The nurse is caring for several patients in the Intensive Care Unit (ICU). Which of the following patients is at the greatest risk of anoxic brain injury?
A patient who was in an assault resulting in basilar skull fracture.
A patient who was found face down in water for an unknown length of time.
A patient who suffered an epidural or subdural hematoma.
A patient who experienced prolonged seizures without regaining consciousness.
The Correct Answer is B
Choice A rationale
Basilar skull fractures can lead to cerebral injuries and CSF leaks, but do not typically cause anoxic brain injury unless they compromise oxygenation or cause cerebral edema severely reducing blood flow.
Choice B rationale
Prolonged submersion compromises oxygen delivery, leading to diffuse cerebral hypoxia or anoxia, the primary cause of brain injury in drowning victims due to interruption of arterial oxygenation over unknown durations.
Choice C rationale
Epidural or subdural hematomas elevate intracranial pressure and compress brain tissue, but they are not as immediately hypoxic as situations involving complete oxygen deprivation like submersion.
Choice D rationale
Prolonged seizures, or status epilepticus, may disrupt normal metabolic processes, potentially causing neuronal injury. However, primary hypoxia is generally less pronounced than in submersion cases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Administering recombinant tissue plasminogen activator (t-PA) may be necessary, but confirming ischemic stroke via CT scan precedes treatment to rule out hemorrhagic stroke, which contraindicates t-PA.
Choice B rationale
Performing a STAT non-contrast CT scan of the head is the priority to differentiate between ischemic and hemorrhagic stroke, enabling appropriate and timely intervention.
Choice C rationale
A STAT EKG and chest X-ray, though helpful in identifying concurrent cardiac or pulmonary issues, are not immediate priorities in acute stroke evaluation.
Choice D rationale
While assessing dysphagia is critical post-stroke, it is not a priority during initial stroke evaluation, which focuses on rapid imaging and differentiation of stroke type. .
Correct Answer is B
Explanation
Choice A rationale
Nitroprusside is a vasodilator for hypertensive crises but is contraindicated in elevated ICP because it increases cerebral blood volume and exacerbates intracranial pressure, worsening the patient's condition.
Choice B rationale
Hypertonic saline (3%) helps reduce ICP by drawing excess fluid from brain tissue into the bloodstream through osmosis, effectively lowering intracranial pressure while maintaining cerebral perfusion.
Choice C rationale
Furosemide is a loop diuretic that reduces fluid overload but does not specifically target ICP. It is less effective in managing the osmotic balance required for intracranial pressure reduction.
Choice D rationale
Norepinephrine is a vasopressor used to treat hypotension and improve perfusion but does not lower ICP and may increase cerebral vasoconstriction, exacerbating intracranial hypertension. .
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