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Showing 16 questions, Sign in for moreA patient with intracranial pressure monitoring has a pressure of 12 mm Hg. The nurse understands that this pressure reflects:
A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to
The nurse is alerted to a possible acute subdural hematoma in the patient who:
During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for
A client involved in a minor car accident initially refuses medical attention but schedules an appointment with a primary care provider six weeks later due to persistent headaches. The provider diagnoses a mild traumatic brain injury (TBI).
Which details from the client's history would support this diagnosis? Select all that apply.
A nurse is caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time?
A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment?
A nurse is caring for a client who has a closed-head injury with ICP readings range from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client’s ICP? (Select all that apply.)
A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (Select all that apply.)
A nurse is caring for a client who has increased ICP and a new prescription for mannitol (Osmitrol). For which of the following adverse effects should the nurse monitor?
The patient has been diagnosed with a cerebral concussion. What should the nurse expect to see in this patient?
The patient comes to the emergency department (ED) with cortical blindness and visual field defects. Which type of head injury does the nurse suspect?
The patient has a depressed skull fracture and scalp lacerations with communication to the intracranial cavity. Which type of injury should the nurse record?
A patient with a head injury has bloody drainage from the ear. What should the nurse do to determine if CSF is present in the drainage?
The nurse suspects the presence of an arterial epidural hematoma in the patient who experiences
The nurse delegates to the assistive personnel hygiene care for an alert older adult patient who had a stroke. Which intervention(s) would be appropriate for the assistive personnel to accomplish during the bath? Select all that apply
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