module 9 target quiz
A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?
3
A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be?
70 mm Hg
A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?
Administer stool softeners.
Which medication classification is used preoperatively to decrease the risk of postoperative seizures?
Anticonvulsants
An unresponsive patient is brought to the ED by a family member. The family states, "We don't know what happened." Which of the following is the priority nursing intervention?
Assess for a patent airway.
A client is diagnosed with a brain tumor. As the nurse assists the client from the bed to a chair, the client begins having a generalized seizure. Which action should the nurse take first?
Assist the client to the floor, in a side-lying position, and protect him with linens.
The nurse is caring for a client who has been admitted with a head injury and continually assesses for signs of increasing intracranial pressure (ICP). The earliest sign of increasing ICP is
Change in level of consciousness
A nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)?
Elevate the head of the bed 30 degrees.
The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient?
Maintenance of a patent airway
The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer?
Mannitol
A client the nurse is caring for experiences a seizure. What would be a priority nursing action?
Protect the client from injury.
After a seizure, the nurse should place the patient in which of the following positions to prevent complications?
Side-lying, to facilitate drainage of oral secretions
A client is having a tonic-clonic seizure. What should the nurse do first?
Take measures to prevent injury.
A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse?
Turn client to side-lying position.
A client with meningitis has a history of seizures. Which action by the nurse is appropriate while the client is actively seizing?
Turn the client to the side
A client with meningitis has a history of seizures. Which activity should the nurse do while the client is actively seizing?
Turn the client to the side during a seizure and do not restrain movements
The nurse is aware that burr holes may be used in neurosurgical procedures. Which of the following is a reason why a neurosurgeon may choose to create a burr hole in a patient?
Visualization of a hemorrhage
The initial sign of increasing intracranial pressure (ICP) includes
decreased level of consciousness.
A client is treated for increased intracranial pressure (ICP). It is important for the client to avoid hypothermia because
shivering in hypothermia can increase ICP.
A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure?
unequal response explanation: In increased ICP, the pupil response is unequal. One pupil responds more sluggishly than the other or becomes fixed and dilated.
