After evacuation of an epidural hematoma, a patient's intracranial pressure (ICP) is being moni-tored with an intraventricular catheter. Which information obtained by the nurse is most im-portant to communicate to the health care provider?
a. Pulse 102 beats/min
b. Temperature 101.6 F
c. Intracranial pressure 15 mm Hg
d. Mean arterial pressure 90 mm Hg
Question 2The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding is most important to report to the health care provider?
a. Complaint of severe headache
b. Large contusion behind left ear
c. Bilateral periorbital ecchymosis
d. Temperature of 101.4 F (38.6 C)
Question 3After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first?
a. A 20-year-old patient whose cranial x-ray shows a linear skull fracture
b. A 30-year-old patient who has an initial Glasgow Coma Scale score of 13
c. A 40-year-old patient who lost conscious-ness for a few seconds after a fall
d. A 50-year-old patient whose right pupil is 10 mm and unresponsive to light
Question 4Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit?
a. A 45-year-old receiving IV antibiotics for meningococcal meningitis
b. A 25-year-old admitted with a skull frac-ture and craniotomy the previous day
c. A 55-year-old who has increased intracra-nial pressure (ICP) and is receiving hyper-ventilation therapy
d. A 35-year-old with ICP monitoring after a head injury last week
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