The nurse is caring for a patient in the ICU with a diagnosis of acute closed head injury whose intracranial pressure (ICP) is 30mmHg. What is the priority action by the nurse?

Suction the patient to minimize secretions

Continue with the assessment and document the finding

Notify the physician and raise HOB to 35-45 degrees

Lower the head of the bed and pad the side rails

Answer and Explanation

The Correct Answer is C

A. Suctioning can increase ICP due to the Valsalva response and should only be done if absolutely necessary.

B. Documenting without intervention could lead to worsening of the patient's condition.

C. Notifying the physician and raising the head of the bed helps to reduce ICP by promoting venous drainage. An ICP of 30 mmHg is critically high, requiring immediate intervention to prevent further damage.

D. Lowering the head of the bed can increase ICP further; head elevation is recommended to improve cerebral drainage.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. While anxiety can cause gastrointestinal symptoms, the context of this patient’s experience with seizures indicates that it is specifically related to the seizure disorder rather than an independent anxiety issue.

B. The sensation of "butterflies" is not typically related to hunger, as hunger is more commonly associated with physical feelings of emptiness or pain rather than a specific butterfly sensation.

C. An aura is a perceptual disturbance experienced by some patients with seizure disorders that precedes a seizure. It can manifest as various sensations, including gastrointestinal feelings like "butterflies," which serve as a warning sign that a seizure is imminent.

D. A postictal sign refers to the state of confusion or altered consciousness following a seizure, rather than sensations experienced prior to the seizure.

A. occipital lobe. B. frontal lobe. C. parietal lobe. D. temporal lobe.

Correct Answer is C

Explanation

A. The occipital lobe primarily processes visual information and is less involved in object identification errors.

B. The frontal lobe governs behavior, personality, and decision-making rather than object identification.

C. The parietal lobe is involved in processing sensory information and object recognition. Misidentifying objects can indicate damage to this area of the brain.

D. The temporal lobe is associated with auditory processing and memory, not typically object recognition errors.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a patient in the ICU with a diagnosis of acute closed head injury whose intracranial pressure (ICP) is 30mmHg. What is the priority action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient diagnosed with a seizure disorder tells the nurse that they feel like they have "butterflies" in their stomach. The patient has felt this in the past before having a seizure. The nurse recognizes that this feeling is:

Correct Answer is C

Explanation

The nurse in the rehabilitation unit is caring for a patient with a chronic head injury. During the assessment, the nurse holds up a pen and asks the patient to identify the object. The patient replies, "It's a key." When considering the patient's response, which part of the brain is involved? The:

Correct Answer is C

Explanation

The nurse teaches a patient diagnosed with Bell's Palsy about the use of an eye patch to prevent which eye complication?

The nurse is caring for a patient with an acute head injury. Which assessment finding would first alert the nurse that the patient is developing an increase in intracranial pressure (ICP)?

The nurse is caring for a patient with a spinal cord injury (SCI) who is about to be transferred to a wheelchair for Physical Therapy. The patient complains of feeling dizzy and is diaphoretic. What would be the priority nursing action?

The nurse suspects a subarachnoid hemorrhage in a patient admitted to the emergency department. Which of the following symptoms is commonly seen in a patient diagnosed with a subarachnoid hemorrhage?

The nurse is caring for a patient with a complete spinal cord injury at the level of C7. Which intervention would the nurse implement in order to prevent complications related to immobility?

The nurse is caring for a patient in the acute care setting with a spinal cord injury (SCI) at the level of C-3. What is the main cause of complications or death related to this injury?

The nurse anticipates which antibiotic class, due to the lack of ototoxicity, will be ordered for a patient diagnosed with tympanic membrane rupture?