ICP, head and spinal injury QUESTIONS

a patient has ICP monitoring with an intraventricular catheter. what is the priority nursing intervention for the patient? 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

a patient has a nursing diagnosis o risk for ineffective cerebral tissue perfusion related to cerebral edema. what is an appropriate nursing intervention for the patient A. avoid positioning the patient with neck and hip flexion B. maintain hyperventilation to a PaCO2 of 15-20 C. cluster nursing activities to provide periods of uninterrupted rest D. routinely suction to prevent accumulation of respiratory secretions

A. avoid positioning the patient with neck and hip flexion

which components are able to adapt to small increases in ICP (select all that apply) A. blood B. skull bone C. brain tissue D. scalp tissue E. cerebrospinal fluid

A. blood C. brain tissue E. cerebrospinal fluid

an unconscious patient with multiple injuries arrives in the ED. which nursing intervention receives the highest priority? A. establishing an airway B. replacing blood loss C. stopping bleeding from open wound D. checking for a neck fracture

A. establishing an airway

the nurse is monitoring a patient of increased ICP following a head injury. what are manifestations of increased ICP (select all that apply) A. fever B. oriented to name only C. narrowing pulse pressure D. right pupil dilated greater that left E. decorticate posturing to painful stimulus

A. fever B. oriented to name only D. right pupil dilated greater that left E. decorticate posturing to painful stimulus

when a patient is admitted to the ED following a head injury, what should be the nurse's first priority in management of the patient once a patent airway is confirmed? A. maintain a cervical spine precautions B. monitor for changes in neurologic status C. determine the presence of increased ICP D. establish IV access with a large-bore catheter

A. maintain a cervical spine precautions

the nurse in the neuro ICU is caring for a client with a new C6 SCI who is breathing independently. which nursing interventions should be implemented? (select all that apply) A. monitor pulse ox reading B. provide pureed foods 6 times a day C. encourage coughing and deep breathing D. assess for autonomic dyreflexia E. administer IV corticosteroids

A. monitor pulse ox reading C. encourage coughing and deep breathing E. administer IV corticosteroids

in assessing a client with a T12 spinal cord injury (SCI), which clinical manifestations would the nurse expect to find to support the diagnosis of spinal shock? A. no reflex activity below the waist B. inability to move upper extremities C. complains of a pounding headache D. hypotension and bradycardia

A. no reflex activity below the waist

which of the following respiratory patterns indicates increasing ICP in the brain stem? A. slow, irregular B. rapid, shallow C. asymmetric chest excursion D. nasal flaring

A. slow, irregular

the nurse is monitoring a client with increased ICP. what indications are the most critical for the nurse to monitor? (select all that apply) A. systolic BP B. urine output C. breath sounds D. cerebral perfusion pressure E. level of pain

A. systolic BP D. cerebral perfusion pressure

the client has a sustained ICP of 20. which client position would be most appropriate? A. the head of the bed elevated 30-45 degrees B. trendelenburg C. left sim's position D. the head elevated on two pillows

A. the head of the bed elevated 30-45 degrees

a 54 year old man is recovering from a skull fracture with a subacute subdural hematoma that caused unconsciousness. he has return of motor control and orientation but appears apathetic and has reduced awareness of his environment. when planning discharge of the patient, what should the nurse explain to the patient and the family A. the patient is likely to have long-term emotional and mental changes that may require professional help B. continuous improvement in the patient's condition should occur until he has returned to pretrauma care C. the patients complete recovery may take years and the family should plan for his long-term dependent care D. role changes in family membranes will be necessary because the patient will be dependent on his family for care

A. the patient is likely to have long-term emotional and mental changes that may require professional help

why is the Glasgow Coma scale used? A. to quickly assess the LOC B. to assess the patient's ability to communicate C. to assess the patient's ability to respond to commands D. to assess the patient's coordination with motor responses

A. to quickly assess the LOC

a client is at risk for increased ICP. which off the following would be the priority for the nurse to monitor? A. unequal pupil size B. decreasing systolic BP C. tachycardia D. decreasing body temperature

A. unequal pupil size

which events causes increased ICP (select all that apply) A. vasodilation B. necrotic tissue edema C. blood vessel compression D. edema from initial brain insult E. brainstem compression and herniation

A. vasodilation B. necrotic tissue edema D. edema from initial brain insult

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 arms in response to painful stimuli. what should the nurse report as the GCS score? A. 6 B. 7 C. 9 D. 11

B. 7

the nurse administers mannitol to the client with increased ICP. which parameter requires close monitoring? A. muscle relaxation B. I/O's C. widening pulse pressure D. pupil dilation

B. I/O's

the rehabilitation nurse caring for the client with an L1 SCI is developing the nursing care plan. which intervention should the nurse implement? A. keep O2 via nasal cannula on at all times B. administer low-dose subq anticoagulants C. perform active lower extremity ROM exercises D. refer to a speech therapist for ventilator-assisted speech

B. administer low-dose subq anticoagulants

the nurse is caring for a client diagnosed with a epidural hematoma. which nursing intervention should the nurse implement? (select all that apply) A. maintain the HOB at 60 degrees B. administer stool softener daily C. ensure that pulse oximeter reading is higher than 93% D. perform deep nasal suction every 2 hours E. administer mild sedatives

B. administer stool softener daily C. ensure that pulse oximeter reading is higher than 93%

the nurse is admitting a client from the ED following a fall that resulted in increased ICP. the nurse interprets that the client's GCS score has improved the most after making which of the latest assessments? A. best eye opening response 5, best motor response 4, best verbal response 8 B. best eye opening response 4, best motor response 6, best verbal response 5 C. best eye opening response 6, best motor response 5, best verbal response 4 D. best eye opening response 3, best motor response 8, best verbal response 6

B. best eye opening response 4, best motor response 6, best verbal response 5

the nurse is caring for a client following a motor vehicle accident. during the neurological assessment when eliciting the client's response to pain, the client pulls his arms inward and upward. this position represents: (select all that apply) A. decerebrate posturing B. decorticate posturing C. injury to the brain stem D. injury to the pons E. injury to the midbrain

B. decorticate posturing E. injury to the midbrain

following a craniotomy, a client has been admitted to the neurological ICU. the nurse has established a goal to maintain intracranial pressure (ICP) within the normal range. what should the nurse do? (select all that apply) A. encourage the client to cough and take deep breathes B. elevate the head of bed 15-30 degress C. contact the health care provider if ICP is greater than 20 D. monitor neurologic status using the GCS E. stimulate the client with active ROM exercises

B. elevate the head of bed 15-30 degress C. contact the health care provider if ICP is greater than 20 D. monitor neurologic status using the GCS

the client is being admitted to rule out a brain tumor. which classic triad of symptoms supports a diagnosis of brain tumor? A. nervousness, metastasis to the lungs, and seizures B. headache, vomiting, and papilledema C. hypotnsion, tachycardia, and tachypnea D. abrupt loss of motor function, diarrhea, and changes in taste

B. headache, vomiting, and papilledema

a patient with a head injury has bloody drainage from the ear. what should the nurse do to determine if CS is present in the drainage? A. examine the tympanic membrane for a tear B. test the fluid for a halo sign on a white dressing C. test the fluid with a glucose-identifying strip D. collect 5mL of fluid in a test tube and send to the lab

B. test the fluid for a halo sign on a white dressing

a client is being admitted with a spinal cord transection at C7. which of the following assessments take priority upon the client's arrival? (select all that apply) A. reflexes B. bladder function C. BP D. Temp E. Resp

C. BP D. Temp E. Resp

the client with a C6 SCI is admitted to the ED complaining of a severe pounding headache and has a BP of 180/110. which intervention should the ED nurse implement? A. keep the client flat in bed B. dim the lights in the room C. assess for bladder distention D. administer a narcotic analgesic

C. assess for bladder distention

the patient has a depressed skull fracture and scalp lacerations with communication to the intracranial cavity. which type of injury should the nurse record? A. linear skull fracture B. depressed skull fracture C. compound skull fracture D. comminuted skull fracture

C. compound skull fracture

which activity should the nurse encourage the client to avoid when there is a risk for increased ICP? A. deep breathing B. turning C. coughing D. passive ROM exercises

C. coughing

an early sign of increased ICP that the nurse should assess for is? A. Cushing's triad B. unexpected vomiting C. decreased LOC D. dilated pupil with sluggish response to light

C. decreased LOC

which of the following nursing interventions is appropriate for a client with an increased ICP of 20? A. give the client a warming blanket B. administer low-dose barbiturates C. encourage the client to hyperventilate D. restrict fluids

C. encourage the client to hyperventilate hyperventilation causes vasoconstriction

on physical examination of a patient with headache and fever, the nurse should suspect a brain abscess when the patient has A. seizures B. nuchal rigidity C. focal symptoms D. signs of increased ICP

C. focal symptoms

what should the nurse do first when a client with a head injury begins to have clear drainage from his nose? A. compress the nares B. tilt the head back C. give the client tissue to collect the fluid D. administer an antihistamine for postnasal drip

C. give the client tissue to collect the fluid

a nurse obtains a specimen of clear nasal drainage from a client with a head injury. which of the following test differentiates mucus from CSF? A. pH B. specific gravity C. glucose D. microorganisms

C. glucose

which drug treatment helps to decrease ICP by expanding plasma and the osmotic effect to move fluid? A. O2 administration B. pentobarbital C. mannitol D. dexamethasone

C. mannitol

the patient comes to the ED with cortical blindness and visual field defects. which type of head injury does the nurse suspect? A. cerebral contusion B. orbital skull fracture C. posterior fossa fracture D. frontal lobe skull fracture

C. posterior fossa fracture

a client with spinal cord injury is at risk for experiencing autonomic dysreflexia. the nurse would carefully monitor for which of the following manifestations? A. tachycardia B. hypotension C. severe, throbbing headache D. cyanosis of the head and neck

C. severe, throbbing headache

the client with closed head injury has clear fluid draining from the nose. which action should the nurse implement first? A. notify the health care provider immediately B. prepare to administer an antihistamine C. test the drainage for presence of glucose D. place 2X2 gauze under the nose to collect drainage

C. test the drainage for presence of glucose

which of the following describes decerebrate posturing? A. internal rotation and adduction of arms with flexion of elbows, wrist, and fingers B. back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of feet C. supination of arms, dorsiflexion of the feet D. back arched, rigid extension of all four extremities

D. back arched, rigid extension of all four extremities

how are the metabolic nutritional needs of the patient with increased ICP best met? A. enteral feedings that are low in sodium B. simple glucose available in D5W IV C. fluid restrictions that promotes a moderate dehydration D. balanced, essential nutrition in a form that the patient can tolerate

D. balanced, essential nutrition in a form that the patient can tolerate

when assessing the body functions of a patient with increased ICP, what should the nurse assess first? A. corneal reflex testing B. pupilllary reaction to light C. extremity strength testing D. circulatory and respiratory status

D. circulatory and respiratory status

which cranial surgery would require the patient to learn how to protect the surgical area from trauma? A. burr holes B. craniotomy C. cranioplasty D. craniectomy

D. craniectomy

a client has signs of ICP. which of the following is an early indicator of deterioration in the client's condition? A. widening pulse pressure B. decrease in pulse rate C. dilated, fixed pupils D. decreased in LOC

D. decreased in LOC

the client has been diagnosed with a brain tumor. which presenting sign and symptoms help to localize the tumor position? A. widening pulse pressure and bounding pulse B. diplopia and decreased visual acuity C. bradykinesia and scanning speech D. hemiparesis and personality changes

D. hemiparesis and personality changes

a nurse monitoring a client who has sustained a head injury would determine that the ICP is rising if which of the following vital signs trend? A. increased temp, decreased pulse, increased resp, decreased BP B. decreased temp, increased pulse, decreased resp, increased BP C. decreased temp, increased pulse, increased resp, decreased BP D. increased temp, decreased pulse, decreased resp, increased BP

D. increased temp, decreased pulse, decreased resp, increased BP

the ICU nurse is caring for a client with a T1 SCI. when the nurse elevates the HOB 30 degrees, the client complains of lightheadedness and dizziness. the client's vitals are T99.2, P 98, R 24, and BP 84/40. which action should the nurse implement? A. notify the health care provider ASAP B. calm the client down by talking therapeutically C. increase the IV rate by 50 mL/hour D. lower the HOB immediately

D. lower the HOB immediately

a nurse witnessed a water skier hit the boat ramp. the skier is in the water not responding to verbal stimuli. the nurse is the first health care provider to respond to the accident. which intervention should be implemented first? A. assess the client's LOC B. organize onlookers to remove the client from the lake C. perform a head-to-toe assessment to determine injuries D. stabilize the client's cervical spine

D. stabilize the client's cervical spine

the client diagnosed with a brain tumor was admitted to the ICU with decorticate posturing. which indicates that the client's condition is becoming worse? A. the client has purposeful movements with painful stimuli B. the client has assumed adduction of the upper extremities C. the client is aimlessly thrashing in the bed D. the client has become flaccid and does not respond to stimuli

D. the client has become flaccid and does not respond to stimuli

the nurse is assessing a client for movement after halo traction placement for a C8 fracture. the nurse should document which of the following? A. the client's shoulders shrug against downward pressure of the examiner's hands B. the client's arm pulls up from a resting position against resistance C. the client's are straightens out from a flexed position against resistance D. the client's hand-grasp strength is equal

D. the client's hand-grasp strength is equal

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 25-48 hours folowing head injury C. nonspecific, nonlocalizing progression of alteration in LOC occurring over weeks to months D. unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC

D. unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC