Author Question: Which action will the emergency department nurse anticipate for a patient diagnosed with a ... (Read 56 times)

Alainaaa8 · **on:** Jun 25, 2018

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness?

a. Coordinate the transfer of the patient to the operating room.
b. Provide discharge instructions about mon-itoring neurologic status.
c. Transport the patient to radiology for magnetic resonance imaging (MRI).
d. Arrange to admit the patient to the neuro-logic unit for 24 hours of observation.

Question 2

A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care?

a. Encourage coughing and deep breathing.
b. Position the patient with knees and hips flexed.
c. Keep the head of the bed elevated to 30 degrees.
d. Cluster nursing interventions to provide rest periods.

zenzy · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: B
A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need to return if neurologic status deteriorates. MRI, hospital admission, or surgery are not usually indicated in a patient with a concussion.

Answer to Question 2

ANS: C
The patient with increased intracranial pressure (ICP) should be maintained in the head-up posi-tion to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.