You are working in the ED and receive a patient with a scalp laceration. What do you anticipate will be part of your care with this patient?
They will likely need ICP monitoring
They will need continuous blood pressure and oxygen saturation monitoring
Holding pressure on the laceration because profuse bleeding can occur
You will need to make sure they have warm blankets to prevent temperature from decreasing
The Correct Answer is C
A. They will likely need ICP monitoring is incorrect because a simple scalp laceration does not typically cause increased intracranial pressure. ICP monitoring is reserved for patients with suspected or confirmed brain injury, not isolated scalp injuries.
B. They will need continuous blood pressure and oxygen saturation monitoring is incorrect because while vital signs are routinely monitored in the ED, continuous cardiac and oxygen monitoring is not generally required for a minor scalp laceration unless there are signs of hemodynamic instability or other injuries.
C. Holding pressure on the laceration because profuse bleeding can occur is correct. The scalp is highly vascular, and even a relatively small laceration can lead to significant blood loss. Immediate nursing care focuses on applying direct pressure, controlling bleeding, and preparing for wound closure (sutures, staples, or adhesive strips). Proper hemorrhage control is essential to prevent hypovolemia and shock.
D. You will need to make sure they have warm blankets to prevent temperature from decreasing is incorrect because hypothermia prevention is not a primary concern for a patient with an isolated scalp laceration. While warming measures may be used in trauma patients with extensive blood loss or environmental exposure, it is not the main priority in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Subdural hematoma is correctbecause older adults are at high risk for subdural hematomas following head trauma, even with minor injuries. Brain atrophy in the elderly causes stretching of bridging veins, increasing the likelihood of bleeding. Symptoms can be subtle, delayed, or mistaken for baseline confusion or dementia. A change in mental status after a head injury should always prompt concern for intracranial bleeding, making this the priority and most serious potential complication.
B. Delirium related to being in the hospital is incorrectbecause although hospitalization can cause delirium in elderly patients, this explanation should not be assumed when there is a recent head injury. Intracranial bleeding must be ruled out first, as it is life-threatening and requires urgent intervention.
C. Diabetes is incorrectbecause there is no information provided indicating hypoglycemia or hyperglycemia, and diabetes would not be the most immediate concern related to confusion following a head injury. While glucose abnormalities can cause altered mental status, they are not the highest-priority concern in this scenario.
D. Scalp laceration is incorrectbecause scalp injuries can cause significant bleeding but do not typically cause changes in mental status. The presence of confusion after head trauma raises concern for deeper intracranial injury rather than a superficial wound.
Correct Answer is A
Explanation
A. Mannitol is correct because it is an osmotic diuretic commonly used to reduce intracranial pressure. Mannitol increases plasma osmolality, drawing water out of cerebral tissue and into the intravascular space, which decreases cerebral edema and lowers ICP. It is frequently ordered in patients with increased ICP due to intracranial bleeding, such as a subdural hemorrhage.
B. Ibuprofen is incorrect because nonsteroidal anti-inflammatory drugs increase the risk of bleeding and do not reduce intracranial pressure. In a patient with an active intracranial hemorrhage, ibuprofen may worsen bleeding and is contraindicated.
C. IV heparin is incorrect because anticoagulants increase the risk of continued or worsening intracranial bleeding. Heparin would be avoided in a patient with a subdural hemorrhage unless there is a compelling and unrelated indication.
D. Warfarin is incorrect because it is an oral anticoagulant that significantly increases bleeding risk. In the setting of a subdural hemorrhage and increased ICP, warfarin would worsen hemorrhage and is contraindicated.
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