Question 15Type: MCSAFollowing a fall, a patient is brought to the emergency department. There was a brief loss of consciousness; the patient complains of headache, has vomited twice, has a dilated pupil on the same side as a hematoma over the temporal area, and is currently having a seizure. The nurse prepares to care for this patient based on which evaluation of this assessment?
1. This is an emergency situation likely involving an epidural hematoma and requires surgery.2. This is a controlled situation once the seizure stops.3. This is a serious situation in which a subdural hematoma is developing and requires surgery.4. This is a typical situation seen with most patients who fall, and symptoms will subside with observation.Correct Answer: Rationale 1: Classic signs of an epidural hematoma include a loss of consciousness followed by a brief lucid period before rapid deterioration.Rationale 2: Because this injury involves a skull fracture that tears an artery, the patient is bleeding uncontrollably into the head. The bleeding may continue until herniation occurs. The situation is not controlled.Rationale 3: A subdural hematoma would be manifested by drowsiness, confusion, and enlargement of the ipsilateral pupil within minutes of the injury. Hemiparesis and changes in respiratory pattern may soon follow.
1
Rationale 4: The assessments as stated indicate that the patient will require immediate intervention, not simply observation.
Global Rationale:
Cognitive Level:
Analyzing
Client Need:
Physiological Integrity
Client Need Sub:
Physiological Adaptation
Nursing/Integrated Concepts:
Nursing Process: Implementation
Learning Outcome:
21-3
Question 16Type: MCSAA patient is having a seizure that involves a blank stare, unresponsiveness to questions, and smacking of the lips. The seizure lasts less than a minute. How would the nurse categorize this seizure?
1
Global Rationale:
Cognitive Level:
Applying
Client Need:
Physiological Integrity
Client Need Sub:
Physiological Adaptation
Nursing/Integrated Concepts:
Nursing Process: Assessment
Learning Outcome:
21-6
Question 17
Type:
MCSA
