What is one of the management strategies in a patient with a brain tissue laceration?
Antibiotics until meningitis can be ruled out
Placing patient on anticoagulants
Encouraging deep breathing and coughing
Monitoring for peripheral edema
The Correct Answer is A
A. Antibiotics until meningitis can be ruled out is correct because a brain tissue laceration disrupts the protective barriers of the brain, such as the meninges, increasing the risk for infection including meningitis or abscess formation. Prophylactic antibiotics are often administered until infection is ruled out or controlled.
B. Placing patient on anticoagulants is incorrect because anticoagulants increase the risk of bleeding, which can worsen intracranial hemorrhage in patients with brain tissue injury.
C. Encouraging deep breathing and coughing is incorrect because while generally beneficial for pulmonary function, vigorous coughing can increase intracranial pressure (ICP) and worsen brain injury, so it is not routinely encouraged in patients with brain lacerations.
D. Monitoring for peripheral edema is incorrect because edema in the extremities is not a primary concern in managing brain tissue lacerations. The critical focus is neurological status, ICP, and prevention of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. That the patient will be alert and oriented is incorrect because a GCS of 8 indicates severe impairment of consciousness, not alertness. Patients who are alert and oriented typically have a GCS of 13–15.
B. The patient will be comatose is correct because a GCS score of 8 or lessis generally considered coma or severe brain injury. This indicates significant neurological impairment, and the patient is likely unable to respond appropriately to verbal or painful stimuli. Immediate interventions often focus on airway protection, stabilization, and rapid neurological assessment.
C. The patient will likely have a UTI is incorrect because a urinary tract infection is not related to the GCS score. While a UTI can cause confusion in older adults, it does not directly correlate with a GCS of 8 in trauma or acute neurological events.
D. That the patient will be vomiting is incorrect because vomiting may occur in patients with elevated intracranial pressure or head trauma, but it is not a defining feature of a GCS of 8. The key concern is level of consciousnessand neurological status.
Correct Answer is ["A","C"]
Explanation
A. Elevate HOB to 30 degrees is correct because head-of-bed elevation promotes venous drainage from the brain, which can help reduce intracranial pressure. This position also supports adequate cerebral perfusion while avoiding neck flexion or extreme hip flexion, which can impair venous outflow and worsen ICP.
B. Make sure patient has a bowel movement every day is incorrect in the context of body positioning. While preventing constipation is important in patients with increased ICP to avoid straining (Valsalva maneuver), it is not a direct positioning intervention.
C. Turn patient with slow, gentle movements to prevent increase in ICP is correct because sudden or vigorous movements can transiently increase ICP. Gentle, coordinated turning and repositioning help minimize fluctuations in intracranial pressure and reduce the risk of neurological deterioration.
D. Place patient in prone position every 2 hours is incorrect because prone positioning is generally avoidedin patients with increased ICP. Prone positioning can impair venous return from the brain, increase ICP, and compromise airway management. Lateral or supine positioning with head elevation is preferred.
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