A patient is admitted to the Emergency Department (ED). The nurse documents "postictal upon transfer" as evidenced by which observation?
Abnormal sensory sensations including tingling of the skin
Yellowing of the skin
Severe itching of the eyes
Is in a drowsy confused state after a seizure
The Correct Answer is D
A. Abnormal sensory sensations such as tingling may be associated with the aura phase of a seizure but are not typically observed postictally.
B. Yellowing of the skin is usually indicative of jaundice, unrelated to seizure activity or the postictal state.
C. Itching of the eyes is unrelated to seizure activity and would not typically be documented in the context of postictal observations.
D. The postictal state is characterized by drowsiness, confusion, and other altered mental statuses that follow a seizure. This period can vary in duration depending on the patient and seizure type.
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Correct Answer is A
Explanation
A. A patient found facedown in water is at high risk of anoxic brain injury due to potential prolonged oxygen deprivation, which is directly associated with lack of oxygen to the brain.
B. Multiple concussions can lead to other types of brain injury but are less associated with anoxic injury than prolonged oxygen deprivation.
C. A basilar skull fracture can cause complications such as CSF leaks but does not directly cause an anoxic brain injury.
D. An epidural hematoma may increase ICP, but with timely intervention, anoxic injury may be avoided; anoxic brain injury is more directly related to oxygen deprivation.
Correct Answer is D
Explanation
A. EEG is a monitoring tool for brain activity, but it is not a prerequisite for ventriculostomy placement.
B. While the procedure is carefully managed to reduce infection risk, ventriculostomy does have an infection risk due to its invasive nature.
C. Ventriculostomy is not inserted via the femoral artery; it is placed directly in the brain’s ventricles.
D. A ventriculostomy is used to monitor ICP and allows for the drainage of cerebrospinal fluid, which helps in managing elevated ICP in patients with brain injuries.