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Med Surg Ch. 57-TBI-Found On NCLEX Questions & Detailed Answers
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Med Surg Ch. 57-TBI-Found On NCLEX Questions & Detailed Answers
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Med Surg Ch. 57-TBI-Found On NCLEXQuestions & Detailed Answers
Family members of a patient who has a traumatic brain injury ask the nurse about
the purpose of the ventriculostomy system being used for intracranial pressure
monitoring. Which response by the nurse is best?
a.
"This type of monitoring system is complex and it is managed by skilled staff."
b.
"The monitoring system helps show whether blood flow to the brain is adequate."
c.
"The ventriculostomy monitoring system helps check for alterations in cerebral
perfusion pressure."
d.
"This monitoring system has multiple benefits including facilitation of
cerebrospinal fluid drainage." - ANS b. "the monitoring system helps show whether
blood flow to the brain is adequate"
Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse
110, and respirations 26. Which set of vital signs, if taken 1 hour after admission,
will be of most concern to the nurse?
a.
Blood pressure 154/68, pulse 56, respirations 12
b.
,Blood pressure 134/72, pulse 90, respirations 32
c.
Blood pressure 148/78, pulse 112, respirations 28
d.
Blood pressure 110/70, pulse 120, respirations 30 - ANS a. blood pressure 154/68,
pulse 56, respirations 12
When a brain-injured patient responds to nail bed pressure with internal rotation,
adduction, and flexion of the arms, the nurse reports the response as
a.
flexion withdrawal.
b.
localization of pain.
c.
decorticate posturing.
d.
decerebrate posturing. - ANS c. decorticate posturing
The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious
patient. Which parameter should the nurse monitor to determine the medication's
effectiveness?
a.
Blood pressure
, b.
Oxygen saturation
c.
Intracranial pressure
d.
Hemoglobin and hematocrit - ANS c. intracranial pressure
A 46-year-old patient with a head injury opens the eyes to verbal stimulation,
curses when stimulated, and does not respond to a verbal command to move but
attempts to push away a painful stimulus. The nurse records the patient's Glasgow
Coma Scale score as
a.
9.
b.
11.
c.
13.
d.
15. - ANS b. 11
An unconscious 39-year-old male patient is admitted to the emergency
department (ED) with a head injury. The patient's spouse and teenage children
stay at the patient's side and ask many questions about the treatment being given.
What action is best for the nurse to take?
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