EXAM 5

During the eye assessment of a patient with increased ICP, you need to assess the oculocephalic reflex. If the patient has brain stem damage what response will you find? A. The eyes will roll down as the head is moved side to side. B. The eyes will move in the opposite direction as the head is moved side to side. C. The eyes will roll back as the head is moved side to side. D. The eyes will be in a fixed mid-line position as the head is moved side to side.

d

The nurse is caring for a patient who is being evaluated clinically for brain death by a physician. Which assessment findings by the nurse support brain death? a. Absence of a corneal reflex b. Unequal, reactive pupils c. Withdrawal from painful stimuli d. Core temperature of 100.8 F

a

vasogenic cerebral edema increases intracranial pressure by a. shifting fluid in the gray matter b. altering the endothelial lining of cerebral capillaries c. leaking molecules from the intracellular to the capillaries d. altering the osmotic gradient flow into the intravascular component

b

A patient is experiencing hyperventilation and has a PaCO2 level of 52. The patient has an ICP of 20 mmHg. As the nurse you know that the PaCO2 level will? A. cause vasoconstriction and decrease the ICP B. promote diuresis and decrease the ICP C. cause vasodilation and increase the ICP D. cause vasodilation and decrease the ICP

c - An elevated carbon dioxide level in the blood will cause vasodilation (NOT constriction), which will increase ICP (normal ICP 5 to 15 mmHg).

A physician has prescribed propylthiouracil (PTU) for a client with hyperthyroidism and the nurse develops a plan of care for the client. A priority nursing assessment to be included in the plan regarding this medication is to assess for: a) relief of pain b) signs of renal toxicity c) signs and symptoms of hyperglycemia d) signs and symptoms of hypothyroidism

d

Which option indicates a sign of Cushing's triad, an indication of increased intracranial pressure (ICP)? A. Heart rate increases from 90 to 110 beats/minute B. Kussmaul respirations C. Temperature over 100.4° F (38° C) D. Heart rate decreases from 75 to 55 beats/minute

d

he nurse is aware that the following is the most common cause of hyperaldosteronism? a. Excessive sodium intake b. A pituitary adenoma c. Deficient potassium intake d. An adrenal adenoma

d

t/f: you need to be healthy to donate

false

t/f: the pancreases is controlled from the hypothalamus

false - it does it own thing

During admission of a patient with a severe head injury to the ED, the nurse places highest priority on assessment for a. patency of of airway b. presence of a neck injury c. neurologic status with Glascow Coma Scale d. CSF leakage from ears and nose

a

For the first 72 hours after thyroidectomy surgery, nurse Jamie would assess the female client for Chvostek's sign and Trousseau's sign because they indicate which of the following? a. Hypocalcemia b. Hypercalcemia c. Hypokalemia d. Hyperkalemia

a

Nurse Louie is developing a teaching plan for a male client diagnosed with diabetes insipidus. The nurse should include information about which hormone lacking in clients with diabetes insipidus? a. antidiuretic hormone (ADH). b. thyroid-stimulating hormone (TSH). c. follicle-stimulating hormone (FSH). d. luteinizing hormone (LH).

a

The ICP measurement is 20 and the CR measures 2.6. Which of the physician orders should be clarified according to the laboratory results? a. Mannitol 50 gms IV push b. Dexamethasone 4 mg IV push c. Enalapril 2.5 mg IV push d. Diazepam 5 mg IV push

a

The charge nurse is reviewing the status of patients in the critical care unit. Which patient should the nurse notify the organ procurement organization to evaluate for possible organ donation? a. A 36-year-old patient with a Glasgow Coma Scale score of 3 with no activity on electroencephalogram b. A 68-year-old male admitted with unstable atrial fibrillation who has suffered a stroke c. A 40-year-old brain-injured female with a history of ovarian cancer and a Glasgow Coma Scale score of 7 d. A 53-year-old diabetic male with a history of unstable angina status post resuscitation

a

The nurse checks the ETT hold in the back of the neck of a ICH (intracranial hemorrhage). The preceptee asks what is the rationale. The nurse's best response is: a. If the ETT holder is too tight; it can obstruct venous outflow b. If the ETT holder needs to be changed c. If the ETT holder is too loose; the ETT will dislodge d. If the ETT holder needs to be adjusted

a

The nurse is caring for a client who is about to undergo an adrenalectomy. Which of the following Preoperative interventions is most appropriate for this client? a. Maintain careful use of medical and surgical asepsis when providing care and treatments. b. Teach the client about a diet high in sodium to correct any potential sodium imbalances preoperatively. c. Explain to the client that electrolytes and glucose levels will be measured postoperatively. d. Teach the client how to effectively cough and deep breathe once surgery is complete.

a

The nurse is working for a hospital that holds an agreement with a local organ procurement organization (OPO). The patient has a Glasgow Coma Scale (GCS) score of 3 and discussions have been held with the family about withdrawing life support. Which statement by the nurse best describes requirements that must be met to sustain Centers for Medicare and Medicaid Services (CMS) Conditions of Participation? a. I need to notify TransLife (OPO) of my patients impending death. b. I will contact the physician to obtain informed consent for organ donation. c. The charge nurse will notify TransLife (OPO) once the patient has been pronounced brain dead. d. I need the physician to evaluate my patients suitability for organ donation.

a

The nurse plans long-term goals for the patient who has had a heart transplant with the knowledge that a common cause of death in heart transplant patients during the first year is: a. infection b. heart failure. c. embolization d. malignant conditions

a

Which outcome indicates that treatment of a male client with diabetes insipidus has been effective? a. Fluid intake is less than 2,500 ml/day. b. Urine output measures more than 200 ml/hour. c. Blood pressure is 90/50 mm Hg. d. The heart rate is 126 beats/minute

a

Nurse Troy is aware that the most appropriate for a client with Addison's disease? a. Risk for infection b. Excessive fluid volume c. Urinary retention d. Hypothermia

a - Addison's disease decreases the production of all adrenal hormones, compromising the body's normal stress response and increasing the risk of infection. Other appropriate nursing diagnoses for a client with Addison's disease include Deficient fluid volume and Hyperthermia. Urinary retention isn't appropriate because Addison's disease causes polyuria.

A female client with Cushing's syndrome is admitted to the medical-surgical unit. During the admission assessment, nurse Tyzz notes that the client is agitated and irritable, has poor memory, reports loss of appetite, and appears disheveled. These findings are consistent with which problem? a. Depression b. Neuropathy c. Hypoglycemia d. Hyperthyroidism

a - Agitation, irritability, poor memory, loss of appetite, and neglect of one's appearance may signal depression, which is common in clients with Cushing's syndrome. Neuropathy affects clients with diabetes mellitus — not Cushing's syndrome. Although hypoglycemia can cause irritability, it also produces increased appetite, rather than loss of appetite. Hyperthyroidism typically causes such signs as goiter, nervousness, heat intolerance, and weight loss despite increased appetite.

The patient reports falling when he his foot got "stuck" on a crack in the sidewalk, hitting his head when he fell, and "passing out". The paramedics found the patient walking at the scene and talking before transporting the patient to the hospital. In the emergency department, the patient starts to lose consciousness. This is a classic scenario for which complication? A. Epidural hematoma B. Subdural hematoma C. Subarachnoid bleed D. Diffuse axial inju

a - Epidural hematoma often results from a linear fracture crossing a major artery in the dura. The classic sign is an initial period of unconsciousness at the scene and a brief lucid interval followed by a decrease in LOC. A subdural hematoma often results from injury to the brain and veins and develops more slowly. The classic sign or symptom of subarachnoid hemorrhage is a patient describing "the worst headache of my life." Diffuse axonal injury is widespread axonal damage occurring after a traumatic brain injury.

Which nursing action should be implemented in the care of a patient who is experiencing increased ICP? A. Monitor fluid and electrolyte status astutely. B. Position the patient in a high-Fowler's position. C. Administer vasoconstrictors to maintain cerebral perfusion. D. Maintain physical restraints to prevent episodes of agitation.

a - Fluid and electrolyte disturbances can have an adverse effect on ICP and must be vigilantly monitored. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically administered in the treatment of ICP.

In a 29-year-old female client who is being successfully treated for Cushing's syndrome, nurse Lyzette would expect a decline in: a. Serum glucose level. b. Hair loss. c. Bone mineralization. d. Menstrual flow.

a - Hyperglycemia, which develops from glucocorticoid excess, is a manifestation of Cushing's syndrome. With successful treatment of the disorder, serum glucose levels decline. Hirsutism is common in Cushing's syndrome; therefore, with successful treatment, abnormal hair growth also declines. Osteoporosis occurs in Cushing's syndrome; therefore, with successful treatment, bone mineralization increases. Amenorrhea develops in Cushing's syndrome. With successful treatment, the client experiences a return of menstrual flow, not a decline in it.

A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema. An appropriate nursing intervention for the patient is a. avoiding positioning the patient with neck and hip flexion b. maintaining hyperventilation to a PaCO2 of 15 to 20 mm Hg c. clustering nursing activities to provide periods of uninterrupted rest d. routine suctioning to prevent accumulation of respiratory secretions

a - Nursing care activities that increase ICP include hip and neck flexion, suctioning, clustering care activities, and noxious stimuli; they should be avoided or performed as little as possible in the patient with increased ICP. Lowering the PaCO2 below 20 mm Hg can cause ischemia and worsening of ICP; the PaCO2 should be maintained at 30 to 35 mm Hg.

A patient is admitted to the hospital with a diagnosis of Cushing syndrome. On physical assessment of the patient, the nurse would expect to find a. HTN, peripheral edema, and petechiae b. weight loss, buffalo hump, and moon face with acne c. abdominal and buttock striae, truncal obesity, and hypotension d. anorexia, signs of dehydration, and hyper pigmentation of the skin

a - The effects of glucocorticoid excess include weight gain from accumulation and redistribution of adipose tissue, sodium and water retention, glucose intolerance, protein wasting, loss of bone structure, loss of collagen, and capillary fragility. Clinical manifestations of corticosteroid deficiency include hypotension, dehydration, weight loss, and hyperpigmentation of the skin

A patient who has received a solid organ transplant is experiencing chronic rejection. What symptoms does the nurse most expect? A) Lack of T-cell activity or increase B) Evidence of deteriorating organ function C) Evidence of immune suppression D) Negative antigenantibody reactions

b

A patient with SIADH is treated with water restriction and administration of IV fluids. The nurses evaluates that treatment has been effective when the patient experiences a. increased urine output, decreased serum sodium, and increased urine specific gravity b. increased urine output, increased serum sodium, and decreased urine specific gravity c. decreased urine output, increased serum sodium, and decreased urine specific gravity d. decreased urine output, decreased serum sodium, and increased urine specific gravity

b

Early this morning, a female client had a subtotal thyroidectomy. During evening rounds, nurse Tina assesses the client, who now has nausea, a temperature of 105° F (40.5° C), tachycardia, and extreme restlessness. What is the most likely cause of these signs? a. Diabetic ketoacidosis b. Thyroid crisis c. Hypoglycemia d. Tetany

b

Of what precautions should a client receiving radioactive iodine-131 be made aware? a.) Drink plenty of fluids, especially those high in calcium. b.) Avoid close contact with children or pregnant women for one week after administration of drug. c.) Be aware of the symptoms of tachycardia, increased metabolic rate, and anxiety. d.) Wear a mask if around children or pregnant women.

b

The nurse plans care for a patient with increased ICP with the knowledge that the best way to position the patient is to a. keep the head of the bed flat b. elevate the head of the bed to 30 degrees c. maintain patient on the left side with the head supported on a pillow d. use a continuous rotation bed to continuously change patient position

b

The patient has rhinorrhea after a head injury. What action should you take? A. Pack the nares with sterile gauze. B. A loose collection pad may be placed under the nose. C. Suction the drainage with an inline suction catheter. D. Obtain a sample for culture.

b

You are caring for a patient admitted with a subdural hematoma after a motor vehicle accident. Which change in vital signs would you interpret as a manifestation of increased intracranial pressure? A. Tachypnea B. Bradycardia C. Hypotension D. Narrowing pulse pressure

b

You're providing education to a group of nursing students about ICP. You explain that when cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies. A student asks, "What is a normal cerebral perfusion pressure level?" Your response is: A. 5-15 mmHg B. 60-100 mmHg C. 30-45 mmHg D. >160 mmHg

b

a nursing measure that is indicated to reduce the potential for seizures and increased ICP in the patient with bacterial meningitis is a. administering codeine for relief of head and neck pain b. controlling fever with prescribed drugs and cooling techniques c. keeping the room dark and quiet to minimize environmental stimulation d. maintaining the pt on strict bed rest withthe HOB slightly elevated

b

A patient with hypothyroidism is treated with Synthroid. When teaching the patient about the therapy, the nurse a. explains that caloric intake must be reduced when drug therapy is started b. provides written instruction for all information related to the medication therapy c. assures the patient that a return to normal function will occur with replacement therapy d. informs the patient that medications must be taken until hormone balance is reestablished

b - (rationale- because of the mental sluggishness, inattentiveness, and memory loss that occur with hypothyroidism, it is important to provide written instructions and repeat information when teaching the patient. Caloric intake can be increased when drug therapy is started, because of an increased metabolic rate, and replacement therapy must be taken for life. Although most patients return to a normal state with treatment, cardiovascular conditions and psychoses may persist.)

A client newly diagnosed with Addison's disease is giving a return explanation of teaching done by the primary nurse. Which of the following statements indicates that further teaching is necessary? a. "I need to increase how much I drink each day." b. "I need to weigh myself if I think I am losing or gaining weight." c. "I need to maintain a diet high in sodium and low in potassium." d. "I need to take my medications each day."

b - Clients with Addison's disease must learn to provide lifelong self-care that involves varied components: medications, diet, and recognizing and responding to stress. Changes in lifestyle are difficult to maintain permanently. The client needs to take the medications on a daily basis. The client needs to perform daily weights to monitor for signs of dehydration. The client needs to maintain a diet high in sodium and low in potassium, as well as maintain an increased fluid intake.

The nurse is managing a donor patient six hours prior to the scheduled harvesting of the patients organs. Which assessment finding requires immediate action by the nurse? a. Morning serum blood glucose of 128 mg/dL b. pH 7.30; PaCO2 38 mm Hg; HCO3 16 mEq/L c. Pulmonary artery temperature of 97.8 F d. Central venous pressure of 8 mm Hg

b - Donor management, focuses on maintaining hemodynamic stability and normal

Nurse Oliver should expect a client with hypothyroidism to report which health concerns? a. Increased appetite and weight loss b. Puffiness of the face and hands c. Nervousness and tremors d. Thyroid gland swelling

b - Hypothyroidism (myxedema) causes facial puffiness, extremity edema, and weight gain. Signs and symptoms of hyperthyroidism (Graves' disease) include an increased appetite, weight loss, nervousness, tremors, and thyroid gland enlargement (goiter).

Which of these signs suggests that a male client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications? a. Tetanic contractions b. Neck vein distention c. Weight loss d. Polyuria

b - SIADH secretion causes antidiuretic hormone overproduction, which leads to fluid retention. Severe SIADH can cause such complications as vascular fluid overload, signaled by neck vein distention. This syndrome isn't associated with tetanic contractions. It may cause weight gain and fluid retention (secondary to oliguria).

A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. The nurse records the patients GCS score a. 6 b. 7 c. 9 d. 11

b - no opening of eyes = 1; incomprehensible words= 2, flexion withdrawal = 4Total = 7

Why is it important to make sure the patient with increase ICP be euvolemic when giving Mannitol? (Select all that apply) a. Sodium shifts can cause evulovolemia b. Hypotension can cause a secondary brain injury c. Large amounts of urine output from Mannitol puts the patient at risk of hypovolemia d. Hypovolemia can cause hypotension

b, c, d

A client presents to the emergency room with a history of Graves' disease. The client reports having symptoms for a few days, but has not previously sought or received any additional treatment. The client also reports having had a cold a few days back. Which of the following interventions would be appropriate to implement for this client, based on the history and current symptoms? Select all that apply. a. Administer aspirin b. Replace intravenous fluids c. Induce shivering d. Relieve respiratory distress e. Administer a cooling blanket

b, c, d, e

A 21-year-old is dying after an automobile accident. The family members want to donate the patient's organs and ask the nurse how the decision about brain death is made. The nurse explains that the patient will be considered brain dead when a. the patient is flaccid and unresponsive. b. CPR is ineffective in restoring heartbeat. c. the patient is apneic and without brainstem reflexes. d. respiratory efforts cease and no apical pulse is audible.

c

A family member approaches the nurse caring for their gravely ill son and states, We want to donate our sons organs. What is the best action by the nurse? a. Arrange a multidisciplinary meeting with physicians. b. Consult the hospitals ethics committee for a ruling. c. Notify the organ procurement organization (OPO). d. Obtain family consent to withdraw life support.

c

A female client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg P.O. daily. Which finding should nurse Hans recognize as an adverse drug effect? a. Dysuria b. Leg cramps c. Tachycardia d. Blurred vision

c

A nursing student is studying for a test on care of the client with endocrine disorders. Which of the following statements demonstrates an understanding of the difference between hyperthyroidism and hypothyroidism? a. "Deficient amounts of TH cause abnormalities in lipid metabolism, with decreased serum cholesterol and triglyceride levels." b. "Graves' disease is the most common cause of hypothyroidism." c. "Decreased renal blood flow and glomerular filtration rate reduces the kidney's ability to excrete water, which may cause hyponatremia." d. "Increased amounts of TH cause a decrease in cardiac output and peripheral blood flow."

c

A patient has a ventriculostomy. Which finding would you immediately report to the doctor? A. Temperature 98.4 'F B. CPP 70 mmHg C. ICP 24 mmHg D. PaCO2 35

c

A patient has experienced brain death after a head injury and the family has consented to organ donation. In this situation, who does the nurse now recognize as managing the care of that donor? A) Attending physician B) Intensive care physician team C) Registered nurse from organ procurement organization D) Pathophysiologist from the medical examiners office

c

A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication? A. Bradycardia B. Decerebrate posturing C. Restlessness D. Unequal pupil size

c

A patient with increased ICP has mannitol (Osmitrol) prescribed. Which option is the best indication that the drug is achieving the desired therapeutic effects? A. Urine output increases from 30 mL to 50 mL/hour. B. Blood pressure remains less than 150/90 mm Hg. C. The LOC improves. D. No crackles are auscultated in the lung fields

c

A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these findings you would? A. Administered PRN dose of a vasopressor B. Administer 2 L of oxygen C. Remove extra blankets and give the patient a cool bath D. Perform suctioning

c

An incoherent female client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area. Knowing that these findings suggest severe hypothyroidism, nurse Libby prepares to take emergency action to prevent the potential complication of: a. Thyroid storm. b. Cretinism. c. Myxedema coma. d. Hashimoto's thyroiditis.

c

In the administration of a drug such as levothyroxine (Synthroid), the nurse should teach the client: A) That therapy typically lasts about 6 months. B) That weekly laboratory tests for T4 levels will be required. C) To report weight loss, anxiety, insomnia, and palpitations. D) That the drug may be taken every other day if diarrhea occurs.

c

Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a head injury. To evaluate the effectiveness of the therapy, the nurse should a. monitor oxygen saturation. b. check arterial blood gases (ABGs). c. monitor intracranial pressure (ICP). d. assess patient breath sounds.

c

When assessing a patient who had a liver transplant a week previously, the nurse obtains the following data. Which finding is most important to communicate to the health care provider? a. Dry lips and oral mucous b. Crackles at both lung bases c. Temperature 100.8° F (38.2° C) d. No bowel movement for 4 days

c

Which of the following nursing implications is most important in a client being medicated for Addison's disease? a. Administer oral forms of the drug with food to minimize its ulcerogenic effect. b. Monitor capillary blood glucose for hypoglycemia in the diabetic client. c. Instruct the client to never abruptly discontinue the medication. d. Teach the client to consume a diet that is high in potassium, low in sodium, and high in protein.

c

While the nurse performs ROM on an unconscious patient with increased ICP, the patient experiences severe decerebrate posturing reflexes. The nurse should a. use restraints to protect the patient from injury b. administer CNS depressants to lightly sedate the patient c. perform the exercises less frequently because posturing can increase ICP d. continue the exercises because they are necessary to maintain musculoskeletal function

c

The earliest signs of increased ICP the nurse should assess for include a. Cushing's triad b. unexpected vomiting c. decreasing level of consciousness (LOC) d. dilated pupil with sluggish response to light

c - A decrease in LOC will occur before changes in vital signs, ocular signs, and projectile vomiting occur

The nurse is caring for a patient in the critical care unit who, after being declared brain dead, is being managed by the OPO transplant coordinator. Thirty minutes into the shift, assessment by the nurse includes a blood pressure 75/50 mm Hg, heart rate 85 beats/min, and respiratory rate 12 breaths/min via assist/control ventilation. The oxygen saturation (SpO2) is 99% and core temperature 93.8 F. Which physician order should the nurse implement first? a. Apply forced air warming device to keep temperature > 96.8 b. Obtain basic metabolic panel every 4 hours until surgery c. Begin phenylephrine (Neo-Synephrine) for systolic BP < 90 mm Hg d. Draw arterial blood gas every 4 hours until surgery

c - Hemodynamic stability is a priority in donor management. Following brain death, loss of autoregulation results in intense vasodilation. To maintain perfusion to the vital organs, the priority action is to begin a phenylephrine (Neo-Synephrine) infusion to get systolic BP > 90 mm Hg. Maintaining normothermia is the next priority. Obtaining laboratory tests and arterial blood gasses is a part of donor management but not the priority in this scenario.

A 54-year old man is recovering from a skull fracture with a subacute subdural hematoma. He has return of motor control and orientation but appears apathetic and has reduced awareness of his environment. When planning discharge or the patient, the nurse explains to the patient and the family that a. continuous improvement in the patient's condition should occur until he has returned to pre trauma status b. the patient's complete recovery may take years, and the family should plan for his long term dependent care c. the patient is likely to have long term emotional and mental changes that may require continued professional help d. role changes in family members will be necessary because the patient will be dependent on his family for care and support

c - Residual mental and emotional changes of brain trauma with personality changes are often the most incapacitating problems following head injury and are common in patients who have been comatose longer than 6 hours. Families must be prepared for changes in the patient's behavior to avoid family-patient friction and maintain family functioning, and professional assistance may be required. There is no indication he will be dependent on others for care, but he likely will not return to pre trauma status

A male client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? a. Infusing I.V. fluids rapidly as ordered b. Encouraging increased oral intake c. Restricting fluids d. Administering glucose-containing I.V. fluids as ordered

c - To reduce water retention in a client with the SIADH, the nurse should restrict fluids. Administering fluids by any route would further increase the client's already heightened fluid load.

A patient with increased ICP is being monitored in the intensive care unit (ICU) with a fiberoptic catheter. Which order is a priority for you?A. Perform hourly neurologic checks. B. Take a complete set of vital signs. C. Administer the prescribed mannitol (Osmitrol). D. Give an H2-receptor blocker.

c -the priority is to treat the known existing problem, and mannitol is the only thing that can do that. Because the patient is having the current pressure measured with objective numbers, treating the known problem is a priority over additional assessments. H2-blockers are given when corticosteroids are administered to help prevent gastrointestinal bleeding, but they are not a priority compared with the treatment of ICP.

nursing management of a patient with a brain tumor includes (select all that apply) a. discussing with the patient the methods to control inappropirate behavior b. using diversion techniques to keep the pt stimulated and motivated c. assissting and supporting the family in understanding any changes in behavior d. limiting self care activities until the pt has regained maximal physical functioning e. planning for seizure precautions and teaching the pt and the caregivers about anti seizure drugs

c and e

A patient with hyperthyroidism is taking propylthiouracil (PTU). The nurse will monitor the patient for: A) gingival hyperplasia and lycopenemia. B) dyspnea and a dry cough. C) blurred vision and nystagmus. D) fever and sore throat.

d

Causes of primary hypothyroidism in adults include a. malignant or benign thyroid nodules b. surgical removal or failure of the pituitary gland c. surgical removal or radiation of thyroid gland d. autoimmune-induced atrophy of the gland

d

A patient presents to the outpatient transplant clinic stating, I would like to donate one of my kidneys. What is the best response by the nurse? a. To be a living donor, you must be related to the recipient. b. You must be over the age of 30 to be a living donor. c. Living donor donation is coordinated by UNOS. d. Let us orient you to the process required to become a donor.

d - An altruistic living donor is an individual who makes a decision to donate an organ or part of an organ to a stranger. The nurse can help the patient navigate the donation process. Living donors may be related or unrelated to the potential recipient. In general, living donors are usually between the ages of 18 and 60 years. All transplant centers coordinate the living donation process.

Successful achievement of patient outcomes for the patient with cranial surgery would be best indicated by the a. ability to return home in 6 days b. ability to meet all self-care needs c. acceptance of residual neurologic deficits d. absence of signs and symptoms of increased ICP

d - The primary goal after cranial surgery is prevention of increased ICP, and interventions to prevent ICP and infection postoperatively are nursing priorities. The residual deficits, rehabilitation potential, and ultimate function of the patient depend on the reason for surgery, the postoperative course, and the patient's general state of health

The charge nurse of a transplant unit is reviewing the clinical course of several transplant patients being cared for in the unit. Which patient assessed by the charge nurse requires immediate action? a. Renal transplant recipient, 1 day post op with a 3/10 pain level b. Lung transplant recipient, 1 day post op with a productive cough c. Heart transplant recipient, 1 day post op with a cardiac output of 4 L/min d. Liver transplant recipient, 12 hours post op with a serum glucose of 58 mg/dL

d - indicates hypoglycemia which is not good. the other answers are within normal range following a transplant

The nurse obtains initial vital signs on a patient 2 weeks posttransplant who presents for follow-up monitoring to the outpatient transplant clinic. Which assessment finding by the nurse requires immediate action? a. Blood pressure of 100/60 mm Hg b. Serum creatinine of 1.5 mg/dL c. Hemoglobin of 9.2 gm/dL d. Tenderness over graft site

d - the other values are within normal range for a transplant

Which nursing diagnosis takes highest priority for a female client with hyperthyroidism? a. Risk for imbalanced nutrition: More than body requirements related to thyroid hormone excess b. Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing c. Body image disturbance related to weight gain and edema d. Imbalanced nutrition: Less than body requirements related to thyroid hormone excess

d -In the client with hyperthyroidism, excessive thyroid hormone production leads to hypermetabolism and increased nutrient metabolism. These conditions may result in a negative nitrogen balance, increased protein synthesis and breakdown, decreased glucose tolerance, and fat mobilization and depletion. This puts the client at risk for marked nutrient and calorie deficiency, making Imbalanced nutrition: Less than body requirements the most important nursing diagnosis. Options B and C may be appropriate for a client with hypothyroidism, which slows the metabolic rate.

what is a secondary adrenal/thyroid issue from?

disorder outside of the thyroid or adrenal which usually means something is going on with the hypothalamus or pituitary gland

what is primary adrenal/thyroid issue from?

due to lack in the thyroid or adrenal gland. - THE SOURCE ITSELF

PRESSURE Acronym treatment for increased ICP: 2nd E

edema management with mannitol!!!

what is nephrogenic diabetes insipidus

from an issue in the kidney - due to infection, meds, renal disease

what is neurogenic diabetes insipidus

from posterior pituitary gland and ADH - from a tumor, cancer, head trauma, removal of PP

what is a hyperglycemic emergency?

reduction circulating insulin with concurrent counter of regulatory hormones

what is part of the hourly neuro exam

- GCS - focal motor - pupils - check cranial nerves - gag reflex

what is the age range for organ donation?

18 - 80 years old

When hyperventilating a patient with increased ICP, what is the PaCO2 goal?

25

When a patient is admitted to the emergency department following a head injury, the nurse's first priority in management of the patient once a patent airway is confirmed is a. maintaining cervical spine precautions b. determining the presence of increased ICP c. monitoring for changes in neurologic status d. establishing IV access with a large-bore catheter

A - think of the trauma process, A comes with c spine immobilization

what does the posterior pituitary gland include?

ADH which helps conserve the fluid volume in the body and control urine output

what are the labs we take with neuro patients?

CBC, CMP, MG, phosphorus, coag., ABG, NA

if we suspect a neuro change or increase in ICP in the patient, what is the main DX test we would do

CT scan - MRI is down the road once they are STABLE

A patient with Addison's is scheduled for discharge after being hospitalized for an adrenal crisis. Which statement by the patient would indicate that education by the nurse has been effective? ONLY ONE ANSWER A."I have to take my steroids for ten days" B."I need to count my calories and weigh daily" C."I need to call the provider before I have dental work" D."I will call my provide if I suddenly feel weak" E."I will expect my blood pressure to be high" F."I need to wear a medic alert bracelet"

F - not a bc its a lifetime drug - not b because more so for heart failure patients - not c because more patients with valve replacement - not D because its a symptom but not something to call provider about not E because blood pressure will be LOW

what is the OPO?

Organ Procurement Organization - which are assigned to different areas all over states for organ donation - must have a different one for eye banks

what is this? can come from neuro issue, lung issue, GI issue, drugs and is an issue with antidiuretic hormone. we will see a large urine output and low NA

SIADH

what is the role of the pituitary gland

To control the release of hormones from all the other endocrine glands in the body, works in a negative feedback loop

A physician prescribes levothyroxine sodium (Synthroid), 0.15 mg orally daily, for a client with hypothyroidism. The nurse will prepare to administer this medication: a) in the morning to prevent insomnia b) only when the client complains of fatigue and cold intolerance c) at various times during the day to prevent tolerance from occurring d) three times daily in equal doses of 0.5 mg each to ensure consistent serum drug levels

a

When assessing a patient with a head injury, the nurse recognizes that the earliest indication of increased intracranial pressure (ICP) is a. vomiting. b. headache. c. change in level of consciousness (LOC). d. sluggish pupil response to light.

c

Which IV fluid should be avoided in a patient with increased ICP? a. LR b. 3% saline c. D5W d. NSS

c

Which patient below with ICP is experiencing Cushing's Triad? A patient with the following: A. BP 150/112, HR 110, RR 8 B. BP 90/60, HR 80, RR 22 C. BP 200/60, HR 50, RR 8 D. BP 80/40, HR 49, RR 12

c - These vital signs represent Cushing's triad. There is an increase in the systolic pressure, widening pulse pressure of 140 (200-60=140), bradycardia, and bradypnea.

A 67-year-old male client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, nurse Richard would suspect which of the following disorders? a. Diabetes mellitus b. Diabetes insipidus c. Hypoparathyroidism d. Hyperparathyroidism

d

A patient being monitored has an ICP pressure of 12 mm Hg. You understand that this pressure reflects A. a severe decrease in cerebral perfusion pressure B. an alteration in the production of cerebrospinal fluid. C. the loss of autoregulatory control of intracranial pressure. D. a normal balance between brain tissue, blood, and cerebrospinal fluid.

d

A patient with ICP monitoring has pressure of 12 mm Hg. The nurse understand that this pressure reflects a. a severe decrease in cerebral perfusion pressure b. an alteration in the production of CSF c. the loss of autoregulatory control of ICP d. a normal balance between brain tissue, blood, and CSF

d

While positioning a patient in bed with increased ICP, it important to avoid? A. Midline positioning of the head B. Placing the HOB at 30-35 degrees C. Preventing flexion of the neck D. Flexion of the hips

d

Metabolic and nutritional needs of the patient with increased ICP are best met with a. enteral feedings that are low in sodium b. the simple glucose available in D5W IV solutions c. a fluid restriction that promotes a moderate dehydration d. balanced, essential nutrition in a form that the patient can tolerate

d - A patient with increased ICP is in a hypermetabolic and hypercatabolic state and needs adequate glucose to maintain fuel for the brain and other nutrients to meet metabolic needs.

When assessing the body function of a patient with increased ICP, the nurse should initially assess a. corneal reflex testing b. extremity strength testing c. pupillary reaction to light d. circulatory and respiratory status

d - think ABC's

ACTH - what is it - where is it released from

stimulates the adrenal cortex to release aldosterone and cortisol that is sent from the anterior pituitary

PRESSURE Acronym treatment for increased ICP: S

systems to monitor for like GCS, pupils, nerves, motor

if death is imminent, what will the OPO team do?

they will talk to the patient before they die to see if they want to donate anything

Cushing's triad

three classic signs—bradycardia, hypertension, and bradypnea—seen with pressure on the medulla as a result of brain stem herniation

TSH - what is it - where is it released from

thyroid stimulating hormone to stimulate the thyroid sent from the anterior pituitary

the nurse is training a new nurse to the neuro ICU. The patient has a ventriculostomy. The new nurse understands how to properly monitor ICP by stating "the transducer of a ventriculostomy be leveled to __________."

tragus in the ear

t/f: donation becomes a possibility when life saving methods have failed

true

t/f: with a patient who has an increased ICP, we would initiate seizure precautions

true

t/f: you need another consent for tissue donation even if you are an organ donor

true

the brain usually used to the affected or unaffected side?

unaffected side

if the patients ICP is less than 20 how do we treat that?

we watch with intense monitoring

What is a midline shift?

when the brain is shifted to the opposite side of injury

A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L), a decreasing level of consciousness (LOC) and complains of a headache. All of the following orders have been received. Which one should the nurse accomplish first? a. Administer acetaminophen (Tylenol) 650 mg orally. b. Administer 5% hypertonic saline intravenously c. Draw blood for arterial blood gases (ABGs). d. Send patient to radiology for computed tomography (CT) of the head.

b - this will help treat hypoatremia

PRESSURE Acronym treatment for increased ICP: U

care for unconscious patients with no over sedation, listen to lungs, look at skin and nutrition, contracutres, eye solution and blood thinners

what is this? a rare endocrine condition featuring hyponatremia and dehydration in response to trauma/injury or the presence of tumors in or surrounding the brain. will see a increase in urine output and low sodium

cerebral salt wasting

The patient has a change in neurological status. The nurse evaluates the the ICP waveform. Which of the following ICP readings would indicate giving Mannitol? a. 22 mmHg b. 10 mmHg c. 17 mmHg d. 15 mmHg

a

The patient with an intracranial bleed is vented and receiving enteral nutrition. The physician orders 100 mL of free water with the enteral feedings. Which electrolyte should be closely monitored? Group of answer choices a. Sodium b. Magnesium c. Glucose d. Potassium

a

When the nurse applies a painful stimulus to the nailbeds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as a. decorticate posturing. b. decerebrate posturing. c. localization of pain. d. flexion withdrawal.

a

A patient has ICP monitoring with an intraventricular catheter. A priority nursing intervention for the patient is a. aseptic technique to prevent infection b. constant monitoring of ICP waveforms c. removal of CSF to maintain normal ICP d. sampling CSF to determine abnormalities

a - Aseptic technique to prevent infection- An intraventricular catheter is a fluid coupled system that can provide direct access for microorganisms to enter the ventricles of the brain, and aseptic technique is a very high nursing priority to decrease the risk for infection. Constant monitoring of ICP waveforms is not usually necessary, and removal of CSF for sampling or to maintain normal ICP is done only when specifically ordered

You're collecting vital signs on a patient with ICP. The patient has a Glascoma Scale rating of 4. How will you assess the patient's temperature? A. Rectal B. Oral C. Axillary

a - This GCS rating demonstrates the patient is unconscious. If a patient is unconscious the nurse should take the patient's temperature either via the rectal, tympanic, or temporal method. Oral and axillary are not reliable.

When caring for a male client with diabetes insipidus, nurse Juliet expects to administer: a. vasopressin (Pitressin Synthetic) b. furosemide (Lasix). c. regular insulin. d. 10% dextrose.

a -Because diabetes insipidus results from decreased antidiuretic hormone (vasopressin) production, the nurse should expect to administer synthetic vasopressin for hormone replacement therapy. Furosemide, a diuretic, is contraindicated because a client with diabetes insipidus experiences polyuria. Insulin and dextrose are used to treat diabetes mellitus and its complications, not diabetes insipidus.

A patient is being discharged after having a thyroidectomy. Which discharge instructions would it be a priority for the nurse to review with the patient? select all that apply: A.Report signs and symptoms of hypoglycemia B.Take methimazole medication as ordered C.Monitor for bradycardia and edema D.Avoid all over the counter medications E.Carry injectable dexmethasone at all times

a and c - not b bc thats for hyper - not d because never ALL - not E bc not for adrenal crisis

A patient with cirrhosis asks the nurse about the possibility of a liver transplant. The best response by the nurse is: a. "liver transplants are only indicated in children with irreversible liver disease" b. "If you are interested in a transplant, you really should talk to your doctor about it. " c. "rejection is such a problem in liver transplants that it is seldom attempted in patients with cirrhosis. " d. "Cirrhosis is an indication for transplantation in some cases. Have you talked to your doctor about this? "

d

The nurse is planning care for a client with hyperthyroidism. Which of the following nursing interventions are appropriate? Select all that apply a) instill isotonic eye drops as necessary b) provide several, small, well-balanced meals c) provide rest periods d) keep environment warm e) encourage frequent visitors and conversation f) weigh the client daily

a, b, c, f - (a) The client with hyperthyroidism may experience exopthalmos. This requires instillation of eye drops to prevent dryness and ulceration of the cornea. - (b and f) The client experiences weight loss because of hypermetabolism. Several, small, well-balanced meals are given to improve nutritional status of the client and daily weights should be monitored. Weight is the most objective indicator of nutritional status. - (c) The client is usually exhausted due to restlessness and agitation. Frequent rest periods help the client regain energy.

A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing? A. Coughing B. Sneezing C. Talking D. Valsalva maneuver E. Vomiting

a, b, d, e

The nurse is monitoring a patient for increased ICP following a head injury. Which of the following manifestations indicate an increased ICP (select all that apply) a. fever b. oriented to name only c. narrowing pulse pressure d. dilated right pupil > left pupil e. decorticate posturing to painful stimulus

a, b, d, e

Which assessment findings would indicate to the nurse the patient is in myxedema coma? (Select all that apply) A.Cardiac output of 2 l/min B.Decrease in T3 and increase in TSH C.Increase in T3 and decrease in TSH D.Tachycardia and hypertension E.PaCO2 of 50 mmHg

a, b, e - yes A because will have LOW CO - yes B because t3 sucks and ash in brain is trying to fix it - not d because its the opposite - yes E because will have too much CO2

Select the main structures below that play a role with altering intracranial pressure: select all that apply A. Brain B. Neurons C. Cerebrospinal Fluid D. Blood

a, c, d

Select all the signs and symptoms that occur with increased ICP: A. Decorticate posturing B. Tachycardia C. Decrease in pulse pressure D. Cheyne-stokes E. Hemiplegia F. Decerebrate posturing

a, d, e, f - Option B is wrong because bradycardia (not tachycardia) happens in the late stage along with an INCREASE (not decrease) in pulse pressure.

ADH - what is it - where is it released from

antidiuretic hormone released from posterior pituitary sent to the kidneys

PRESSURE Acronym treatment for increased ICP: 2nd S

avoid straining activities like vomitting, sneezing, coughing, Valsalva, keep environments calm with no restrains

A patient is receiving Mannitol for increased ICP. Which statement is INCORRECT about this medication? A. Mannitol will remove water from the brain and place it in the blood to be removed from the body. B. Mannitol will cause water and electrolyte reabsorption in the renal tubules. C. When a patient receives Mannitol the nurse must monitor the patient for both fluid volume overload and depletion. D. Mannitol is not for patients who are experiencing anuria.

b

During the assessment of a patient with increased ICP, you note that the patient's arms are extended straight out and toes pointed downward. You will document this as: A. Decorticate posturing B. Decerebrate posturing C. Flaccid posturing

b

The nurse recognizes the presence of Cushing's triad in the patient with a. Increased pulse, irregular respiration, increased BP b. decreased pulse, irregular respiration, increased pulse pressure c. increased pulse, decreased respiration, increased pulse pressure d. decreased pulse, increased respiration, decreased systolic BP

b

What assessment finding requires immediate intervention if found while a patient is receiving Mannitol? A. An ICP of 10 mmHg B. Crackles throughout lung fields C. BP 110/72 D. Patient complains of dry mouth and thirst

b

Which effects does Labetalol non selective beta blocker have on the ICP patient? a. Does not affect cerebral vasculature b. Decrease sympathetic response and catecholamine release c. Creates an osmotic gradient d. Maintain blood pressure within set parameters

b

Which is an early sign/symptom of increased ICP? a. Abnormal motor reflexes b. Nausea/vomiting c. dilated non-reactive pupils d. Widening Pulse Pressure

b

Which of the following assessment findings characterize thyroid storm? a) increased body temperature, decreased pulse, and increased blood pressure b) increased body temperature, increased pulse, and increased blood pressure c) increased body temperature, decreased pulse, and decreased blood pressure d) increased body temperature, increased pulse, and decreased blood pressure

b

Which patient below is at MOST risk for increased intracranial pressure? A. A patient who is experiencing severe hypotension. B. A patient who is admitted with a traumatic brain injury. C. A patient who recently experienced a myocardial infarction. D. A patient post-op from eye surgery

b

A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial pressure of 24 mm Hg. The nurse determines that the cerebral perfusion pressure (CPP) of this patient indicates a. high blood flow to the brain. b. normal intracranial pressure (ICP). c. impaired brain blood flow. d. adequate cerebral perfusion.

b - MAP: diastolic blood pressure is doubled and added to the higher (systolic) blood pressure and that composite sum then is divided by 3 to estimate MAP. - The patient's CPP is 56, below the normal of 70 to 100 mm Hg and approaching the level of ischemia and neuronal death. The patient has low cerebral blood flow/perfusion. Normal ICP is 0 to 15 mm Hg.

When caring for a patient who has had a head injury, which assessment information is of most concern to the nurse? a. The blood pressure increases from 120/54 to 136/62. b. The patient is more difficult to arouse. c. The patient complains of a headache at pain level 5 of a 10-point scale. d. The patient's apical pulse is slightly irregular.

b - The change in level of consciousness (LOC) is an indicator of increased ICP and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache is not unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual

The Monro-Kellie hypothesis explains the compensatory relationship among the structures in the skull that play a role with intracranial pressure. Which of the following are NOT compensatory mechanisms performed by the body to decrease intracranial pressure naturally? Select all that apply: A. Shifting cerebrospinal fluid to other areas of the brain and spinal cord B. Vasodilation of cerebral vessels C. Decreasing cerebrospinal fluid production D. Leaking proteins into the brain barrier

b and d - These are NOT compensatory mechanisms, but actions that will actually increase intracranial pressure. Vasoconstriction (not dilation) decreases blood flow and helps lower ICP. Leaking of protein actually leads to more swelling of the brain tissue. Remember water is attracted to protein (oncotic pressure).

The OPO notes an organ donation on the potential organ donor's license. The nurse understands the first consent; however, the family arrived to the bedside. What is the best response by the nurse in regards to potential organ donation? a. The nurse will obtain consent for organ donation b. The nurse will establish a rapport with the family for consent for organ donation c. The nurse will not approach for consent for organ donation. The OPO will obtain consent. d. The nurse will notify the physician to obtain consent for organ donation

c

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first? a. patient with a skull fracture whose nose is bleeding b. elderly patient with a stroke who is confused and whose daughter is present c. patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale d. patient who had a craniotomy for a brain tumor who is now 3 days postoperative and has had continued emesis

c

Which information about patient and donor tissue typing results for a patient who needs a kidney transplant is most important for the nurse to communicate to the health care provider? a. Patient is Rh positive and donor is Rh negative. b. Six antigen matches are present in HLA typing. c. Results of patient-donor cross matching are positive. d. Panel of reactive antibodies (PRA) percentage is low.

c

Nurse Ronn is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse would expect to find: a. Hypotension. b. Thick, coarse skin. c. Deposits of adipose tissue in the trunk and dorsocervical area. d. Weight gain in arms and legs.

c - Deposits of adipose tissue in the trunk and dorsocervical area Because of changes in fat distribution, adipose tissue accumulates in the trunk, face (moonface), and dorsocervical areas (buffalo hump). Hypertension is caused by fluid retention. Skin becomes thin and bruises easily because of a loss of collagen. Muscle wasting causes muscle atrophy and thin extremities.

A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 130/72, pulse 90, respirations 32 b. Blood pressure 148/78, pulse 112, respirations 28 c. Blood pressure 156/60, pulse 60, respirations 14 d. Blood pressure 110/70, pulse 120, respirations 30

c - Rationale: Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the ICP has increased and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.

A patient with a head injury has an arterial blood pressure is 92/50 mm Hg and an intracranial pressure of 18 mm Hg. Which action by the nurse is appropriate? a. Document and continue to monitor the parameters. b. Elevate the head of the patient's bed. c. Notify the health care provider about the assessments. d. Check the patient's pupillary response to light.

c - The patient's cerebral perfusion pressure is only 46 mm Hg, which will rapidly lead to cerebral ischemia and neuronal death unless rapid action is taken to reduce ICP and increase arterial BP. Documentation and monitoring are inadequate responses to the patient's problem. Elevating the head of the bed will lower the ICP but may also lower cerebral blood flow and further decrease CPP. Changes in pupil response to light are signs of increased ICP, so the nurse will only take more time doing this without adding any useful information.

When the nurse is admitting a patient who has acute rejection of an organ transplant, which of these already admitted patients will be the most appropriate roommate? a. A patient who has viral pneumonia b. A patient with second degree burns c. A patient who is recovering from an anaphylactic reaction to a bee sting d. A patient with graft-versus-host disease after a recent bone marrow transplant

c - treatment for a patient with acute rejection includes administration of additional immunosuppressants, and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns. There is no increased exposure to infection from a patient with anaphylaxis.

Which medications have a therapeutic blood level? (select all that apply) Group of answer choices a. Lorazepam (Ativan) b. Levetiracetam (Keppra) c. Phenobarbital d. Phenytoin (Dilantin) e. Mannitol

c and d

The evaluation team for cardiac transplantation determines that the patient who would most benefit from a new heart is: a. a 24-year-old man with Down Syndrome who has received excellent care from parents in their 60's b. a 46-year-old single woman with a limited support system who has alcohol-induced cardiomyopathy. c. a 60-year-old man with inoperable coronary artery disease who has not been compliant with lifestyle changes and rehabilitation programs. d. a 52 -year-old woman with end-stage coronary artery disease who has limited financial resources but is emotionally stable and has strong social support.

d

Which of the following accurately describes rejection following transplantation? a. Hyperacute rejection can be treated with OKT3 b.Acute rejection can be treated with sirolimusor tacrolimus. c.Chronic rejection can be treated with tacrolimus or cyclosporine. d. Hyper-acute reaction can usually be avoided is crossmatching is done before the transplantation.

d

the nurse suspects the presence of an arterial epidural hematoma in the patient who experiences a. failure to regain consciousness following a head injury b. a rapid deterioration of neurologic function within 24 to 48 hours following a head injury c. nonspecific, nonlocalizing progression of alteration in LOC occurring over weeks or months d. unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC

d - An arterial epidural hematoma is the most acute neurologic emergency, and the typical symptoms include unconsciousness at the scene, with a brief lucid interval followed by a decrease in LOC. An acute subdural hematoma manifests signs within 48 hours of an injury; a chronic subdural hematoma develops over weeks or months

Skull radiographs and a computed tomography (CT) scan provide evidence of a depressed parietal fracture with a subdural hematoma in a patient admitted to the emergency department following an automobile accident. In planning care for the patient, the nurse anticipates that a. the patient will receive life-support measures until the condition stabilizes b. immediate burr holes will be made to rapidly decompress the intracranial activity c. the patient will be treated conservatively with close monitoring for changes in neurologic condition d. the patient will be taken to surgery for a craniotomy for evacuation of blood and decompression of the cranium

d - When there is a depressed fracture and fractures with loose fragments, a craniotomy is indicated to elevate the depressed bone and remove free fragments. A craniotomy is also indicated in cases of acute subdural and epidural hematomas to remove the blood and control the bleeding. Burr holes may be used in an extreme emergency for rapid decompression, but with a depressed fracture, surgery would be the treatment of choice

what is this? antidiuretic hormone is not secreted adequately, or the kidney is resistant to its effect. we will see a large urine output and low NA

diabetes insidious

decerebrate - what is it - what number on a GCS

extension away from body, pronation of arms/legs and #2

decorticate - what is it - what number on a GCS

flexion into body and #3

GH - what is it - where is it released from

growth hormone that stimulates bone and soft tissue sent from the anterior pituitary

hospitals must report all death to OPO when?

in a timely matter of 1-2 hours after death to allow possible screening of potential donations

how does a decompressive craniotomy help treat an increased ICP

it takes a piece of the skull and stores it in the freezer while the brain swells and tries to return to normal size - we have to protect the open area of the skull with a helmet

Which is the best method to assess the patient's response to painful stimuli?

nailbed pressure

The patient arrives to the unit ventilated with a GCS of 3. After completing the nurse's assessment, what is the next action by the nurse?

notify the OPO

PRESSURE Acronym treatment for increased ICP: P

position HOB 30-35, head midline, no flexion in head or hip

PRESSURE Acronym treatment for increased ICP: 2nd R

prescriptions like barbibutes, vasopressors, anticonvulsants

PRESSURE Acronym treatment for increased ICP: E

prevent elevated temp with cool room, administer antipyretics, cool bath and blankets

PRESSURE Acronym treatment for increased ICP: R

prevent hypoxia or hypercapnia by monitoring ABG, SPO2, suction 15 seconds only

ICP Patients should remain in a normovolemic fluid state with close monitoring of clinical factors such as what?

urine output, fluid intake, serum and urine osmolality, serum electrolytes, and insensible losses.

if a 40 y/o randomly seizes, what should you suspect and asses?

you would suspect that they may have a tumor and increase ICP so measure ICP and get CT scan