The nurse is teaching a class to a group of staff nurses about traumatic brain injury which condition would the nurse identify as having the highest risk of a fatal outcome within the first 24 hours post-injury?

Subdural hematoma

Diffuse axonal injury

Intracranial hemorrhage

Epidural hematoma

Answer and Explanation

The Correct Answer is D

A. Subdural hematoma: Subdural hematomas develop more slowly and typically present a higher risk for delayed deterioration, but not usually within the first 24 hours.

B. Diffuse axonal injury: While severe, diffuse axonal injury typically causes a prolonged coma rather than immediate fatality within 24 hours.

C. Intracranial hemorrhage: This is severe but often depends on the size and location of the bleed.

D. Epidural hematoma: Epidural hematomas are associated with arterial bleeding and rapid deterioration due to increased intracranial pressure, making them the most fatal within 24 hours.

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Correct Answer is D

Explanation

A. The client's head should be turned to the side with the head of the bed elevated 60 degrees. Elevating the head of the bed too high can cause a decrease in venous return, which can increase intracranial pressure.

B. The client's head should be placed on a flat pillow with the foot of the bed higher than the head. This position would not help with reducing intracranial pressure and may worsen it.

C. The client should be placed in dorsal recumbent with the head placed on pillows for comfort. This position does not provide optimal head elevation to decrease intracranial pressure.

D. The head of the bed should be elevated 30 degrees with the head in neutral midline position. A head elevation of 30 degrees with the head in a neutral midline position is ideal for promoting venous drainage from the brain, which helps reduce intracranial pressure.

A. “There is some swelling in your right leg that is making you feel this way." B. "Your brain is responding to being inactive from the surgery." C. "Don't worry about your right foot. The pain will go away within a few days." D. "Your brain is still receiving impulses about your right foot."

Correct Answer is D

Explanation

A. “There is some swelling in your right leg that is making you feel this way.” Swelling would typically cause discomfort or pressure, but it would not be responsible for the sensation of pain in the amputated limb.

B. "Your brain is responding to being inactive from the surgery." This answer does not address the real cause of the pain, which is related to the brain's continued perception of the missing limb.

C. "Don't worry about your right foot. The pain will go away within a few days." Phantom limb pain is a common phenomenon after amputation and may persist long-term. Dismissing it is not appropriate.

D. "Your brain is still receiving impulses about your right foot." This is an accurate explanation for phantom limb pain. After amputation, the brain may still interpret sensations from the absent limb, causing pain or discomfort in the "missing" foot.

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The nurse is teaching a class to a group of staff nurses about traumatic brain injury which condition would the nurse identify as having the highest risk of a fatal outcome within the first 24 hours post-injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who suffered a hemorrhagic stroke. In order to prevent increased intracranial pressure, the client should be placed in which position for the first 72 hours after the onset of a stroke?

Correct Answer is D

Explanation

The nurse is caring for a client who is postoperative following a right below-the-knee amputation. The client asks the nurse, " I keep having pain in my right foot. Why is that?" Which response would be appropriate for the nurse to make?

Correct Answer is D

Explanation

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