Certified Medical-Surgical Registered Nurse Practice Exam

If a patient with a head injury exhibits slurred speech and disorientation, what should the nurse's initial action be?

1. Continue hourly neurologic assessments

2. Inform the neurosurgeon of the patient's status

3. Prepare the patient for emergency surgery

4. Recheck the patient's neurologic status in 15 minutes

The correct answer is: Inform the neurosurgeon of the patient's status

In cases involving patients with head injuries, the neurological status can change rapidly and may indicate a worsening condition, such as increased intracranial pressure or a potential life-threatening scenario. When a patient exhibits symptoms like slurred speech and disorientation, these can be signs of significant neurological compromise. The immediate priority in such a situation is to ensure that skilled medical intervention is promptly arranged. Informing the neurosurgeon about the patient's status is crucial because they can evaluate the need for further diagnostics or potentially urgent interventions, such as imaging studies or emergency surgical procedures. It is essential to provide the neurosurgeon with detailed observations of the patient's neurological changes as this could influence the treatment strategy and lead to appropriate actions being taken quickly. In contrast, while conducting hourly neurologic assessments, preparing for surgery, or rechecking neurologic status are important nursing actions, they may delay necessary interventions. Continuous assessment is critical, but notifying the neurosurgeon should take precedence as it could lead to vital changes in patient management that directly address the acute symptoms experienced by the patient.