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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: This is correct. A white blood cell count of 1000/mm3 indicates severe neutropenia, which is a condition of having abnormally low levels of neutrophils, a type of white blood cell that fights infections. Neutropenic precautions are measures to protect the client from exposure to pathogens, such as wearing a mask, gloves, and gown, avoiding contact with sick people, and practicing good hygiene.

Choice B reason: This is incorrect. A red blood cell count of 5 million/mm3 is within the normal range for both males and females. It does not indicate any risk of infection or bleeding.

Choice C reason: This is incorrect. A clotting time of 10 minutes is also within the normal range, which is 8 to 15 minutes. It does not indicate any risk of infection or bleeding.

Choice D reason: This is incorrect. A thrombocyte count of 90,000 cells/mm3 is low, but not low enough to require neutropenic precautions. Thrombocytes, also known as platelets, are responsible for blood clotting. A low thrombocyte count increases the risk of bleeding, but not infection. The normal range for thrombocyte count is 150,000 to 450,000 cells/mm3.

A. Flexion of the hip causes resistance to extension of the leg. B. Flexion of the neck causes flexion of the hips and knees. C. Flexion of the ankle causes upward fanning of the toes. D. Flexion of the neck causes pain and spasm in the leg muscles.

Correct Answer is B

Explanation

Choice A reason: Flexion of the hip causing resistance to extension of the leg is not a sign of meningitis. It is a sign of hip joint inflammation or injury.

Choice B reason: Flexion of the neck causing flexion of the hips and knees is a positive Brudzinski's sign. It indicates irritation of the meninges, the membranes that cover the brain and spinal cord.

Choice C reason: Flexion of the ankle causing upward fanning of the toes is not a sign of meningitis. It is a sign of an upper motor neuron lesion, such as a stroke or spinal cord injury.

Choice D reason: Flexion of the neck causing pain and spasm in the leg muscles is not a sign of meningitis. It is a sign of muscle strain or nerve compression.

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Postoperative care for a patient having a craniotomy to relieve increased intracranial pressure, the nurse should implement which intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing hematology laboratory results of a client receiving intravenous chemotherapy for leukemia. Which of the following laboratory findings prompts the nurse to initiate neutropenic precautions?

Correct Answer is A

Explanation

The nurse assesses a patient who potentially may have meningitis. The patient demonstrates a positive Brudzinski's sign with which changes in position.

Correct Answer is B

Explanation

The nurse evaluates the Babinski reflex and strokes the sole of the patient's foot from the outer heel to the little toe. The patient was in an automobile accident and has a decreased level of consciousness. Which response indicates an abnormality in the cerebral cortex?

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The nurse completes a Romberg's test on a patient with neurologic changes. The nurse would notify the provider if they observe which response?