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:

prevents a further increase in intracranial pressure.

promotes comfort and rest

restores neutral position of the joints.

prevents the formation of blood clots

Answer and Explanation

The Correct Answer is A

A.. Keeping the neck in midline and avoiding excessive hip flexion helps promote venous drainage from the brain, reducing the risk of increased intracranial pressure (ICP).
B. Incorrect. While comfort is important, the primary rationale is related to ICP management, not just comfort.
C. Restoring neutral joint position is not the main concern in postcraniotomy care regarding neck and hip positioning.
D. Preventing blood clots is related to mobility and circulation but not directly related to neck and hip positioning in this context.

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Correct Answer is C

Explanation

A. Analgesics address pain but do not treat the underlying cause of symptoms.
B. Lowering the head of the bed can increase intracranial pressure and worsen hypertension in autonomic dysreflexia.
C. Bladder distention is a common trigger of autonomic dysreflexia; assessing and relieving bladder distention is the priority intervention.
D. Antihypertensive medication may be necessary but only after removing the triggering cause to avoid sudden drops in blood pressure.

A. Reports of a headache B. An altered level of consciousness (LOC) C. Steady vital signs D. Increased motor function

Correct Answer is B

Explanation

A. Headache is a common symptom but subjective and less reliable as an early sign of increased ICP.
B. Altered level of consciousness is the most sensitive and reliable early clinical indicator of increased ICP, reflecting impaired brain function.
C. Vital signs may remain stable initially; changes often occur later in the course of increased ICP.
D. Increased motor function is unlikely; motor deficits or decreased motor response are more common with increased ICP.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

For the patient with a closed head injury from a blunt object, which assessment would the nurse perform as the most reliable clinical indication of a patient's development of an increased intracranial pressure (ICP)?

Correct Answer is B

Explanation

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 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)?

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?

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The nurse is caring for a client who has cerebral edema. Which of the following therapies should the nurse recognize as appropriate for the treatment of cerebral edema? (Select All that Apply.)

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?

Which is a priority nonoperative treatment following a spinal cord injury?