Management of patient with Neurologic Dysfunction

Pataasin ang iyong marka sa homework at exams ngayon gamit ang Quizwiz!

The nurse is caring for the patient in the neurologic ICU 2ho sustained head trauma in a physical altercation. What would the nurse knowis an optimal range of ICPfor this patient?

0 mmHg to 10 mmHg

A nurse assess the patient's LOC using GCS. What score indicates severe impairment in neurologic function?

3

A patient is admitted to the hospital with an ICP reading of 20 mmHg and MAP 90mmHg. What woukd the nurse calculate the CPP be?

70 mmHg

A nurse caring for a patient with head trauma will be monitoring the patient for Cushing triad. What will the nurse recognizeas the symptoms associated with Cushing triad? SATA

Bradycardia Bradypnea Hypertension

The earliest sign of increased ICP is

Change in LOC (Level of Consciousness)

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

Flaccid

Maintain dorsiflexion to affected area

Footdrop

Assist with daily active or passive range of motion

Footdrop Paralyzed extremity

The nurse is educatinga patient with a seizure disorder. What nutritional approach for seizure management would be beneficialfor this patient?

High in protein and low in carbohydrate

Place the patient in lateral position

Impaired cough reflex

Elevate thr head of the bed 30⁰

Impaired cough reflex paralyzed diaphragm

Institute a bowel training program

Incontinence

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

Increased ICP

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?

Lethargy and stupor

The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who isexperiencing a convulsive seizure? SATA

Loosening constrictive clothing Positioning the patient on their side with head flexed forward Providing for privacy

The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient?

Maintain patent airway

The nurse is caring for a patient with increased ICP. As the oressure rises, what osmotic diuretic does the nurse prepare to administer?

Mannitol

A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate?

Notify the physician of a possible CSF leak

When educating a patient about the use of anticonvulsant medication, what shoukd the nurse inform the patient is a result os long-term use of the medication in women?

Osteoporosis

A patient has a small pituitary adenoma removed by the transsphenoidal approach and has developed DI. What pharmacologic therapy will the nurse be administering to this patient to control symptoms?

Vasopressin

The primary lethal complication of ICP

brain herniation resulting to death

Three primary complications of increased ICP

brain stem herniation diabetes insipidus SIADH (syndrome of inappropriate antidiuretic hormone)

Nursing postoperative management includes detecting and reducing _______, relieving _____, preventing ________, and monitoring ________ and ________.

cerebral edema pain seizure increased ICP neurologic status

The leading cause of seizure in older adult

cerebrovascular disease

A patient has a lesion affecting the pons, resulting in paralysis and inability to speak, but has vertical eye movements and lid elevation. This patient is suffering from

locked-in syndrome

A nurse is assessing a patient's UI as an indicator for DI related to a traumatic brain injury. The nurse knows that an hourly output of what volume over 2 hrs maybe a positive indicator?

more than 200mL/h

Three major potentialcomplications in a patient with depressed level of conciousness (LOC)

pneumonia, aspiration, respirarory failure

A major potential complication of epilepsy

status epilepticus


Kaugnay na mga set ng pag-aaral

Organization: structure and culture (Chapter 3)

View Set

(ISC)2 Certified in Cybersecurity - Exam Prep

View Set

Module 10 Common Administrative Tasks

View Set

Rikki-tikki-tavi Study Guide Review

View Set

Intellectual Property - Trademarks and Passing Off

View Set

ISE 2500 Chapter 14: Processing of Polymer Matrix Composites and Rubber

View Set