A patient presents to the emergency department with signs of an epidural hematoma. Which manifestation is characteristic of this type of hematoma?

Loss of consciousness greater than 30 minutes following injury.

Lucid intervals followed by momentary unconsciousness.

Memory loss of the prior day's activities.

Amnesia of the injury event.

Answer and Explanation

The Correct Answer is B

Choice A reason:

Loss of consciousness greater than 30 minutes following injury can occur in various types of head injuries but is not specific to epidural hematomas.

Choice B reason:

Lucid intervals followed by momentary unconsciousness are characteristic of epidural hematomas. Patients with epidural hematomas often experience a period of lucidity following the initial loss of consciousness, followed by a rapid decline in mental status as the hematoma enlarges and increases intracranial pressure.

Choice C reason:

Memory loss of the prior day's activities can occur with various head injuries but is not specific to epidural hematomas.

Choice D reason:

Amnesia of the injury event is common in head injuries but is not specific to epidural hematomas. The hallmark of epidural hematomas is the pattern of lucid intervals followed by rapid deterioration.

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Correct Answer is B,A,C

Explanation

Choice A reason:

Completing a Glasgow Coma Scale assessment is crucial in evaluating the neurological status of a patient with a suspected traumatic cervical spine injury. However, it should be done after ensuring that there is no uncontrolled bleeding.

Choice B reason:

Applying pressure to any areas of uncontrolled bleeding is the highest priority. Controlling bleeding is essential to prevent hypovolemic shock and maintain hemodynamic stability, which takes precedence over other assessments and interventions.

Choice C reason:

Placing an indwelling Foley catheter to monitor urine output is important for ongoing assessment of renal function and fluid balance. However, it is not the immediate priority compared to controlling bleeding and assessing neurological status.

A. Elevate the head of the bed immediately and notify the provider B. Administer PRN tylenol for the patient's headache C. Recheck all of the patient's vital signs D. Elevate the patient's knees and lower the head of the bed

Correct Answer is A

Explanation

Choice A reason:

Elevating the head of the bed and notifying the provider is the correct initial action when a patient with a spinal cord lesion at T4 experiences a significantly elevated blood pressure (190/100), headache, and flushing. These symptoms suggest autonomic dysreflexia, a potentially life-threatening condition that requires immediate intervention. Elevating the head of the bed helps to lower blood pressure, and notifying the provider ensures that further medical treatment can be administered promptly.

Choice B reason:

Administering PRN Tylenol for the patient's headache is not the appropriate first action in this scenario. While Tylenol may help with the headache, it does not address the underlying cause of the elevated blood pressure and autonomic dysreflexia. Immediate intervention to lower blood pressure is critical to prevent complications.

Choice C reason:

Rechecking all of the patient's vital signs is important but not the priority action in this situation. The nurse should first take measures to lower the blood pressure and address the symptoms of autonomic dysreflexia by elevating the head of the bed and notifying the provider. Monitoring vital signs can be done concurrently, but it should not delay the immediate intervention required.

Choice D reason:

Elevating the patient's knees and lowering the head of the bed is contraindicated in this situation. Lowering the head of the bed can further increase intracranial pressure and exacerbate symptoms of autonomic dysreflexia. The proper position to help reduce blood pressure is to elevate the head of the bed.

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A patient presents to the emergency department with signs of an epidural hematoma. Which manifestation is characteristic of this type of hematoma?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a patient with suspected traumatic cervical spine injury who just arrived to the emergency department. The nurse knows the priority actions for caring for this patient include all of the following. Place the actions in order of priority.

Correct Answer is B,A,C

Explanation

A patient with a spinal cord lesion at T4 tells the nurse that he has a headache and feels flushed. The BP is significantly elevated to 190/100. The first action by the nurse is to:

Correct Answer is A

Explanation

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