Chapter 61 (chapter questions)

Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply. Administering prescribed antipyretics Elevating the head of the bed to 90 degrees Encouraging deep breathing and coughing every 2 hours Frequent oral care Maintaining aseptic technique with an intraventricular catheter

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

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

Altered respiratory patterns

The nurse is taking care of a client with a history of headaches. The nurse takes measures to reduce headaches and administer medications. Which appropriate nursing interventions may be provided by the nurse to such a client?

Apply warm or cool cloths to the forehead or back of the neck

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.

Which positions is used to help reduce intracranial pressure (ICP)?

Avoiding flexion of the neck with use of a cervical collar

Which is the earliest sign of increasing intracranial pressure?

Change in level of consciousness

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?

Decorticate

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

Increased ICP is 12 mm Hg.

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

Ineffective cerebral tissue perfusion

A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?

Restricting fluid intake and hydration

A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?

Restricting fluid intake and hydration

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.

Which method is used to help reduce intracranial pressure?

Using a cervical collar

When the nurse observes that the client has extension and external rotation of the arms and wrists and plantar flexion of the feet, the nurse records the client's posture as

decerebrate.

The initial sign of increasing intracranial pressure (ICP) includes

decreased level of consciousness.

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to

dehydrate the brain and reduce cerebral edema.

The nurse is caring for a client who was involved in a motorcycle accident 7 days ago. Since admission the client has been unresponsive to painful stimuli. The client had a ventriculostomy placed upon admission to the ICU. The current assessment findings include ICP of 14 with good waveforms, pulse 92, respirations per ventilator, temperature 102.7°F (rectal), urine output 320 mL in 4 hours, pupils pinpoint and briskly reactive, and hot, dry skin. Which is the priority nursing action?

Administer acetaminophen per orders.

The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention?

Administer corticosteroids as ordered.

Which medication classification is used preoperatively to decrease the risk of postoperative seizures?

Anticonvulsants

Which activity should be avoided in clients with increased intracranial pressure (ICP)

Enemas

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

Herniation

The nurse is educating a group of people newly diagnosed with migraine headaches. What information should the nurse include in the educational session? Select all that apply. Maintain a headache diary. Exercise in a dark room. Use St. John's Wort. Sleep no more than 5 hours at a time. Keep a food diary.

Maintain a headache diary. Keep a food diary.

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

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. This CPP reading is considered

low.

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.

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.

The Monro-Kellie hypothesis explains

the dynamic equilibrium of cranial contents.

Cerebral edema peaks at which time point after intracranial surgery?

24 hours

Which value indicates a normal intracranial pressure (ICP)?

5 mm Hg