Janine is a 7-year-old girl involved in a motor vehicle accident while riding of her tricycle. A car was going approximately 40 kms/hr. and hit Janine at her rear. She was thrown 3 meters away and she landed on the sidewalk. She lost consciousness and was brought immediately to the ER.
41. Upon arrival at the ER, Janine's intracranial pressure is 15 umHg, which means that she is having_______increased intracranial pressure:
A. Severe
B. Moderate
C. Mild
D. Mild to moderate
42. The head nurse diagnosed Janine to have "Altered thought processes secondary to blunt injuries." Which of the following nursing assessments should be done by the nurse?
I. Assess level of consciousness
II. Perform neurologic examination
III. Monitor Glasgow Coma Scale
IV. Reassess memory of event
A. I, III and Iv
B. I, II adn IV
C. II, III and IV
D. I, II and III
43. Considering the degree of increased intracranial pressure, what would be the best position of Janine's head?
A. Maintained flat on bed
B. Elevated to 60 degree
C. Turned to the side
D. Elevated to 30 degrees
44. Her parents were very anxious about Janice's brief loss of consciousness. Which of the following should not be included in the nurse's examination?
A. There is a need for the parents to participate in planning for her care
B. This is associated with delayed response to head injury
C. It frequently result in temporary memory loss
D. This can cause a lifelong memory loss
45. CT scan showed a liver laceration. Which of the following nursing diagnosis is most appropriate for this problem?
A. Alteration in cardiac output related to fluids shifts
B. Altered tissue perfusion related to bleeding
C. Fluid volume deficit related to blunt injury of the liver
D. Potential for injury-related to liver laceration
