NURS405 unit2 KC/AC

glasgow coma scale: eye response

1-4 1 - no response 2 - to pain only 3 - to verbal stimuli, speech, command 4 - spontaneously

glasgow coma scale: verbal response

1-5 1 - no response 2 - incomprehensible speech 3 - inappropriate words 4 - confused conversation, but able to answer questions 5 - oriented

glasgow coma scale: motor response

1-6 1 - no response 2- extension in response to pain (decerebrate) 3 - flexion in response to pain (decorticate) 4 - withdraws in response to pain 5 - purposeful movement to painful stimulus 6 - obeys command for movement

A client sustained a head injury as a result of trauma. The health care provider has instituted seizure prophylactic measures. The nurse anticipates which specific measures being initiated for this client? Aspiration precautions on day four of injury Antiemetic medications on day three of injury Anticonvulsant medications on day two of injury Intubation and ventilator support on day one of injury

Anticonvulsant medications on day two of injury Clients with head injury are at an increased risk for posttraumatic seizures. Posttraumatic seizures are classified as immediate (within 24 hours after injury), early (within 1 to 7 days after injury), or late (more than 7 days after injury). Seizure prophylaxis is the practice of administering anticonvulsant medications to clients with head injury to prevent seizures. It is important to prevent posttraumatic seizures, especially in the immediate and early phases of recovery, because seizures may increase ICP and decrease oxygenation. All of the other interventions are not part of the seizure prophylactic protocol nor have a specific timeline of administration.

The nurse is reviewing the medication administration record of a client who possesses numerous risk factors for stroke. Which of the client's medications carries the greatest potential for reducing her risk of stroke? Calcium carbonate 1,000 mg PO b.i.d. Naproxen 250 PO b.i.d. Aspirin 81 mg PO o.d. Lorazepam 1 mg SL b.i.d. PRN

Aspirin 81 mg PO o.d. Research findings suggest that low-dose aspirin may lower the risk of stroke in clients who are at risk. Naproxen, lorazepam, and calcium supplements do not have this effect.

A hospitalized child is scheduled for magnetic resonance imaging (MRI) with contrast. What nursing intervention(s) will the nurse complete to ensure safety during the examination? Select all that apply. Assess for a latex allergy Assess the IV site for patency Connect the child to a heart monitor Place child in clothing with no metal Review any prescriptions for sedation

Assess the IV site for patency Place child in clothing with no metal Review any prescriptions for sedation

A 10-month-old infant is brought to the emergency department by the parents after they found the infant face down in the bathtub. The parent states, "I just left the bathroom to answer the phone. When I came back, I found my infant." Which nursing action is priority? Assess the client's respiratory rate Start cardiopulmonary resuscitative measures Apply a heart monitor to the client Determine how long the client was face down in the water

Assess the client's respiratory rate With a submersion injury, hypoxia is the primary problem. Therefore, assessment of airway and breathing are priority. Based on this assessment, the nurse would determine if resuscitative measures were needed. Other actions such as applying a heart monitor and obtaining additional information about the event would be done once the infant's airway and breathing are assessed and emergency interventions are instituted.

A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client? Respiratory distress and projectile vomiting Tachycardia and agitation Third-spacing and hyperthermia Bradycardia and hypertension

Bradycardia and hypertension Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion, piloerection ("goose bumps"), bradycardia, and hypertension. It occurs in cord lesions above T6 after spinal shock has resolved; it does not result in vomiting, tachycardia, or third-spacing.

The nurse is caring for a client who is rapidly progressing toward brain death. The nurse should be aware of what cardinal sign(s) of brain death? Select all that apply. Coma Absence of pain response Absence of brain stem reflexes Absence of deep tendon reflexes Apnea

Coma Absence of brain stem reflexes Apnea The three cardinal signs of brain death upon clinical examination are coma, the absence of brain stem reflexes, and apnea. Absences of pain response and deep tendon reflexes are not necessarily indicative of brain death.

Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply. Eye opening Intelligence Motor response Verbal response Muscle strength

Eye opening Motor response Verbal response LOC can be assessed based on the criteria in the GCS, which include eye opening, verbal response, and motor response. The patient's responses are rated on a scale from 3 to 15. Intelligence and muscle strength are not measured in the GCS.

Which is a nonmodifiable risk factor for ischemic stroke? Gender Smoking Hyperlipidemia Atrial fibrillation

Gender Nonmodifiable risk factors include gender, age, and race. Modifiable risk factors include atrial fibrillation, hyperlipidemia, and smoking.

The nurse is caring for a child hospitalized with Reye syndrome who is in the acute stage of the illness. The nurse would assess the child most carefully for what finding? Indications of increased intracranial pressure An increase in the blood glucose level A decrease in the liver enzymes A presence of protein in the urine

Indications of increased intracranial pressure Reye syndrome is characterized by brain swelling, liver failure, and death in hours if treatment is not initiated. Therefore, increased intracranial pressure could occur. Liver enzyme levels typically increase. Blood glucose levels and protein in the urine are not characteristic of this illness.

During a client's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help clients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply. LOC at time of admission National Institutes of Health Stroke Scale (NIHSS) score Age Race Gender

LOC at time of admission National Institutes of Health Stroke Scale (NIHSS) score Age It is helpful for clinicians to be knowledgeable about the relative importance of predictors of stroke outcome (age, NIHSS score, and LOC at time of admission) to provide stroke survivors and their families with realistic goals. Race and gender are not significant predictors of stroke outcome.

The nurse assesses a child's level of consciousness, noting that the child falls asleep unless he is stimulated. What is the child's level of consciousness? Obtunded Confusion Stupor Coma

Obtunded Obtunded is a state in which the child has limited responses to the environment and falls asleep unless stimulation is provided. Confusion involves disorientation; the child may be alert but responds inappropriately to questions. Stupor exists when the child responds only to vigorous stimulation. Coma is a state in which the child cannot be aroused even with painful stimuli.

A 13-year-old was brought to the ED after being hit in the head by a baseball and is subsequently diagnosed with a concussion. Which assessment finding would rule out discharging the client? The client is visibly fatigued. The client reports a headache. The client reports pain at the site where the ball hits his head. The client's speech is slightly slurred.

The client's speech is slightly slurred. Slurred speech would indicate a need for further assessment and observation due to the possibility of more serious trauma. Localized pain, a headache and fatigue are consistent with a concussion and do not necessarily require further intervention.

The nurse caring for a client in a persistent vegetative state is regularly assessing for potential complications. The nurse should assess for which complications? Select all that apply. Venous thromboembolism Hemorrhage Pneumonia Contractures Pressure ulcers

Venous thromboembolism Pneumonia Contractures Pressure ulcers Based on the assessment data, potential complications (partially based on immobility) may include respiratory distress or failure, pneumonia, aspiration, pressure ulcer, deep vein thrombosis (DVT), and contractures. A persistent vegetative state does not directly create a heightened risk for hemorrhage.. A persistent vegetative state condition is when the client is wakeful but devoid of conscious content, without cognitive or affective mental function

glasgow coma scale, head injury classifications

mild head injury: 13-15 moderate head injury: 9-12 severe head injury: <8 if less than 8, intubate!

A 16-year-old boy reports to the school nurse with headaches and a stiff neck. Which sign or symptom would alert the nurse that the child may have bacterial meningitis? Sunlight is "too bright" Fixed and dilated pupils Frequent urination Sunset eyes

Sunlight is "too bright" Photophobia, or intolerance of light, is another symptom of bacterial meningitis. Fixed and dilated pupils are a symptom of head trauma and warrant prompt intervention. Frequent urination is a symptom of a type I Arnold-Chiari malformation. Sunset eyes indicate increased intracranial pressure typical of hydrocephalus.

The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipate administering to halt the seizure immediately? Intravenous diazepam Intravenous phenobarbital Oral phenytoin Oral lorazepam

Intravenous diazepam Medical management of status epilepticus includes IV diazepam and IV lorazepam given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state. Oral medications are not given during status epilepticus.

During class, a student states, "I didn't think children could have strokes. I thought this only occurred in older adults." When responding to the student, what would be most important for the instructor to integrate into the response? The signs and symptoms in children are different from an adult. Ischemic strokes are more common than hemorrhagic strokes. Strokes in children often have an identifiable cause. Research has identified specific treatments for children.

Ischemic strokes are more common than hemorrhagic strokes. In children, ischemic strokes are more common than hemorrhagic strokes. However, the cause of the stroke in many children remains unidentified. Signs and symptoms are similar to those in adults and will vary based on age; underlying cause, if known; and location of the stroke. Historically, children have been excluded from adult stroke studies and thus, many treatments used have had to be adapted from adult studies.

Which of the following is accurate regarding a hemorrhagic stroke? One of the main presenting symptoms is numbness or weakness of the face. Main presenting symptom is an "exploding headache." Functional recovery usually plateaus at 6 months. It is caused by a large-artery thrombosis.

Main presenting symptom is an "exploding headache." One of hemorrhagic stroke's main presenting symptom is an "exploding headache." In ischemic stroke, functional recovery usually plateaus at 6 months; it may be caused by a large artery thrombosis and may have a presenting symptoms of numbness or weakness of the face.

A client is suspected of having had a stroke. Which is the initial diagnostic test for a stroke? Electrocardiography Transcranial Doppler studies Carotid Doppler Noncontrast computed tomography

Noncontrast computed tomography The initial diagnostic test for a stroke is usually a noncontrast computed tomography (CT) scan. This should be performed within 25 minutes or less from the time the client presents to the ED to determine whether the event is ischemic or hemorrhagic (the category of stroke determines treatment). Further diagnostics include a carotid Doppler, electrocardiogram, and transcranial Doppler.

The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action? Prepare to transfuse packed red blood cells. Prepare an ice bath to lower core body temperature. Prepare for interventions to increase the client's BP. Place the client in the Trendelenburg position.

Prepare for interventions to increase the client's BP. Manifestations of neurogenic shock include decreased BP and heart rate. Cardiac markers would be expected to rise in cardiogenic shock. Transfusion, repositioning, and ice baths are not indicated interventions.

The nurse is caring for a client recovering from an ischemic stroke. What intervention(s) best addresses potential complications after an ischemic stroke? Select all that apply. Limiting intake of insoluble fiber, carbohydrates, and simple sugars. Encourage the client to stay in bed and assist with turning and repositioning. Providing frequent small meals rather than three larger meals Keeping a urinary catheter in place for the full duration of recovery. Teaching the client to perform deep breathing and coughing exercises.

Providing frequent small meals rather than three larger meals Teaching the client to perform deep breathing and coughing exercises. Because pneumonia is a potential complication of stroke, deep breathing and coughing exercises should be encouraged unless contraindicated. Providing small frequent meals during recovery will decrease the likelihood of aspiration. Dietary restrictions are based on individual client needs, and fiber, carbohydrates, and sugars are not typically restricted. Urinary catheters should be discontinued as soon as possible to prevent the increased risk of catheter associated urinary tract infections (CAUTI). It is also important to get the client out of bed as soon as possible to prevent pressure ulcers and encourage mobility.

The nurse is caring for a client with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the client may be experiencing increased brain compression causing brain stem damage? Hypertension Tachycardia Bradypnea Hyperthermia

Hyperthermia Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic BP, and widening pulse pressure. As brain compression increases, respirations become rapid, BP may decrease, and the pulse slows further. A rapid rise in body temperature is regarded as unfavorable. Hyperthermia increases the metabolic demands of the brain and may indicate brain stem damage.

The nurse caring for a client with a spinal cord injury notes that the client is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action? Increase the frequency of ROM exercises. Educate the client about the importance of frequent position changes. Collaborate with the physical therapist and immobilize the client's extremities temporarily. Limit the amount of assistance provided with ADLs.

Increase the frequency of ROM exercises. To prevent disuse syndrome, ROM exercises must be provided at least four times a day, and care is taken to stretch the Achilles tendon with exercises. The client is repositioned frequently and is maintained in proper body alignment whether in bed or in a wheelchair. The client must be repositioned by caregivers, not just taught about repositioning. It is inappropriate to limit assistance for the sole purpose of preventing disuse syndrome.

A nurse on the neurologic unit is providing care for a client who has spinal cord injury at the level of C4. When planning the client's care, what aspect of the client's neurologic and functional status should the nurse consider? Requires full assistance for elimination Inability to use a wheelchair Incontinent in bowel movements Unable to swallow liquid and solid food

Requires full assistance for elimination Clients with a lesion at C4 are fully dependent for elimination. The client is dependent for feeding, but is able to swallow. The client will be capable of using an electric wheelchair.

A group of students are reviewing information about head injuries in children. The students demonstrate understanding of this information when they identify what as the most common type of skull fracture in children? Basilar Depressed Linear Diastatic

Linear The most common type of skull fracture in children is a linear skull fracture, which can result from minor head injuries. Other, less common types of skull fractures in children include depressed, diastatic, and basilar.

The nurse is admitting a client to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this client's admission orders? Select all that apply. MRI Cranial radiography Cerebral angiography Electromyography (EMG) Transcranial Doppler flow study

MRI Cerebral angiography Transcranial Doppler flow study Preoperative diagnostic procedures may include a CT scan to demonstrate the lesion and show the degree of surrounding brain edema, the ventricular size, and the displacement. An MRI scan provides information similar to that of a CT scan with improved tissue contrast, resolution, and anatomic definition. Cerebral angiography may be used to study a tumor's blood supply or to obtain information about vascular lesions. Transcranial Doppler flow studies are used to evaluate the blood flow within intracranial blood vessels. Regular x-rays of the skull would not be diagnostic for an intracranial mass. An EMG would not be ordered prior to intracranial surgery to remove a mass.

The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client? Position the client supine. Maintain bed in Trendelenburg position. Maintain head of bed (HOB) elevated at 30 to 45 degrees. Position client in prone position.

Maintain head of bed (HOB) elevated at 30 to 45 degrees. The client with increased ICP should be placed with the HOB elevated 30 to 45 degrees, with the neck in neutral alignment. Each of the other listed positions would cause a dangerous elevation in ICP.

A nurse has received an unconscious client with a traumatic brain injury (TBI). The nurse is concerned about the client's skin integrity and implements interventions to prevent pressure injuries. Which action should the nurse implement during the shift? Providing skin care with barrier care ointments once a day Assisting the client to get out of bed to a chair four times a day. Assessing all body surfaces and documenting skin integrity every 8 hours Turning and repositioning the client every 6 hours

Assessing all body surfaces and documenting skin integrity every 8 hours Clients with TBI often require assistance in turning and positioning because of immobility or unconsciousness. Prolonged pressure on the tissues decreases circulation and leads to tissue necrosis. Specific nursing measures include the following: Assessing all body surfaces and documenting skin integrity every 8 hours. Turning and repositioning the client should occur every 2 hours. Skin care should be done every 4 hours and includes more than applying an ointment. Other interventions include keeping the skin dry, offloading bony prominences and with pillows or wedge devices. Since this client is unconscious; assisting the client to get out of bed needs his/her cooperation which is not possible. It should also be three times a day and not four.

The nurse planning the care of a client with head injuries is addressing the client's nursing diagnosis of "sleep deprivation." What action should the nurse implement? Cluster overnight nursing activities to minimize disturbances. Administer a benzodiazepine at bedtime each night. Ensure that the client does not sleep during the day. Do not disturb the client between 2200 and 0600.

Cluster overnight nursing activities to minimize disturbances. To allow the client longer times of uninterrupted sleep and rest, the nurse can group nursing care activities so that the client is disturbed less frequently. However, it is impractical and unsafe to provide no care for an 8-hour period. The use of benzodiazepines should be avoided.

A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the emergency department (ED). The nurse should first gauge the client's LOC on the results of what diagnostic tool? Mental status examination Glasgow Coma scale Monro-Kellie hypothesis Cranial nerve function

Glasgow Coma scale LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma scale: eye opening, verbal response, and motor response. The Monro-Kellie hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components (blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others. Cranial nerve function and the mental status examination would be part of the neurologic examination for this client, but would not be the priority in evaluating LOC. Glasgow coma scale can be done quickly and establishes a baseline of neurologic function.

A child is in the emergency department with a head injury obtained in a motor vehicle crash. The glascow coma scale assessment is rated at 10 (3 eye opening, 3 motor, 4 verbal). How should the nurse interpret these findings? The child's eyes open to pain, opens to extension and says incomprehensible words The child's eyes open to speech, is able to obey commands but is confused The child's eyes open spontaneously, able to localize pain and uses inappropriate words The child's eyes open to verbal stimuli, is confused and flexes with painful stimuli

The child's eyes open to verbal stimuli, is confused and flexes with painful stimuli The glascow coma scale is a widely used tool for assessing the extent of brain injury and prognosis. The scores are based on eye opening, motor response and verbal response. The perfect score is 15. The lower the score the more severe the injury and prognosis. Scores for a severe head injury are 8 or less. A moderate head injury scores between 9-12 points and a mild head injury scores between 13 and 15. With a score of 10 this child would be classified as having a moderate head injury. the eyes open spontaneously (4), localizes pain (5) and uses incomprehensive words(2) for a total score of 11. The eyes open to speech (3), uses inappropriate words (2) and has flexion withdrawal (4) for a total score of 9. The eyes open to pain (2) extremities open to extension (2) and uses incomprehensible words (2) for a score of 6.