For the patient with a closed head injury from a blunt object, which assessment would the nurse perform as the most reliable clinical indication of a patient's development of an increased intracranial pressure (ICP)?

Reports of a headache

An altered level of consciousness (LOC)

Steady vital signs

Increased motor function

Answer and Explanation

The Correct Answer is B

A. Headache is a common symptom but subjective and less reliable as an early sign of increased ICP.
B. Altered level of consciousness is the most sensitive and reliable early clinical indicator of increased ICP, reflecting impaired brain function.
C. Vital signs may remain stable initially; changes often occur later in the course of increased ICP.
D. Increased motor function is unlikely; motor deficits or decreased motor response are more common with increased ICP.

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Correct Answer is A

Explanation

A. Falls are the leading cause of spinal cord injuries in older adults due to factors like decreased balance, muscle weakness, and osteoporosis.
B. Sporting accidents are more common causes of spinal injuries in younger populations.
C. Motor vehicle accidents are a common cause overall but less so in the elderly compared to falls.
D. Gunshot wounds are a less common cause of spinal cord injuries in older adults.

A. Placement in Trendelenburg position B. Surgical decompression of the brain C. Infusion of hypertonic IV solution D. Administration of IV mannitol E. Regularly scheduled suctioning of secretions F. Regularly scheduled suctioning of secretions

Correct Answer is ["B","C","D"]

Explanation

A. Trendelenburg position (head lower than feet) increases intracranial pressure and is contraindicated in cerebral edema.
B. Surgical decompression (e.g., craniectomy) can relieve increased pressure by allowing the brain to expand safely.
C. Hypertonic IV solutions (like hypertonic saline) draw fluid out of brain cells, reducing cerebral edema.
D. Mannitol is an osmotic diuretic used to reduce cerebral edema by promoting fluid removal from brain tissue.
E. Suctioning can increase ICP due to stimulation and should be done only when necessary and carefully. Regular suctioning is not recommended.

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For the patient with a closed head injury from a blunt object, which assessment would the nurse perform as the most reliable clinical indication of a patient's development of an increased intracranial pressure (ICP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

nurse is teaching a group of nursing students about spinal cord injuries in clients who are aged 65 years and older. Which of the following should the nurse identify as the most common cause of spinal cord injuries for this age group?

Correct Answer is A

Explanation

The nurse is caring for a client who has cerebral edema. Which of the following therapies should the nurse recognize as appropriate for the treatment of cerebral edema? (Select All that Apply.)

Correct Answer is ["B","C","D"]

Explanation

The nurse assists with the prehospital care of a patient who experienced a 15-foot fall. Which action by the nurse will limit the damage if a spinal cord injury (SCI) has occurred?

A nurse is preparing a client with a possible cervical spine injury for a prescribed CT scan of the head and neck after the client sustained a fall down a stairwell. Which intervention by the nurse is the most important?

The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring?

Which patient is the nurse most concerned with developing a subdural hematoma following an injury that resulted with a blow to the head?

Which is a priority nonoperative treatment following a spinal cord injury?

When planning the care for a patient with an increased intracranial pressure (ICP), which interventions would the nurse integrate to provide the most comfort? Select all that apply. (Select All that Apply.)

A nurse in the emergency department has assessed a client's airway, breathing, and circulation (ABC) following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next?

Which position would the nurse utilize when repositioning a patient who has an increased intracranial pressure (ICP)?