A client has had a traumatic brain injury and is mechanically ventilated. Which technique does the nurse use to prevent increasing intracranial pressure (ICP)?
- Assessing for Grey Turner’s sign
- Maintaining neutral head position
- Placing the client in the
- Trendelenburg position Suctioning the client frequently
B. Maintaining neutral head position
A client is considering treatments for a malignant brain tumor. Which statement by the client indicates a need for further instruction by the nurse?
- “A combination of treatments might be necessary.”
- “In a craniotomy, holes are cut in the skull to access the tumor.”
- “I can go home the day of my craniotomy.”
- “The goal is to decrease tumor size and improve survival time.”
C. “I can go home the day of my craniotomy.”
A client hospitalized for hypertension presses the call light and reports “feeling funny.” When the nurse gets to the room, the client is slurring words and has right-sided weakness. What does the nurse do first?
- Assesses airway, breathing, and circulation
- Calls the provider
- Performs a neurologic check
- Assists the client to a sitting position
A. Assesses airway, breathing, and circulation
The nurse is evaluating the collaborative care of a client with traumatic brain injury (TBI). What is the most important goal for this client?
- Achieving the highest level of functioning
- Increasing cerebral perfusion
- Preventing further injury
- Preventing skin breakdown
A. Achieving the highest level of functioning
The nurse is monitoring a postoperative craniotomy client with increased intracranial pressure (ICP). Which pharmacologic agent does the nurse expect to be requested to maintain the ICP within a specified range?
- Dexamethasone (Decadron)
- Hydrochlorothiazide (HydroDIURIL)
- Mannitol (Osmitrol)
- Phenytoin (Dilantin)
C. Mannitol (Osmitrol)
A client with a traumatic brain injury from a motor vehicle crash is monitored for signs/symptoms of increased intracranial pressure (ICP). Which sign/symptoms does the nurse monitor for?
- Changes in breathing pattern
- Increasing level of consciousness
- Reactive pupils
A. Changes in breathing pattern
The nurse is assessing a client with a traumatic brain injury after a skateboarding accident. Which sign/symptom is the nurse most concerned about?
- Asymmetric pupils
- Head laceration
B. Asymmetric pupils
A client presents to the Emergency Department from an assisted living facility after a ground level fall with a head strike. The client has a Glasgow Coma Score (GCS) of 12, which is decreased for this client, and has projectile vomiting. What is the priority intervention for this client?
- Calling the Stroke Team
- Establishing an IV
- Positioning the client to prevent aspiration
- Preparing for thrombolytic administration
C. Positioning the client to prevent aspiration
An alert and oriented person is admitted to the emergency department with a GCS of 10, indicating a moderate brain injury. Which assessment finding will the nurse report immediately to the health care provider?
- Photophobia accompanied by headache
- New onset of dizziness when lying quietly in bed
- A brisk pupillary reaction to light
- New difficulty in responsiveness or sudden drowsiness
D. New difficulty in responsiveness or sudden drowsiness
A client returns from the postanesthesia care unit (PACU) after a craniotomy for removal of a left parietal lobe tumor. How will the nurse position the client after surgery?
- Flex the client's knees to decrease intra-abdominal pressure and cerebral hypertension.
- Keep the client on the left side to prevent surgical site bleeding or cerebrospinal fluid leakage.
- Elevate the client's head to at least 30 degrees to promote cerebral venous drainage.
- Hyperextend the client's neck to maintain the airway and prevent aspiration regardless of supine or side-lying positioning.
C. Elevate the client's head to at least 30 degrees to promote cerebral venous drainage.