Health and Healing IV: Chapter 59 Acute Intracranial
Problems Questions With Complete Solutions
A client is brought to the emergency department (ED) by
ambulance after being found
unconscious on the bathroom floor by the partner. Which of the
following actions should
the nurse take first?
a. Obtain oxygen saturation.
b. Check pupil reaction to light.
c. Palpate the head for hematoma.
d. Assess Glasgow Coma Scale (GCS). Correct Answers Obtain
oxygen saturation.
A client who is suspected of having an epidural hematoma is
admitted to the emergency
department. Which of the following actions should the nurse
plan to take?
a. Administer IV furosemide.
b. Initiate high-dose barbiturate therapy.
c. Type and crossmatch for blood transfusion.
d. Prepare the client for immediate craniotomy. Correct Answers
Prepare the client for immediate craniotomy.
,A client who is unconscious has a nursing diagnosis of
ineffective cerebral tissue
perfusion related to cerebral tissue swelling. Which of the
following nursing interventions
should be included in the plan of care?
a. Keep the head of the bed elevated to 30 degrees.
b. Position the client with the knees and hips flexed.
c. Encourage coughing and deep breathing to improve
oxygenation.
d. Cluster nursing interventions to provide uninterrupted rest
periods. Correct Answers Keep the head of the bed elevated to
30 degrees.
A client with a head injury opens his or her eyes to verbal
stimulation, curses when
stimulated, and does not respond to a verbal command to move
but attempts to remove a
painful stimulus. Which of the following Glasgow Coma Scale
scores should the nurse
document?
a. 9
b. 11
c. 13
, d. 15 Correct Answers 11
After receiving change of shift report, which of the following
clients should the nurse
assess first?
a. A 44-year-old receiving IV antibiotics for meningococcal
meningitis
b. A 23-year-old who had a skull fracture and craniotomy the
previous day
c. A 30-year-old who has an intracranial pressure (ICP) monitor
in place after a head
injury a week ago
d. A 61-year-old who has increased ICP and is receiving
hyperventilation therapy Correct Answers A 61-year-old who
has increased ICP and is receiving hyperventilation therapy
After the emergency department nurse has received a status
report on the following clients
who have been admitted with head injuries, which client should
the nurse assess first?
a. A client whose cranial radiograph shows a linear skull
fracture
b. A client who has an initial Glasgow Coma Scale score of 13
Problems Questions With Complete Solutions
A client is brought to the emergency department (ED) by
ambulance after being found
unconscious on the bathroom floor by the partner. Which of the
following actions should
the nurse take first?
a. Obtain oxygen saturation.
b. Check pupil reaction to light.
c. Palpate the head for hematoma.
d. Assess Glasgow Coma Scale (GCS). Correct Answers Obtain
oxygen saturation.
A client who is suspected of having an epidural hematoma is
admitted to the emergency
department. Which of the following actions should the nurse
plan to take?
a. Administer IV furosemide.
b. Initiate high-dose barbiturate therapy.
c. Type and crossmatch for blood transfusion.
d. Prepare the client for immediate craniotomy. Correct Answers
Prepare the client for immediate craniotomy.
,A client who is unconscious has a nursing diagnosis of
ineffective cerebral tissue
perfusion related to cerebral tissue swelling. Which of the
following nursing interventions
should be included in the plan of care?
a. Keep the head of the bed elevated to 30 degrees.
b. Position the client with the knees and hips flexed.
c. Encourage coughing and deep breathing to improve
oxygenation.
d. Cluster nursing interventions to provide uninterrupted rest
periods. Correct Answers Keep the head of the bed elevated to
30 degrees.
A client with a head injury opens his or her eyes to verbal
stimulation, curses when
stimulated, and does not respond to a verbal command to move
but attempts to remove a
painful stimulus. Which of the following Glasgow Coma Scale
scores should the nurse
document?
a. 9
b. 11
c. 13
, d. 15 Correct Answers 11
After receiving change of shift report, which of the following
clients should the nurse
assess first?
a. A 44-year-old receiving IV antibiotics for meningococcal
meningitis
b. A 23-year-old who had a skull fracture and craniotomy the
previous day
c. A 30-year-old who has an intracranial pressure (ICP) monitor
in place after a head
injury a week ago
d. A 61-year-old who has increased ICP and is receiving
hyperventilation therapy Correct Answers A 61-year-old who
has increased ICP and is receiving hyperventilation therapy
After the emergency department nurse has received a status
report on the following clients
who have been admitted with head injuries, which client should
the nurse assess first?
a. A client whose cranial radiograph shows a linear skull
fracture
b. A client who has an initial Glasgow Coma Scale score of 13
