The nurse is caring for several patients in the Intensive Care Unit (ICU). Which of the following patients is at the greatest risk of anoxic brain injury?
A patient who was in an assault resulting in basilar skull fracture.
A patient who was found face down in water for an unknown length of time.
A patient who suffered an epidural or subdural hematoma.
A patient who experienced prolonged seizures without regaining consciousness.
The Correct Answer is B
Choice A rationale
Basilar skull fractures can lead to cerebral injuries and CSF leaks, but do not typically cause anoxic brain injury unless they compromise oxygenation or cause cerebral edema severely reducing blood flow.
Choice B rationale
Prolonged submersion compromises oxygen delivery, leading to diffuse cerebral hypoxia or anoxia, the primary cause of brain injury in drowning victims due to interruption of arterial oxygenation over unknown durations.
Choice C rationale
Epidural or subdural hematomas elevate intracranial pressure and compress brain tissue, but they are not as immediately hypoxic as situations involving complete oxygen deprivation like submersion.
Choice D rationale
Prolonged seizures, or status epilepticus, may disrupt normal metabolic processes, potentially causing neuronal injury. However, primary hypoxia is generally less pronounced than in submersion cases.
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Correct Answer is C
Explanation
Choice A rationale
Childhood memory recall reflects cognitive functioning but is unrelated to the patient's rehabilitation involvement, which focuses on regaining lost functional capacities following injury. Such a goal lacks immediate functional relevance.
Choice B rationale
Returning to work as a corporate attorney may be an eventual aim but depends on higher cognitive recovery levels and is too specific. Early rehabilitation outcomes focus on participation in the recovery process.
Choice C rationale
Active participation indicates readiness and willingness to engage in therapies essential for regaining lost functions. It aligns with goals for a transition from acute care to rehabilitation emphasizing functional improvement.
Choice D rationale
Motor coordination improvements require therapy timelines extending beyond two weeks. Such a rigid short-term goal undermines individualized rehabilitation focusing on measurable progress over more realistic durations.
Correct Answer is B
Explanation
Choice A rationale
Administering recombinant tissue plasminogen activator (t-PA) may be necessary, but confirming ischemic stroke via CT scan precedes treatment to rule out hemorrhagic stroke, which contraindicates t-PA.
Choice B rationale
Performing a STAT non-contrast CT scan of the head is the priority to differentiate between ischemic and hemorrhagic stroke, enabling appropriate and timely intervention.
Choice C rationale
A STAT EKG and chest X-ray, though helpful in identifying concurrent cardiac or pulmonary issues, are not immediate priorities in acute stroke evaluation.
Choice D rationale
While assessing dysphagia is critical post-stroke, it is not a priority during initial stroke evaluation, which focuses on rapid imaging and differentiation of stroke type. .
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