ATI Head Injury

A Keep neck stabilized.

1. A nurse is caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on his forehead that is bleeding. Which of the following is the priority nupsing action at this time? A Keep neck stabilized. B. Insert nasogastric tube. C. Monitor pulse and blood pressure frequently. D. Establish IV access and start fluid replacement.

C. Oxygen saturation

2. A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? A. Glasgow Coma Scale B. Cranial nerve function C. Oxygen saturation D. Pupillary response

B. Decrease the noise level in the client's room D. Administer a stool softener.

3. A nursing is caring for a client who has a closed-head injury with ICP readings ranging from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (Select all that apply.) A. Suction the endotracheal tube frequently. B. Decrease the noise level in the client's room C. Elevate the client's head on two pillows. D. Administer a stool softener. E. Keep the client well hydrated.

A Headache B. Dilated pupils D. Decorticate posturing

4. A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (Select all that apply.) A Headache B. Dilated pupils C. Tachycardia D. Decorticate posturing E. Hypotension

B. Hyponatremia

5. A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? A. Hyperglycemia B. Hyponatremia C. Hypervolemia D. Oliguria