A nurse is caring for a patient in the intensive care unit who was admitted with severe head trauma and cerebral edema. The patient opens their eyes spontaneously, is oriented, and obeys commands.Which of the following findings indicate the patient is experiencing a decline in their condition?

Patient is confused

Patient mumbles inappropriate words

Eyes do not open to name

Answer and Explanation

The Correct Answer is A

Choice A rationale
A patient in the intensive care unit who was admitted with severe head trauma and cerebral edema, who opens their eyes spontaneously, is oriented, and obeys commands, would be experiencing a decline in their condition if they become confused. Confusion can be a sign of worsening brain function, indicating that the brain is not receiving enough oxygen or is being affected by a buildup of toxins. This could be due to increased intracranial pressure, decreased blood flow to the brain, or further injury to the brain tissue.
Choice B rationale

Mumbling inappropriate words can also be a sign of a decline in a patient’s condition. However, it is less specific than confusion. It could be due to a variety of factors, including medication side effects, sleep deprivation, or mental health issues.
Choice C rationale
If a patient’s eyes do not open to their name, it could indicate a significant decline in their condition. However, this is a more severe symptom than confusion and may not be the first sign of a decline.

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Correct Answer is A

Explanation

Choice A rationale
Vasogenic cerebral edema is the most common type of cerebral edema associated with stroke. It involves swelling outside of brain cells, and leaky blood vessels cause it.
Choice B rationale
Osmotic cerebral edema is not typically associated with stroke. It is more commonly seen in conditions like diabetes-related ketoacidosis and hyponatremia.
Choice C rationale

Cellular, or cytotoxic, cerebral edema can occur due to traumatic brain injury and stroke. However, it is not the most common type of cerebral edema associated with stroke.
Choice D rationale
Interstitial cerebral edema is not typically associated with stroke. It is more commonly seen in conditions like hydrocephalus and meningitis.

A. Administer acetaminophen by mouth for pain control B. Perform a thorough health history C. Prepare for a STAT non-contrast CT scan D. Insert an indwelling urinary catheter to monitor urine output

Correct Answer is C

Explanation

Choice A rationale
Administering acetaminophen by mouth for pain control is important, but it is not the first intervention that should be implemented for a client who has had a traumatic fall. Pain management is crucial, but it is not the immediate priority in this situation.
Choice B rationale
Performing a thorough health history is a part of the nursing assessment, but it is not the first intervention in an acute situation such as a traumatic fall. Immediate physical needs and potential injuries need to be addressed first.
Choice C rationale

Preparing for a STAT non-contrast CT scan is the correct answer. After a traumatic fall, it is crucial to quickly assess for potential injuries, especially to the brain. A CT scan can help identify any immediate life-threatening conditions such as bleeding in the brain.
Choice D rationale
Inserting an indwelling urinary catheter to monitor urine output is an intervention that may be necessary depending on the client’s condition, but it is not the first intervention to be implemented after a traumatic fall.

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A nurse is caring for a patient in the intensive care unit who was admitted with severe head trauma and cerebral edema. The patient opens their eyes spontaneously, is oriented, and obeys commands.Which of the following findings indicate the patient is experiencing a decline in their condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is educating a student about cerebral edema. The student nurse inquires, “What type of cerebral edema is associated with a patient who has had a stroke?” Which of the following is the best response from the nurse?

Correct Answer is A

Explanation

A nurse is caring for a client who has had a traumatic fall. Which of the following interventions should the nurse implement first?

Correct Answer is C

Explanation

A nurse is providing care to a client who has Parkinson’s disease and is having difficulty swallowing. Which of the following departments should the nurse plan to contact for a consultation?

A nurse is teaching a class about the use of pain medications for clients who have an opioid addiction. Which of the following medications are a nonopioid analgesic?

A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse plan to include in the plan of care?

A nurse is caring for a client who has chronic migraine headaches. The client asks if they had a cerebral aneurysm, which of the following responses should the nurse use?

A nurse is caring for a client who has a traumatic brain injury (TBI). Which of the following groups should the nurse understand has a higher risk of sustaining a TBI?

A nurse is caring for a client who has a traumatic brain injury (TBI). Which of the following should the nurse understand is a possible consequence of a TBI?

A nurse is caring for a client who has a traumatic brain injury (TBI). Which of the following secondary conditions should the nurse anticipate the client might develop?

A nurse is caring for a client who has a traumatic brain injury and is being mechanically ventilated. Which of the following can cause unfavorable outcomes for this client?