The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for the patient with an acute head injury. Which action(s) should the nurse take to achieve this goal? (SELECT ALL THAT APPLY)

Encourage the patient to cough to expectorate secretions

Elevate the head of the bed to 30-45 degrees

Stimulate the patient with active range of motion exercises

Perform serial neurologic assessments while hospitalized

Contact the healthcare provider if the ICP is sustained between 30-40mmHg

Answer and Explanation

Correct Answer : B,D,E

A. Coughing can increase ICP by increasing intrathoracic pressure and should be minimized in patients with head injuries.

B. Elevating the head of the bed to 30-45 degrees promotes venous drainage from the head, reducing ICP.

C. Active stimulation can increase ICP and is generally avoided in patients with acute head injuries.

D. Serial neurologic assessments help monitor any changes in the patient’s condition and ICP, allowing for timely intervention.

E. Sustained ICP levels between 30-40 mmHg are significantly elevated and require immediate communication with the healthcare provider, as they are above the normal range and could lead to further complications

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Discussing over-the-counter drugs with the healthcare provider is essential, as they can interact with antiepileptic medications.

B. Discontinuing antiepileptic medications abruptly can lead to rebound seizures and is unsafe, so this statement is correct.

C. Doubling up on doses can lead to toxicity and adverse effects; missed doses should not be made up by doubling the next dose. This response indicates the need for further teaching.

D. Taking medications exactly as prescribed is necessary to maintain therapeutic levels and manage seizure control effectively.

A. Severe headache B. Generalized weakness C. Gradual blurry vision D. Chest pain

Correct Answer is A

Explanation

A. A severe headache, often described as a "thunderclap" headache or the worst headache of the patient’s life, is a classic symptom of subarachnoid hemorrhage due to irritation of the meninges and increased intracranial pressure.

B. Generalized weakness may occur in some neurological conditions but is not a hallmark symptom of subarachnoid hemorrhage.

C. Gradual blurry vision is more associated with conditions like increased intracranial pressure or other eye-related issues rather than acute subarachnoid hemorrhage.

D. Chest pain is not typically associated with subarachnoid hemorrhage; it may indicate other conditions such as myocardial infarction or pulmonary issues.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for the patient with an acute head injury. Which action(s) should the nurse take to achieve this goal? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient diagnosed with epilepsy who is prescribed antiepileptic medications. The nurse would identify the need for further teaching when the patient states:

Correct Answer is C

Explanation

The nurse suspects a subarachnoid hemorrhage in a patient admitted to the emergency department. Which of the following symptoms is commonly seen in a patient diagnosed with a subarachnoid hemorrhage?

Correct Answer is A

Explanation

The nurse is caring for a patient who has sustained eye trauma as a result of a motor vehicle crash (MVC). Which intervention should the nurse provide regarding a foreign body?

The nurse is caring for a patient who had a serious head injury. The patient has recovered enough to be to be transferred to a rehabilitation facility. Which of the following rehabilitation goals would be most appropriate for the patient? The patient will:

The healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?

The nurse anticipates which antibiotic class, due to the lack of ototoxicity, will be ordered for a patient diagnosed with tympanic membrane rupture?

A patient diagnosed with a seizure disorder tells the nurse that they feel like they have "butterflies" in their stomach. The patient has felt this in the past before having a seizure. The nurse recognizes that this feeling is:

The nurse is caring for a patient who will be discharged with a prescription for lisinopril. What discharge teaching should be provided related to this medication?

The nurse is caring for a patient who will be discharged with a prescription for lisinopril. What discharge teaching should be provided related to this medication?

The nurse is assessing a patient with a cochlear implant and notices that there is drainage, swelling, and tenderness behind the ear with the implant. What is the priority nursing intervention?