10 notecards = 3 pages (4 cards per page)
A client has had a traumatic brain injury and is mechanically ventilated. Which technique does the nurse use to prevent increasing intracranial pressure (ICP)?
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?
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?
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?
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?
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?
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?
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?
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?
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?
C. Elevate the client's head to at least 30 degrees to promote cerebral venous drainage.