When admitting a 42-year-old patient with a possible brain injury ...

[dmcintosh]

When admitting a 42-year-old patient with a possible brain injury after a car accident to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider?
 
  a. The patient takes warfarin (Coumadin) daily.
  b. The patient's blood pressure is 162/94 mm Hg.
  c. The patient is unable to remember the ac-cident.
  d. The patient complains of a severe dull headache.

Question 2

Which information about a 30-year-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse?
 
  a. Intracranial pressure of 15 mm Hg
  b. Cerebrospinal fluid (CSF) drainage of 25 mL/hour
  c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg
  d. Cardiac monitor shows sinus tachycardia at 128 beats/minute

[k2629]

Answer to Question 1

ANS: A
The use of anticoagulants increases the risk for intracranial hemorrhage and should be immedi-ately reported. The other information would not be unusual in a patient with a head injury who had just arrived in the ED.

Answer to Question 2

ANS: C
The PbtO2 should be 20 to 40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20 to 30 mL/hour. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2.