pH and normal PaCO2, do not align with the characteristics of respiratory acidosis.
Choice C rationale
Respiratory alkalosis is characterized by a primary decrease in PaCO2, below the normal range of 35 mm Hg, leading to an elevated pH above 7.45. Uncompensated means the bicarbonate level remains within the normal range of 22-26 mmol/L. The provided PaCO2 is within normal limits, and bicarbonate is elevated, which contradicts the criteria for respiratory alkalosis.
Choice D rationale
Metabolic alkalosis is characterized by a primary increase in serum bicarbonate (HCO3), typically above the normal range of 26 mmol/L, which results in an elevated blood pH above 7.45. Uncompensated metabolic alkalosis indicates that the PaCO2 remains within its normal range (35-45 mm Hg) as the respiratory system has not yet initiated or completed compensatory hypoventilation. The provided pH of 7.5, PaCO2 of 40 mm Hg, and HCO3 of 34 mmol/L precisely fit this definition.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.