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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: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 21-3Question 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?1Global Rationale: Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 21-6Question 17Type: MCSA