A client with a traumatic brain injury (TBI) presents to the emergency department with a Glasgow Coma Scale (GCS) score of 10. What should be the nurse's primary focus in this situation?
Monitor and manage airway, breathing, and circulation (ABCs).
Initiate physical therapy to prevent contractures.
Administer intravenous antibiotics.
Perform a comprehensive neuropsychological assessment.
The Correct Answer is A
Management of traumatic brain injury requires immediate application of the ABC protocol and neurologic monitoring. This scenario necessitates understanding the Glasgow Coma Scale, where a score of 10 indicates moderate brain injury requiring stabilization to prevent secondary hypoxic injury or herniation.
Choice A rationale
Traumatic brain injury can compromise respiratory drive and gag reflexes. Prioritizing airway, breathing, and circulation prevents secondary brain ischemia. Maintaining adequate oxygenation and perfusion is the gold standard for preventing further neuronal damage in patients with moderate head injuries.
Choice B rationale
While preventing contractures is a component of long term rehabilitative care, it is not a priority during the acute emergency phase of a traumatic brain injury. Initial management must focus on life saving physiological stabilization and monitoring.
Choice C rationale
Antibiotics are indicated if there is an open head wound or suspected infection, but they are not the primary focus for a patient presenting with a Glasgow Coma Scale score of 10. Physiological stabilization precedes pharmacological infection prophylaxis.
Choice D rationale
Neuropsychological assessments are complex evaluations of cognitive function typically performed during the recovery or rehabilitation phase. In the emergency department, rapid neurological assessments like the Glasgow Coma Scale and pupil checks are utilized to guide immediate treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Administering phenytoin requires applying knowledge of intravenous drug compatibility and cardiovascular safety profiles. The nurse must prioritize monitoring for life-threatening complications associated with rapid infusion, specifically focusing on the drug's narrow therapeutic index and its significant irritant properties.
Choice A rationale
Phenytoin is highly unstable and will precipitate if mixed with dextrose solutions. It must only be diluted with 0.9 percent sodium chloride. Incorrect dilution can lead to crystalline emboli and loss of drug efficacy during administration.
Choice B rationale
Intravenous phenytoin is a known vesicant that can cause purple glove syndrome if administered into small peripheral veins like those in the hand. Use of a large-bore catheter in a large vein or central line is preferred.
Choice C rationale
Rapid infusion of phenytoin can lead to severe cardiovascular collapse, including hypotension and fatal dysrhythmias. The infusion rate should not exceed 50 mg per minute to allow the heart to tolerate the drug's membrane-stabilizing effects safely.
Choice D rationale
The standard therapeutic range for phenytoin is 10 to 20 mcg per mL, not 20 to 30 mg per mL. Levels exceeding 20 mcg per mL often result in toxicity, characterized by nystagmus, ataxia, and decreased mental status.
Correct Answer is A
Explanation
Dexamethasone is a potent corticosteroid used to reduce cerebral edema in brain tumor patients. Prioritizing care requires identifying life-threatening neurological changes or severe medication side effects, applying knowledge of intracranial pressure, glucose metabolism, and the hierarchy of clinical needs.
Choice A rationale
Acute loss of orientation to self indicates a significant decline in neurological status or increased intracranial pressure. This is a medical emergency requiring immediate intervention to prevent brain herniation, outweighing stable physical side effects of steroid therapy.
Choice B rationale
Weight gain is a common side effect of long-term dexamethasone use due to fluid retention and increased appetite. While it requires monitoring, it is an expected systemic effect and does not represent an immediate life-threatening crisis.
Choice C rationale
Insomnia is a known side effect of corticosteroids because they can interfere with the circadian rhythm and stimulate the central nervous system. It affects the client's comfort but does not indicate immediate physiological or neurological compromise.
Choice D rationale
Glucocorticoids cause hyperglycemia; 350 mg/dL is high compared to the normal fasting range of 70 to 100 mg/dL. While it requires insulin or dosage adjustment, it is less urgent than an acute neurological deficit..
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