Medical Surgical Head Injury #4

Question

The nurse is assigned to care for a client following a craniotomy. Which action by the nurse would the charge nurse need to intervene?

Answers

  1. Immediately raising the head of the bed to 90 degrees.
    • Rationale:

      This answer is correct since the nurse will assess the physician’s order regarding client positioning. Client positioning following a craniotomy depends on the type of surgery, the specific postoperative phase, and the surgeon’s orders. Incorrect positioning can be fatal.

  2. Monitor for increased intracranial pressure.
    • Rationale:

      This answer is not correct because head trauma can cause increased intracranial pressure (ICP) when cerebrospinal fluid or bleeding from the brain causes increased pressure inside the skull and brain tissue. The nurse will monitor for signs of increased intracranial pressure by observing for mental status changes, pupillary changes, headache, increased respiratory rate, seizures, and nausea, or vomiting.

  3. Record intake and output hourly.
    • Rationale:

      This answer is not correct because the nurse will carefully measure and record input and output hourly to monitor for diabetes insipidus. An acute head trauma can lead to dysfunction of the antidiuretic hormone, causing the client to be at risk for diabetes insipidus.

  4. Monitor neurological status every 30 minutes.
    • Rationale:

      This answer is not correct because following a craniotomy, the nurse will monitor the client’s neurological status every 30 minutes to one hour. Early detection of an abnormality can result in a more positive neurological outcome for the client.

Overview

A craniotomy is the surgical opening of the skull to treat a disease or injury of the brain. Nursing care following a craniotomy involves very close neurological observation.

Explanation

Learning Outcomes

A craniotomy is the surgical opening of the skull to treat a disease or injury of the brain. The nurse will assess the physician’s order regarding client positioning. Client positioning following a craniotomy is critical and depends on the type of surgery, the specific postoperative phase, and the surgeon’s orders. Incorrect positioning can be fatal. Nursing care following a craniotomy involves very close neurological observation. The nurse will monitor for signs of increased intracranial pressure by observing for mental status changes, pupillary changes, headache, increased respiratory rate, seizures, and nausea, or vomiting. An acute head trauma can lead to dysfunction of the antidiuretic hormone, causing the client to be at risk for diabetes insipidus, thus the nurse will also carefully record input and output.

Test Taking Tip

Understanding standards of care post-craniotomy, including neurological assessment is important to help the test-taker choose the correct answer.

Video Rationale