Postoperative care for a patient having a craniotomy to relieve increased intracranial pressure, the nurse should implement which intervention?
Elevate the head of the bed 20 to 30 degrees.
Maintain bright lighting in the room to assess bleeding at the surgical site.
Stimulate the patient every half hour to assess changes in level of consciousness.
Allow the patient to change positions frequently to maintain comfort.
The Correct Answer is A
Choice A reason: Elevating the head of the bed 20 to 30 degrees is an appropriate intervention for a patient who had a craniotomy to relieve increased intracranial pressure. It helps to reduce the venous pressure and improve the cerebral perfusion.
Choice B reason: Maintaining bright lighting in the room to assess bleeding at the surgical site is not an appropriate intervention for a patient who had a craniotomy to relieve increased intracranial pressure. It can increase the sensory stimulation and aggravate the intracranial pressure. The nurse should use dim lighting and monitor the dressing and the drainage system for signs of bleeding.
Choice C reason: Stimulating the patient every half hour to assess changes in level of consciousness is not an appropriate intervention for a patient who had a craniotomy to relieve increased intracranial pressure. It can increase the cerebral metabolic demand and worsen the intracranial pressure. The nurse should assess the level of consciousness using the Glasgow Coma Scale and avoid unnecessary stimulation.
Choice D reason: Allowing the patient to change positions frequently to maintain comfort is not an appropriate intervention for a patient who had a craniotomy to relieve increased intracranial pressure. It can increase the intrathoracic pressure and affect the cerebral blood flow. The nurse should limit the patient's movement and avoid extreme flexion, extension, or rotation of the head and neck.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is correct. Monitoring of neurologic status is a priority intervention for a patient with bacterial meningitis, as the infection can cause inflammation and damage to the brain and spinal cord. The nurse should assess the patient's level of consciousness, pupillary response, cranial nerve function, and signs of increased intracranial pressure.
Choice B reason: This is incorrect. Infusion of large volumes of isotonic intravenous fluids is not indicated for a patient with bacterial meningitis, as it can worsen the cerebral edema and increase the intracranial pressure. The patient should receive adequate hydration, but not excessive fluids.
Choice C reason: This is incorrect. Standard precautions are not sufficient for a patient with bacterial meningitis, as the infection can be transmitted through respiratory droplets. The patient should be placed on droplet precautions, which include wearing a mask, gloves, and gown, and limiting the contact with other patients and visitors.
Choice D reason: This is incorrect. Distraction activities to reduce long periods of sleep are not appropriate for a patient with bacterial meningitis, as the patient may need rest and sedation to reduce the agitation and pain. The nurse should provide a quiet and dark environment, and avoid unnecessary stimuli that can increase the intracranial pressure.
Correct Answer is D
Explanation
Choice A reason: This is incorrect. Arm and leg weakness, paresthesia, blurred vision, and facial frown are not specific to Parkinson disease, but may be seen in other neurological disorders, such as multiple sclerosis or stroke.
Choice B reason: This is incorrect. Uncontrollable rapid jerky movements in arms, trunk and facial muscles are characteristic of Huntington disease, not Parkinson disease. Huntington disease is a genetic disorder that causes progressive degeneration of the nerve cells in the brain.
Choice C reason: This is incorrect. Stumbling, backward tilt of the head, quick fluttering hand movements, and quick uncontrolled gait are signs of cerebellar ataxia, not Parkinson disease. Cerebellar ataxia is a disorder that affects the coordination and balance of the movements, caused by damage to the cerebellum.
Choice D reason: This is correct. Hand tremors, bradykinesia, skeletal muscle rigidity, and postural instability are the cardinal signs and symptoms of Parkinson disease. Parkinson disease is a chronic and progressive disorder that affects the dopamine-producing neurons in the brain, resulting in movement problems.
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