Patho Patho #63

Question

The nurse caring for a client with a basilar skull fracture places priority on:

Answers

  1. monitoring the white blood cell count.
    • Rationale:

      This answer choice is not correct as monitoring the oxygen saturation is a higher priority. Infection is a risk with a basilar skull fracture but oxygen saturation is the more important assessment.

  2. maintaining the client in a supine position.
    • Rationale:

      This answer choice is not correct as a client with a basilar skull fracture should be maintained in an upright position in order to reduce intracranial pressure.

  3. alerting the physician to a blood pressure of 108/70.
    • Rationale:

      This answer choice is not correct as a blood pressure of 108/70 is considered acceptable and adequate to maintain cerebral perfusion.

  4. monitoring the client’s O2 saturation.
    • Rationale:

      This answer is correct as oxygen saturation is the most important assessment for a client with a basilar skull fracture. Any change in mental status or respiratory status could alert the nurse to possible brain herniation.

Overview

The focus of this question is asking the nurse to identify which assessment is most important when caring for a client with a basilar skull fracture. A basilar skull fracture is a serious traumatic brain injury in which there is a break at one of the bones at the base of the skull. It is critically important to perform frequent neuro checks to monitor for changes in level of consciousness because brain herniation is the most critical potential complication. The nurse should monitor respiratory status very closely, including oxygen saturation, which will help identify potential complications.

Explanation

Learning Outcomes

A basilar skull fracture is a break at the base of the skull. Classic manifestations include bruising behind the ears (mastoid sign), bruising around the eyes (raccoon eyes), and possible blood leakage from the nose and/or ears. As a result of increased intracranial pressure from bleeding and edema, brain herniation can result. The nurse must monitor for signs of this critical potential complications such as a change in mental and/or respiratory status.

Test Taking Tip

A-B-C

Video Rationale