Author Question: In assessing the patient with a significant right intracerebral hemorrhage, the nurse anticipates ... (Read 35 times)

eruditmonkey@yahoo.com · **on:** Jun 25, 2018

In assessing the patient with a significant right intracerebral hemorrhage, the nurse anticipates that the patient will demonstrate which signs?

a. Left-sided hemiplegia with dilated right pupil
b. Right-sided hemiplegia with brisk right pupil response
c. Bilateral motor hemiplegia with bilaterally dilated pupils
d. Left-sided hemiplegia and bilateral PER-RLA

Question 2

The emergency room nurse is assessing a newly admitted patient with a head injury. The nurse observes clear drainage from the nose. Which action should the nurse perform first?

a. Document the presence of rhinorrhea.
b. Inform the physician of the assessment.
c. Test the fluid with a Dextrostix.
d. Tape a drip pad under the nose.

huda · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

A
An acute intracerebral bleed causing hematoma formation is accompanied by unconsciousness, hemiplegia on the contralateral (opposite) side, and a dilated pupil on the ipsilateral (same) side. However, the symptoms indicating a slow buildup of pressure within the skull are more subtle and less easily detected.

Answer to Question 2

C
Head injury symptoms may include rhinorrhea (fluid from the nose) or otorrhea (fluid from the ear), among many others. Rhinorrhea and otorrhea should be tested to determine if there is a ce-rebrospinal fluid (CSF) leak. Testing with a Dextrostix will determine whether glucose is present; the presence of glucose indicates CSF. Documentation, informing the physician, and applying a drip pad under the nose are actions that should occur after confirmation of the fluid type.