Board-style questions created from the Frances Guide. Authored & peer-reviewed by Adult-Gerontology Acute Care NPs.
Each question is written to resemble the format and topics on the exam, meaning you won’t see any negatively phrased questions, no “all of the following except,” no “A and B”…you know what we mean. Most importantly, all questions include selective distractors (incorrect answer choices), which will help you think critically.
A 72-year-old woman presents to the intensive care unit with headache, lightheadedness, increasing confusion, and lethargy. Imaging reveals a chronic subdural hematoma with 11 mm clot thickness and minimal midline shift. Which of the following is the most appropriate next step?
Chronic subdural hematoma is a collection of blood on the surface of the brain below the dura. While more common in the older population, risk factors include alcohol use disorder, seizures, coagulopathies, cerebrospinal fluid shunts, and patients who are higher fall risks. While chronic subdural hematomas may start out as acute subdurals (such as with trauma from a head injury), the bleeding that leads to chronic formation is often secondary to small veins that slowly leak. Symptoms may be minor, such as headache, confusion, transient-ischemic attack-like symptoms, or language difficulties or may progress in severity to coma, seizures, and hemiplegia. Imaging with a noncontrast computed tomography of the head will determine the diagnosis. For patients with mild symptoms, monitoring closely is recommended. Seizure prophylaxis is used by some but can be safely discontinued after 1 week if no seizure activity is noted. Coagulopathies should be reversed if present. Consult with neurosurgery for surgical evacuation of the hematoma is indicated if there is significant progression of focal deficits or moderate to severe mental status changes, if the thickness of the subdural has progressed to ≥ 10 mm, or if midline shift is ≥ 5 mm. Patients will have clinical improvement if approximately 20% of the collection is removed, resulting in close to zero subdural pressure. Residual subdural fluid collections are common and do not warrant repeat surgery unless they increase in size.
Order strict bedrest with head of the bed flat (B) for 24–48 hours is appropriate following surgical drainage of subdural hematoma to prevent reaccumulation of blood at the surgical site. As the patient in the vignette has not yet had surgery, this is not the most appropriate answer choice. Prepare for intubation (C) is only appropriate if the patient has respiratory decline, which has not been documented in this vignette. Respiratory status should be closely monitored, however, as it can occur rapidly with continued compression on the brain and associated midline shift. Start seizure prophylaxis (D) is recommended by some, particularly if seizures have occurred, but given the information in the vignette, this is not the most appropriate answer choice.
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