The nurse is caring for a patient diagnosed with a traumatic head injury secondary to a work accident.
In the morning assessment, the patient opened his eyes in response to noxious stimuli.
Two hours later, what assessment finding would warrant immediate action by the nurse? The patient:

Can squeeze the nurse's hand upon verbal request.

Follows simple commands with repetition/prompting from nurse.

Has purposeful movement when the nurse rubs the sternum.

Extends upper and lower extremities in response to painful stimuli.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Squeezing the nurse’s hand on verbal request suggests neurological improvement and does not warrant urgent intervention, indicating preserved motor response and cognition.

Choice B rationale

Following commands with repetition/prompting shows mild cognitive delay or reduced processing but does not represent deterioration or life-threatening concern needing immediate action.

Choice C rationale

Purposeful movement to sternal rub implies intact motor response to noxious stimuli. It does not indicate significant neurologic worsening requiring urgent intervention.

Choice D rationale

Extending extremities in response to painful stimuli, known as decerebrate posturing, is a severe neurologic deficit indicating brainstem dysfunction and requires immediate nursing intervention.

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Correct Answer is C

Explanation

Choice A rationale

While bleeding could indicate trauma, EEG does not detect blood presence or volume but instead evaluates electrical brain activity indicative of neuronal function.

Choice B rationale

Cerebral oxygen intake assessment requires pulse oximetry or arterial blood gas analysis rather than EEG, which monitors electrical signals, not oxygenation status.

Choice C rationale

EEG identifies abnormal brain wave patterns suggesting ongoing seizure activity, even in sedated patients, aiding in targeted interventions and preventing potential complications.

A. T98.7 F (36.4 C), BP 220/46, HR 30, RR 6, O2 Sat 98% Room Air. B. T92.5 F (33.6 C), BP 90/64, HR 80, RR 14, O2 Sat 97% Room Air. C. T103.1 F (39.5 C), BP 82/50, HR 132, RR 30, O2 Sat 99% Room Air. D. T98.6 F (37 C), BP 200/94, HR 90, RR 18, O2 Sat 100% Room Air.

Correct Answer is A

Explanation

Choice A rationale

Extremely high systolic BP (220 mmHg), bradycardia (HR 30), and altered respirations (RR 6) suggest Cushing's triad, a hallmark of increased ICP due to severe brain injury.

Choice B rationale

Hypothermia (T92.5°F) and hypotension (BP 90/64) do not indicate increased ICP but may result from shock or hypothermic conditions affecting autonomic responses.

Choice C rationale

Hyperthermia (T103.1°F) and tachycardia (HR 132) are commonly seen in infection or hypermetabolic states, not directly pointing to raised ICP.

Choice D rationale

Mild hypertension (BP 200/94) with normal HR (90) and RR (18) does not fit the classic signs of increased ICP like Cushing's triad.

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The nurse is caring for a patient diagnosed with a traumatic head injury secondary to a work accident.In the morning assessment, the patient opened his eyes in response to noxious stimuli.Two hours later, what assessment finding would warrant immediate action by the nurse? The patient:

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is caring for a patient with an acute brain injury.Which of the following sets of vital signs would concern the nurse about increasing intracranial pressure (ICP)?

Correct Answer is A

Explanation

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The nurse is caring for a patient diagnosed with a traumatic head injury secondary to a work accident.
In the morning assessment, the patient opened his eyes in response to noxious stimuli.
Two hours later, what assessment finding would warrant immediate action by the nurse? The patient: