A nurse is monitoring a client who has a traumatic brain injury and a ventriculostomy drain. The nurse should report which of the following findings as a complication of this therapeutic procedure? (Select all that apply.)
Infection
Vomiting
Widening pulse pressure
Equal and reactive pupils
Intracranial pressure reading of 10 mm Hg
Correct Answer : A,B,C
Choice A Reason:
Infection is a significant complication of a ventriculostomy drain. The presence of a foreign object in the brain increases the risk of infections such as meningitis or ventriculitis. Signs of infection can include fever, redness, swelling at the insertion site, and changes in mental status.
Choice B Reason:
Vomiting can be a sign of increased intracranial pressure (ICP), which is a serious complication in clients with a traumatic brain injury and a ventriculostomy drain. Increased ICP can lead to further brain injury and requires immediate medical attention.
Choice C Reason:
Widening pulse pressure (the difference between systolic and diastolic blood pressure) can indicate increased intracranial pressure. This is a critical finding that should be reported immediately as it can signify worsening brain injury or other complications.
Choice D Reason:
Equal and reactive pupils are generally a normal finding and do not indicate a complication. This suggests that the brainstem is functioning properly and there is no significant increase in intracranial pressure affecting the cranial nerves.
Choice E Reason:
An intracranial pressure reading of 10 mm Hg is within the normal range (typically 7-15 mm Hg for adults). Therefore, this finding does not indicate a complication and does not require immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason
Apply an ice pack directly to the affected area. This statement is incorrect. Applying ice to a snake bite can cause more harm than good. Ice can restrict blood flow and potentially increase tissue damage. The recommended approach is to keep the bite area still and at or below heart level to slow the spread of venom.
Choice B Reason
Immobilize the affected extremity with a splint. This is the correct intervention. Immobilizing the affected limb helps to slow the spread of venom by reducing movement. Keeping the limb still and using a splint can prevent the venom from circulating more rapidly through the body.
Choice C Reason
Place a tourniquet above and below the affected area. This statement is incorrect. Using a tourniquet is not recommended for snake bites as it can cause severe damage to the affected limb by cutting off blood flow completely. This can lead to tissue death and other complications.
Choice D Reason
Elevate the affected extremity. This statement is incorrect. Elevating the limb can increase the spread of venom. The affected limb should be kept at or below heart level to slow the venom’s spread.
Correct Answer is D
Explanation
Choice A Reason
“It is okay to not want to touch the burned areas of your body.” This statement is empathetic and acknowledges the client’s feelings, but it does not provide a constructive way to address their concerns about altered appearance. While it is important to validate the client’s feelings, offering a solution or support mechanism is more beneficial.
Choice B Reason
“Cosmetic surgery should be performed within the next year to be effective.” This statement is misleading. While timely intervention can be important, the timing of reconstructive or cosmetic surgery depends on various factors, including the extent of the burns, the healing process, and the patient’s overall health. It is not accurate to generalize that surgery must be performed within a year.
Choice C Reason
“Reconstructive surgery can completely restore your previous appearance.” This statement is incorrect and can give false hope. Reconstructive surgery aims to improve function and appearance, but it cannot completely restore the previous appearance. Managing expectations is crucial in the recovery process.
Choice D Reason
“It could be helpful for you to attend a support group for people who have burn injuries.” This statement is correct. Support groups provide emotional and psychological support, helping burn survivors cope with changes in appearance and other challenges. They offer a sense of community and shared experiences, which can be very beneficial for recovery.
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