Assessment of the Patient Undergoing Intracranial Surgery would include:
Careful, frequent monitoring of respiratory function, including blood gases
Monitor for signs and symptoms of complications
Monitor fluid status and laboratory data
All of the above
The Correct Answer is D
Choice A: Careful, frequent monitoring of respiratory function, including blood gases is correct, as it can detect and prevent hypoxia, hypercapnia, and acid-base imbalance that can affect the brain and other organs.
Choice B: Monitor for signs and symptoms of complications is correct, as it can identify and treat potential problems such as hemorrhage, infection, seizures, or increased intracranial pressure.
Choice C: Monitor fluid status and laboratory data is correct, as it can maintain fluid and electrolyte balance and prevent dehydration, overhydration, or cerebral edema.
Choice D: All of the above is correct, as all of these assessments are important for the patient undergoing intracranial surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Maintenance of patent airway is correct because it is the most essential and urgent intervention on all head injury patients. A patent airway means that the airway is clear and open for breathing. A head injury can cause obstruction, swelling, bleeding, or paralysis of the airway, leading to hypoxia, brain damage, or death. The nurse should assess and secure the airway as the first step in the primary survey and provide oxygen, suction, or intubation as needed.
Choice B: Maintenance of skin integrity is incorrect because it is not the priority intervention on all head injury patients. Skin integrity means that the skin is intact and free of wounds, infections, or pressure injuries. A head injury can cause skin breakdown, especially in immobilized or unconscious patients. The nurse should prevent and treat skin problems as part of the secondary survey and provide wound care, hygiene, or pressure relief as needed.
Choice C: Prevention of sleep deprivation is incorrect because it is not the priority intervention on all head injury patients. Sleep deprivation means that the patient does not get enough quality or quantity of sleep. A head injury can cause sleep disturbances, such as insomnia, hypersomnia, or altered sleep-wake cycle. The nurse should promote sleep hygiene and rest as part of the ongoing care and provide a quiet, dark, and comfortable environment as needed.
Choice D: Fluid and electrolyte balance is incorrect because it is not the priority intervention on all head injury patients. Fluid and electrolyte balance means that the patient has adequate and stable levels of fluids and minerals in the body. A head injury can cause fluid and electrolyte imbalances, such as dehydration, overhydration, or hyponatremia. The nurse should monitor and regulate fluid and electrolyte status as part of the ongoing care and provide oral or intravenous fluids, medications, or dietary modifications as needed.
Correct Answer is C
Explanation
Choice A: CVA is a temporary neurologic deficit and a TIA is more long-term deficit is not correct, as it reverses the definitions of CVA and TIA.
Choice B: There is no difference is not correct, as there are significant differences between CVA and TIA in terms of duration, severity, and prognosis.
Choice C: TIA is a temporary neurologic deficit and a CVA is more long-term deficit is correct, as it accurately describes the difference between CVA and TIA. A TIA is a brief episode of neurologic dysfunction caused by focal brain ischemia that resolves within 24 hours, while a CVA is a permanent or lasting damage to brain tissue caused by ischemia or hemorrhage.
Choice D: CVA results from temporary impairment of blood flow and TIA is long-term impairment is not correct, as it reverses the causes of CVA and TIA.
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