The nurse is caring for a patient with a new traumatic brain injury and completes a neurologic assessment. The magnetic resonance imaging identifies an intracranial epidural hematoma. The nurse would immediately notify the provider of which assessment finding?

Eyes are deviated to the right.

Amnesia to the cause of the trauma.

Complaint of mild headache.

Pupils constrict from 5 mm to 2 mm with direct light stimulus.

Answer and Explanation

The Correct Answer is A

Choice A reason: Eyes are deviated to the right is an assessment finding that indicates increased intracranial pressure and possible herniation of the brain. It is a sign of cranial nerve III palsy, which affects the movement of the eye and the size of the pupil. It is a medical emergency that requires immediate intervention.

Choice B reason: Amnesia to the cause of the trauma is an assessment finding that indicates memory loss and possible concussion. It is a sign of damage to the temporal lobe, which is involved in memory formation and retrieval. It is not a medical emergency, but it requires further evaluation and monitoring.

Choice C reason: Complaint of mild headache is an assessment finding that indicates pain and discomfort. It is a common symptom of traumatic brain injury, but it is not specific or severe. It can be managed with analgesics and rest.

Choice D reason: Pupils constrict from 5 mm to 2 mm with direct light stimulus is an assessment finding that indicates normal pupillary response. It is a sign of intact cranial nerve II and III function, which control the vision and the pupil size. It is not a cause for concern or notification.

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Correct Answer is B

Explanation

Choice A reason: Decreasing intracranial pressure with decerebrate posturing is not the correct answer. Decerebrate posturing is a sign of severe brain damage that involves the extension and outward rotation of the arms and legs, and the arching of the back. It is not associated with decreasing intracranial pressure, but rather with increased pressure or brainstem compression.

Choice B reason: Increasing intracranial pressure with decorticate posturing is the correct answer. Decorticate posturing is a sign of severe brain damage that involves the flexion of the arms at the elbows and the extension of the legs. It is associated with increased intracranial pressure or lesions in the cerebral hemispheres.

Choice C reason: Decreasing intracranial pressure with decorticate posturing is not the correct answer. Decorticate posturing is a sign of severe brain damage that involves the flexion of the arms at the elbows and the extension of the legs. It is not associated with decreasing intracranial pressure, but rather with increased pressure or lesions in the cerebral hemispheres.

Choice D reason: Increasing intracranial pressure with decerebrate posturing is not the correct answer. Decerebrate posturing is a sign of severe brain damage that involves the extension and outward rotation of the arms and legs, and the arching of the back. It is associated with increased intracranial pressure or brainstem compression, but it is not the posture described in the question.

A. Apples and grapes. B. Popsicles, gelatin, or juice. C. Beans. D. Cheese.

Correct Answer is B

Explanation

Choice A (Apples and grapes): While fruits like apples and grapes are generally healthy options, they may not be the best choice for a client in sickle cell crisis. These fruits are high in fiber and may require a significant amount of chewing, which can be challenging for someone experiencing a sickle cell crisis.

Choice B (Popsicles, gelatin, or juice): This choice is the most suitable for a client in sickle cell crisis. During a crisis, it's important to stay hydrated, and these options provide hydration along with easily digestible carbohydrates, which can be beneficial for maintaining energy levels.

Choice C (Beans): While beans are a good source of protein and fiber, they may not be well tolerated during a sickle cell crisis due to their high fiber content.

Choice D (Cheese): Although cheese is a source of protein and calcium, it may not be the best option during a sickle cell crisis, as dairy products can be harder to digest and may not contribute to hydration.

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The nurse is caring for a patient with a new traumatic brain injury and completes a neurologic assessment. The magnetic resonance imaging identifies an intracranial epidural hematoma. The nurse would immediately notify the provider of which assessment finding?

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