test 1
when is cognition normal?
AOx4 pts following directions pupils same size eye movemnt same distance
cva
stroke
what position do you place the patient
semifowlers position with neck in neutral position no irritation this could increase the icp
primary prevention
sunscreen lotion to protect harmful sunrays eating well running/excercise
teritiary prevention
treatment
whats the highest grade for glasgow coma scale and worst grade
15 and worst is less than 8
A client with a contusion has been admitted for observation following a motor vehicle accident when he was driving his pregnant wife to the hospital. The next morning, instead of asking about his wife and baby, he asked to see the football game on television that he thinks is starting in 5 minutes. He is agitated because the nurse will not turn on the television. What should the nurse do next? Select all that apply. 1.Find a television so the client can view the football game. 2.Determine if the client's pupils are equal and react to light. 3.Ask the client if he has a headache. 4.Arrange for the client to be with his wife and baby. 5.Administer a sedative.
2, 3. The nurse should determine if the client's pupils are equal and react to light, and ask the client if he has a headache. Confusion, agitation, and restlessness are subtle clinical manifestations of increased intracranial pressure (ICP). At this time, it is not appropriate for the nurse to find a television or arrange for the client to see his wife and baby. Administering a sedative at this time will obscure assessment of increased ICP.
The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which strategies should the nurse include in the teaching plan? Select all that apply. 1.maintaining an upright position while eating 2.restricting the diet to liquids until swallowing improves 3.introducing foods on the unaffected side of the mouth 4.keeping distractions to a minimum 5.cutting food into large pieces of finger food
1, 3, 4. A client with dysphagia (difficulty swallowing) commonly has the most difficulty ingesting thin liquids, which are easily aspirated. Liquids should be thickened to avoid aspiration. Maintaining an upright position while eating is appropriate because it minimizes the risk of aspiration. Introducing foods on the unaffected side allows the client to have better control over the food bolus. The client should concentrate on chewing and swallowing; therefore, distractions should be avoided. Large pieces of food could cause choking; the food should be cut into bite-sized pieces.
The nurse is assessing the level of consciousness in a client with a head injury who has been unresponsive for the last 8 hours. Using the Glasgow Coma Scale, the nurse notes that the client opens the eyes only as a response to pain, responds with sounds that are not understandable, and has abnormal extension of the extremities. What should the nurse do?
1.Attempt to arouse the client. 2.Reposition the client with the extremities in normal alignment. 3.Chart the client's level of consciousness as coma. 4.Notify the health care provider (HCP).
A client has received thrombolytic treatment for an ischemic stroke. The nurse should notify the health care provider (HCP) if there is a rapid increase in which vital sign? 1.pulse 2.respirations 3.blood pressure 4.temperature
3. Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored, and blood pressure is maintained as identified by the health care provider (HCP) Billings13e-Glossary-icon and specific to the client's ischemic tissue needs and risk of bleeding from treatment. The other vital signs are important, but the priority is to monitor blood pressure.
A client with a hemorrhagic stroke is slightly agitated, heart rate is 118 bpm, respirations are 22 breaths/min, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88 mm Hg, and oral secretions are noted. What order of interventions from first to last should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion? All options must be used. 1.Suction the airway. 2.Hyperoxygenate. 3.Suction the mouth. 4.Provide sedation.
4, 2, 1, 3. Increased agitation with suctioning will increase ICP; therefore, sedation should be provided first. The client should be hyperoxygenated before and after suctioning to prevent hypoxia since hypoxia causes vasodilation of the cerebral vessels and increases ICP. The airway should then be suctioned for no more than 10 seconds. The mouth can be suctioned once the airway is clear to remove oral secretions. Once the mouth is suctioned, the suction catheter should be discarded.
A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor? 1.unequal pupil size 2.decreasing systolic blood pressure 3.tachycardia 4.decreasing body temperature
1. Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.
A nurse is assessing a client with increasing intracranial pressure. What is a client's mean arterial pressure (MAP) in mm Hg when blood pressure (BP) is 120/60 mm Hg? _______________________ mm Hg.
(60*2+ 120)/3=80mm of Hg
The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Select all that apply. 1.systolic blood pressure 2.urine output 3.breath sounds 4.cerebral perfusion pressure 5.level of pain
1, 4. The nurse must monitor the systolic and diastolic blood pressure to obtain the mean arterial pressure (MAP), which represents the pressure needed for each cardiac cycle to perfuse the brain. The nurse must also monitor the cerebral perfusion pressure (CPP), which is obtained from the ICP and the MAP. The nurse should also monitor urine output, respirations, and pain; however, crucial measurements needed to maintain CPP are ICP and MAP. When ICP equals MAP, there is no CPP.
Following a stroke, a client has dysphagia and left-sided facial paralysis. Which feeding technique will be most helpful at this time? 1.Encourage sipping diluted liquid meal supplements from a straw. 2.Position the client with the bed at a 30-degree angle. 3.Offer solid foods from the unaffected side of the mouth. 4.Feed the client a soft diet from a spoon into the left side of the mouth.
3. Following a stroke, it is easiest for clients with dysphagia (difficulty swallowing) to swallow solid foods; the nurse introduces foods on the unaffected side. Liquid foods are difficult to swallow, and the client with facial paralysis will have difficulty sipping using a straw. The head of the bed is elevated to 90 degrees, or the client is instructed to sit up, if possible, while eating to prevent choking and aspiration.
what do you do for osteoporosis
low intensity excercise vitamin d avoid carbonated drinks
who collects data, collaborates, assists and does some amount of education as per request
lpn
when is it considered negligence and when is it considered malpractice
malpractice is injury while negligence isnt
what medictions can you give the patient to reduce the icp
mannitol(osmotic diuretic steroid), hypertonic solution
spinal injury is considered as what type of shock
neurogenic shock
neurologic disorders are they npo or po
npo and then tube feed when you figure out whats wrong
who does delegation, innitial assessment, planning and diagnosing and evaluating
nurse
who can view patients chart
only personells associated with the patients treatment
when is a consent informed consent
patient should know what the procedure is whos the doctor risk factors should be of right mind to consent
what kind of ties can you as a nurse use for restraints
quick release tie
when can a nurse delegate tasks
right person, right time, right task and right evaluation
secondary prevention
screening mammogram prostate screening
Glasgow Coma Scale
best eye response best verbal response best motor response
6 characteristics to nursing
communication compassion and caring critical thinking competence complexity
what tests will you do for iicp
glasgow coma scale ct scan (first ones without contrast)
stroke we have increased icp what vital responses will you see
increase in bp (systolic) decrease in heart rate decrease in respirations
what do you need to assess befor putting on restraints
why do you need a restraint hydration circulation skin hygiene
Which respiratory pattern indicates increasing intracranial pressure in the brain stem? 1.slow, irregular respirations 2.rapid, shallow respirations 3.asymmetric chest excursion 4.nasal flaring
1. Neural control of respiration takes place in the brain stem. Deterioration and pressure produce slow and irregular respirations. Rapid and shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.
The nurse is observing the unlicensed assistive personnel (UAP) give mouth care to a client who has had a stroke and is unconscious. The nurse should intervene if the UAP does which? 1.positions the client on the back with a small pillow under the head 2.keeps portable suctioning equipment at the bedside 3.opens the client's mouth with a padded tongue blade 4.cleans the client's mouth and teeth with a toothbrush
1. The UAP should position an unconscious client on the side, not on the back, with the head on a small pillow. A lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction the client if he or she aspirates. Suction equipment should be nearby. It is safe to use a padded tongue blade, and the client should receive oral care, including brushing with a toothbrush.
The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate? 1.the head of the bed elevated 15 to 20 degrees 2.Trendelenburg's position 3.left Sims' position 4.the head elevated on two pillows
1. The client's ICP is elevated, and the client should be positioned to avoid extreme neck flexion or extension. The head of the bed is usually elevated 15 to 20 degrees to drain the venous sinuses and thus decrease the ICP. Trendelenburg's position places the client's head lower than the body, which would increase ICP. Sims' position (side lying) and elevating the head on two pillows may extend or flex the neck, which increases ICP.
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the IV line. What should the nurse do to protect the client without increasing the intracranial pressure (ICP)? 1.Place the client in a jacket restraint. 2.Wrap the hands in soft "mitten" restraints. 3.Tuck the arms and hands under the sheet. 4.Apply a wrist restraint to each arm.
2. It is best for the client to wear mitts, which help prevent the client from pulling on the IV without causing additional agitation. Using a jacket or wrist restraint or tucking the client's arms and hands under the sheet restricts movement and adds to feelings of being confined, all of which would add to the agitation and increase ICP.
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? 1.cholesterol level 2.pupil size and pupillary response 3.bowel sounds 4.echocardiogram
2. It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. The cholesterol level is not a priority assessment, although it may be an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but this is not a priority in the first 24 hours, when the primary concerns are cerebral hemorrhage and increased intracranial pressure. An echocardiogram is not needed for the client with a thrombotic stroke without heart problems.
Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)? 1.deep breathing 2.turning 3.coughing 4.passive range-of-motion (ROM) exercises
3. Coughing is contraindicated for a client at risk for increased ICP because coughing increases ICP. Deep breathing can be continued. Turning and passive ROM exercises can be continued with care not to extend or flex the neck.
A client has an increased intracranial pressure (ICP) of 20 mm Hg. What should the nurse do next? 1.Give the client a warming blanket. 2.Administer low-dose barbiturates. 3.Encourage the client to take deep breaths to hyperventilate. 4.Restrict fluids.
3. Normal ICP is 15 mm Hg or less for 15 to 30 seconds or longer. Hyperventilation causes vasoconstriction, which reduces cerebrospinal fluid and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg. A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases ICP. High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure >80 mm Hg.
The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider (HCP) about which early change in the client's condition? 1.widening pulse pressure 2.decrease in the pulse rate 3.dilated, fixed pupils 4.decrease in level of consciousness (LOC)
4. A decrease in the client's LOC is an early indicator of deterioration of the client's neurologic status. Changes in LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated.
A client with a head injury regains consciousness after several days. When the client first awakes, what should the nurse say to the client? 1."I'll get your family." 2."Can you tell me your name and where you live?" 3."I'll bet you are a little confused right now." 4."You're in the hospital. You were in an accident and unconscious.
4. It is important to first explain where a client is to orient him or her to time, person, and place. Offering to get the family and asking questions to determine orientation are important, but the first comments should let the client know where he or she is and what has happened. It is useful to be empathetic to the client, but making a comment such as "I'll bet you are a little confused" is not helpful and may cause anxiety.
The nurse administers mannitol to the client with increased intracranial pressure. Which parameter requires close monitoring? 1.muscle relaxation 2.intake and output 3.widening of the pulse pressure 4.pupil dilation
2. After administering mannitol, the nurse closely monitors intake and output because mannitol promotes diuresis and is given primarily to pull water from the extracellular fluid of the edematous brain. Mannitol can cause hypokalemia and may lead to muscle contractions, not muscle relaxation. Signs and symptoms, such as widening pulse pressure and pupil dilation, should not occur because mannitol serves to decrease ICP.
A client arrives in the emergency department with an ischemic stroke. What should the nurse do before the client receives tissue plasminogen activator (t-PA)? 1.Ask what medications the client is taking. 2.Complete a history and health assessment. 3.Identify the time of onset of the stroke. 4.Determine if the client is scheduled for any surgical procedures.
3. Studies show that clients who receive recombinant t-PA treatment within 3 hours after the onset of a stroke have better outcomes. The time from the onset of a stroke to t-PA treatment is critical. A complete health assessment and history is not possible when a client is receiving emergency care. Upcoming surgical procedures may need to be delayed because of the administration of t-PA, which is a priority in the immediate treatment of the current stroke. While the nurse should identify which medications the client is taking, it is more important to know the time of the onset of the stroke to determine the course of action for administering t-PA.
An unconscious client with multiple injuries to the head and neck arrives in the emergency department. What should the nurse do first? 1.Establish an airway. 2.Determine the identity of the client. 3.Stop bleeding from open wounds. 4.Check for a neck fracture.
1. The highest priority for a client with multiple head and neck injuries is to establish an open airway for effective ventilation and oxygenation. Unless the client has a patent airway, other care measures will be futile. Determining the client's identity, blood loss, stopping bleeding from open wounds, and checking for a neck fracture are important nursing interventions to be completed after the airway and ventilation are established.
The nurse is developing a care plan for a client who has had a stroke. The nurse asks about the client's functional status before the stroke. How will the nurse incorporate this information into the care plan? The client's functional status before the stroke will: 1.guide the rehabilitation plan. 2.help predict outcomes. 3.help the client recognize physical limitations. 4.determine if the client can be expected to regain most functional status.
1. The primary reason for the nursing assessment of a client's functional status before the stroke is to guide the rehabilitation plan. The assessment does not help to predict how far the rehabilitation team can help the client to recover from the residual effects of the stroke, only what plans can help a client who has moved from one functional level to another. The nursing assessment of the client's functional status does not help the client recognize limitations
A client who had a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which outcome of rehabilitation would be appropriate for the client? The client will: 1.exhibit no further episodes of short-term memory loss. 2.be able to return to his construction job in 3 weeks. 3.actively participate in the rehabilitation process as appropriate. 4.be emotionally stable and display preinjury personality traits.
3. Recovery from a serious head injury is a long-term process that may continue for months or years. Depending on the extent of the injury, clients who are transferred to rehabilitation facilities most likely will continue to exhibit cognitive and mobility impairments as well as behavior and personality changes. The client would be expected to participate in the rehabilitation efforts to the extent he is capable. Family members and significant others will need long-term support to help them cope with the changes that have occurred in the client.
What should the nurse do first when a client with a head injury begins to have clear drainage from the nose? 1.Compress the nares. 2.Tilt the head back. 3.Collect the drainage. 4.Administer an antihistamine for postnasal drip.
3. The clear drainage must be analyzed to determine whether it is nasal drainage or cerebrospinal fluid (CSF). The nurse should not give the client tissues because it is important to know how much leakage of CSF is occurring. Compressing the nares will obstruct the drainage flow. It is inappropriate to tilt the head back, which would allow the fluid to drain down the throat and not be collected for a sample. It is inappropriate to administer an antihistamine because the drainage may not be from postnasal drip.
The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply. 1.Encourage the client to cough to expectorate secretions. 2.Elevate the head of the bed 15 to 20 degrees. 3.Contact the health care provider (HCP) if ICP is >28 mm Hg. 4.Monitor neurologic status using the Glasgow Coma Scale. 5.Stimulate the client with active range-of-motion exercises.
2, 3, 4. The nurse should maintain ICP by elevating the head of the bed 15 to 20 degrees and monitoring neurologic status. An ICP of 28 mm Hg with 20 to 25 mm Hg as upper limits of normal indicates increased ICP, and the nurse should notify the HCP Billings13e-Glossary-icon. Coughing and range-of-motion exercises will increase ICP and should be avoided in the early postoperative stage.
5. from text nurse is assessing the level of consciousness in a client with a head injury who has been unresponsive for the last 8 hours. Using the Glasgow Coma Scale, the nurse notes that the client opens the eyes only as a response to pain, responds with sounds that are not understandable, and has abnormal extension of the extremities. What should the nurse do?
The client has a score of 6 (eye opening to pain = 2; verbal response, incomprehensible sounds = 2; best motor response, abnormal extension = 2); a score <7 is indicative of coma. While the nurse should continue to speak to the client, at this time the client will not be able to be aroused. The nurse should continue to provide skin care and appropriate alignment, but the client will continue to have a motor response of limb extension. It is not necessary to notify the HCP Billings13e-Glossary-icon as this assessment does not represent a significant change in neurological status.
