Management of patient with Neurologic Dysfunction
The nurse is caring for the patient in the neurologic ICU 2ho sustained head trauma in a physical altercation. What would the nurse knowis an optimal range of ICPfor this patient?
0 mmHg to 10 mmHg
A nurse assess the patient's LOC using GCS. What score indicates severe impairment in neurologic function?
3
A patient is admitted to the hospital with an ICP reading of 20 mmHg and MAP 90mmHg. What woukd the nurse calculate the CPP be?
70 mmHg
A nurse caring for a patient with head trauma will be monitoring the patient for Cushing triad. What will the nurse recognizeas the symptoms associated with Cushing triad? SATA
Bradycardia Bradypnea Hypertension
The earliest sign of increased ICP is
Change in LOC (Level of Consciousness)
A patient has a severe neurologic impairment from a head trauma. What does the nurse recognize is the type of posturing that occurswith the most severe neurologic impairment?
Flaccid
Maintain dorsiflexion to affected area
Footdrop
Assist with daily active or passive range of motion
Footdrop Paralyzed extremity
The nurse is educatinga patient with a seizure disorder. What nutritional approach for seizure management would be beneficialfor this patient?
High in protein and low in carbohydrate
Place the patient in lateral position
Impaired cough reflex
Elevate thr head of the bed 30⁰
Impaired cough reflex paralyzed diaphragm
Institute a bowel training program
Incontinence
The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of subdural hematoma. The nurse observes an increase in patient's blood pressure from the baseline and a decrease in HR from 86 to 54. The patient has crackles on the bases of the lungs. What does the nurse suspect is occuring?
Increased ICP
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?
Lethargy and stupor
The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who isexperiencing a convulsive seizure? SATA
Loosening constrictive clothing Positioning the patient on their side with head flexed forward Providing for privacy
The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient?
Maintain patent airway
The nurse is caring for a patient with increased ICP. As the oressure rises, what osmotic diuretic does the nurse prepare to administer?
Mannitol
A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate?
Notify the physician of a possible CSF leak
When educating a patient about the use of anticonvulsant medication, what shoukd the nurse inform the patient is a result os long-term use of the medication in women?
Osteoporosis
A patient has a small pituitary adenoma removed by the transsphenoidal approach and has developed DI. What pharmacologic therapy will the nurse be administering to this patient to control symptoms?
Vasopressin
The primary lethal complication of ICP
brain herniation resulting to death
Three primary complications of increased ICP
brain stem herniation diabetes insipidus SIADH (syndrome of inappropriate antidiuretic hormone)
Nursing postoperative management includes detecting and reducing _______, relieving _____, preventing ________, and monitoring ________ and ________.
cerebral edema pain seizure increased ICP neurologic status
The leading cause of seizure in older adult
cerebrovascular disease
A patient has a lesion affecting the pons, resulting in paralysis and inability to speak, but has vertical eye movements and lid elevation. This patient is suffering from
locked-in syndrome
A nurse is assessing a patient's UI as an indicator for DI related to a traumatic brain injury. The nurse knows that an hourly output of what volume over 2 hrs maybe a positive indicator?
more than 200mL/h
Three major potentialcomplications in a patient with depressed level of conciousness (LOC)
pneumonia, aspiration, respirarory failure
A major potential complication of epilepsy
status epilepticus
