Basic Care and Comfort NCLEX PN Questions Nursing Practice Question
A nurse is assessing a 18 year-old female who has recently suffered a TBI. The nurse should report these findings immediately to the physician, due to the possibility the patient is experiencing which of the following conditions?
Correct Answer: A
Rationale: Increased intracranial pressure (ICP) is a critical condition that can arise after a traumatic brain injury (TBI), potentially leading to severe complications. Symptoms such as altered consciousness, severe headache, or vomiting warrant immediate reporting to the physician for prompt intervention.
Increased function of cranial nerve X (vagus nerve) is not typically associated with TBI and does not require urgent attention. A sympathetic response to activity, while significant, is a normal physiological reaction and not an immediate concern. Meningitis, although serious, presents with specific signs such as fever and neck stiffness, which are not indicated in this scenario. Thus, monitoring for ICP is essential for patient safety.