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 C

Explanation

A. Cervical traction is a method used to help achieve spinal stabilization, but it is a technique rather than the overarching priority.
B. Spinal fusion is a surgical (operative) treatment and therefore not considered a nonoperative approach.
C. Stabilization is the priority nonoperative treatment to prevent further injury to the spinal cord and surrounding structures. It may involve immobilization with collars, braces, or traction.
D. Pain management is important for comfort but is not the immediate priority when spinal cord stability and neurologic function are at risk.

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

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

Correct Answer is C

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

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

To prevent the leading cause of death for clients with spinal cord injury, collaboration with which member of the interprofessional health care team is a nursing priority?

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

The nurse in the emergency department is caring for a client who sustained a spinal cord injury at T4. The nurse should recognize that the client is at risk for developing

The nurse is caring for a client with cerebral edema. Which of the following should the nurse recognize as a potential cause of cerebral edema? (Select All that Apply.)

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?

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?

You keep a postcraniotomy patient's neck in midline position and ensure that there is no excessive hip flexion. The rationale for your action would be that this position: