chap 66 prep U questions

Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply.

-Administering prescribed antipyretics -Maintaining aseptic technique with an intraventricular catheter -Frequent oral care

Cerebral edema peaks at which time point after intracranial surgery?

24 hours

Using the Glasgow Coma Scale, the nurse gives a patient who is brain dead a score of

3

Which value indicates a normal intracranial pressure (ICP)? 5 mm Hg 17 mm Hg 20 mm Hg 27 mm Hg

5 mm Hg (0-10 normal)

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 nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply.

Bradycardia Bradypnea Hypertension

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

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

Check the equipment.

The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop?

Damage to the optic nerve

A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP?

Decerebrate posturing and loss of corneal reflex

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities? patient can also become comatose

Decorticate

The cerebral perfusion pressure (CPP) must be maintained at 50 mm Hg to ensure adequate blood flow to the brain.

False

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?

Herniation

Which is the priority nursing diagnosis when caring for a client with increased ICP who has an intraventricular catheter?

Ineffective cerebral tissue perfusion

A nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what complication of ICP monitoring?

Infection

A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP?

Keep the client's neck in a neutral position (no flexing).

A client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure?

Lethargy

A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority?

Maintenance of a patent airway

The most frequently administered hyperosmotic agent used to reduce cerebral edema before intracranial surgery is

Mannitol

When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP?

Rising blood pressure and bradycardia

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?

Shivering

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value?

The CPP is low.Explanation: The normal CPP is 70 to 100 mm Hg.

During assessment of an unconscious patient, the nurse notes "fixed, dilated pupils" and understands that brain injury is at the level of the midbrain.

True

The earliest sign of increasing ICP is a change in LOC.

True

Which method is used to help reduce intracranial pressure?

Using a cervical collar

A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. The expected treatment would consist of which of the following?

Vasopressin therapy

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?

Widened pulse pressure

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:

diminished responsiveness.

For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to?

promote carbon dioxide elimination

The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the

supine position with the head slightly elevated.

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

A client suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure?

vasodilation

A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mm Hg and the ICP is 18 mm Hg; therefore his cerebral perfusion pressure (CPP) is:

52 mm Hg. 60x2= 120 120 +90 =210 210/ 3= 70 mm hg (map) 70-18 = 52 mmhg (MAP- ICP = CPP

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 client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome?

Airway

Which is a late sign of increased intracranial pressure (ICP)?

Altered respiratory patterns

refers to the brain's ability to change the diameter of its blood vessels to maintain a constant cerebral blood flow during alterations in systemic blood pressure

Autoregulation

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?

Body temperature

A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. While assessing the client, the nurse expects which of the following findings?

Excessive urine output and decreased urine osmolality

A patient has a severe neurologic impairment from a head trauma. What does the nurse recognize is the type of posturing that occurs with the most severe neurologic impairment?

Flaccid

The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring?

Increased ICP

The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy?

Increased ICP is 12 mm Hg.

Nursing intervention when caring for a patient with ICP is to maintain the head of the bed at 30 degrees and maintain alignment of the head.

True