Which patient is the nurse most concerned with developing a subdural hematoma following an injury that resulted with a blow to the head?

The 36-year-old patient who has a history of migraine headaches.

The 56-year-old patient who is taking an antihypertensive medication.

The 76-year-old patient who is taking an anticoagulant.

The 16-year-old football player who suffered a concussion

Answer and Explanation

The Correct Answer is C

A. Migraine history does not increase the risk of bleeding or hematoma formation following head trauma.
B. Antihypertensive medications manage blood pressure but do not directly increase the risk of bleeding into the brain.
C. Older adults, especially those on anticoagulants, are at higher risk of developing subdural hematomas due to increased cerebral atrophy and impaired clotting, which makes even minor head trauma potentially life-threatening.
D. While concussions are concerning, a young, otherwise healthy individual is at lower risk of developing a subdural hematoma compared to an elderly patient on anticoagulants.

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Correct Answer is A

Explanation

A. Mannitol is an osmotic diuretic that pulls fluid from brain tissue into the vascular space, which can lead to fluid overload and pulmonary edema. Crackles on auscultation may indicate this complication and should be assessed.
B. While peripheral edema may occur with fluid overload, crackles are a more immediate and concerning sign of pulmonary congestion related to mannitol.
C. An increase in Glasgow Coma Scale score indicates improvement in neurologic function, not a complication.
D. Increased urine output is an expected effect of mannitol; it helps reduce ICP by promoting diuresis.

A. Provide the patient a quiet and calm environment.. B. Minimize procedures that potentially produce agitation. C. Facilitate an increased number of family visits to the patient. D. Encourage the patient's family to increase patient interactions. E. Observe the patient for signs of agitation or irritation and intervene. F. Observe the patient for signs of agitation or irritation and intervene.

Correct Answer is ["A","B","E"]

Explanation

A quiet and calm environment helps reduce stimuli that can increase ICP and cause discomfort.
B. Minimizing procedures that cause agitation prevents spikes in ICP and patient distress.
C. Too many or prolonged family visits can overstimulate the patient, increasing ICP and discomfort.
D. Excessive interaction may overstimulate the patient; interaction should be limited based on tolerance.
E. Early identification and intervention for agitation help maintain stable ICP and patient comfort.

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Which patient is the nurse most concerned with developing a subdural hematoma following an injury that resulted with a blow to the head?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring?

Correct Answer is A

Explanation

When planning the care for a patient with an increased intracranial pressure (ICP), which interventions would the nurse integrate to provide the most comfort? Select all that apply. (Select All that Apply.)

Correct Answer is ["A","B","E"]

Explanation

You keep a postcraniotomy patient's neck in midline position and ensure that there is no excessive hip flexion. The rationale for your action would be that this position:

A nurse is preparing a client with a possible cervical spine injury for a prescribed CT scan of the head and neck after the client sustained a fall down a stairwell. Which intervention by the nurse is the most important?

To prevent the leading cause of death for clients with spinal cord injury, collaboration with which member of the interprofessional health care team is a nursing priority?

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

The nurse assists with the prehospital care of a patient who experienced a 15-foot fall. Which action by the nurse will limit the damage if a spinal cord injury (SCI) has occurred?

A client with a C3 spinal cord injury has a headache and nausea. The client's blood pressure is 170/100 mm Hg. How should the nurse respond initially?

The nurse is caring for a client with a traumatic brain injury following a motor vehicle collision. The client is completely unresponsive to verbal or physical stimuli and does not open the eyes. Which prescription should the nurse clarify with the health care provider?

Which position would the nurse utilize when repositioning a patient who has an increased intracranial pressure (ICP)?