520 ICP

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. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. a. 1Provide sedation. b. 2Suction the airway. c. 3Suction the mouth. d. 4Hyperoxygenate.

a. Provide sedation. d. Hyperoxygenate. b. Suction the airway. c. Suction the mouth. Explanation: 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 has an increased intracranial pressure (ICP) of 20 mm Hg. What should the nurse do next? a. Restrict fluids. b. Encourage the client to take deep breaths to hyperventilate. c. Give the client a warming blanket. d. Administer low-dose barbiturates.

b. Encourage the client to take deep breaths to hyperventilate. Explanation: 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 greater than 80 mm Hg.

The nurse is caring for a child with a head injury. Place the following assessments in order of priority, starting with the nursing assessment the nurse should perform first. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. a. 1Decreased urine output. b. 2Level of consciousness. c. 3Motor strength. d. 4Vital signs.

b. Level of consciousness. c. Motor strength. d. Vital signs. a. Decreased urine output. Explanation: In order of priority, the nurse would assess level of consciousness, motor strength, vital signs, vomiting episodes, and then decreased urine output. Level of consciousness is the best indication of brain function. If the child's condition deteriorates, the nurse would observe changes in level of consciousness before any other changes. Motor strength is primarily assessed as a voluntary action. With a change in level of consciousness, there may be changes in motor function. If the client's fluids are restricted, then the urine output would decrease. In children, the usual urine output is 1 ml/kg/hour.

Which is the nurse's best rationale for positioning a client with decreased level of consciousness related to a head injury? a. decrease of cerebral arterial pressure b. avoidance of impeding venous outflow c. prevention of aspiration of stomach contents d. prevention of flexion contractures

b. avoidance of impeding venous outflow Explanation: Any activity or position that impedes venous outflow from the head may contribute to increased volume inside the skull and possibly increase intracranial pressure. The other choices do not promote head trauma positioning and reduction/flow of cerebral fluid.

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. a. level of pain b. systolic blood pressure c. urine output d. cerebral perfusion pressure e. breath sounds

b. systolic blood pressure d. cerebral perfusion pressure Explanation: 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.

After striking their head on a tree while falling from a ladder, a client is admitted to the emergency department. The client is unconscious and their pupils are nonreactive. Which intervention should the nurse question? a. elevating the head of their bed b. giving the client a barbiturate c. performing a lumbar puncture d. placing the client on mechanical ventilation

c. performing a lumbar puncture Explanation: The client's history and assessment suggest that they may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn't be done because it can quickly decompress the central nervous system, causing additional damage. After a head injury, barbiturates may be given to prevent seizures; mechanical ventilation may be required if breathing deteriorates; and elevating the head of the bed may be used to reduce ICP.

A nurse is comparing the neurological status of a client who suffered a head injury with the status on the previous shift. Using the Glasgow Coma Scale, the nurse determines that the client's score has changed from 11 to 15. Which responses did the nurse assess in this client? Select all that apply. a. unequal pupil size b. tachypnea, bradycardia, and hypotension c. orientation to person, place, and time d. spontaneous eye opening e. motor response to pain localized f. incomprehensible sounds

d. spontaneous eye opening c. orientation to person, place, and time Explanation: The Glasgow Coma Scale is a tool to assess a client's response to stimuli. To achieve a perfect score of 15 on the Glasgow Coma Scale, the client would have to open their eyes spontaneously (4), obey verbal commands (6), and be oriented to person, place, and time (5). Vital signs and pupil size are not assessed with the Glasgow Coma Scale. The ability to localize pain earns a motor response score of 5, not the top score of 6. Making incomprehensible sounds earns a verbal response score of 2, not a 5.

A client is admitted to the medical-surgical unit after undergoing intracranial surgery to remove a tumor from the left cerebral hemisphere. Which nursing interventions are appropriate for the client's postoperative care? Select all that apply. a. Apply a soft collar to keep the client's neck in a neutral position. b. Maintain the client in the supine position. c. Place pillows under the client's legs to promote hip flexion and venous return. d. Place a pillow under the client's head so that the neck is flexed. e. Turn the client on the right side.

e. Turn the client on the right side. a. Apply a soft collar to keep the client's neck in a neutral position. Explanation: The client should be turned on the right side, because lying on the left side would cause the brain to shift into the space previously occupied by the tumor. A soft collar keeps the neck neutral, allowing for adequate perfusion and venous drainage of the brain. Placing a pillow under the head flexes the neck and impairs circulation to the brain. Flexion of the hip increases intracranial pressure and, therefore, is contraindicated. Exclusive use of the supine position is not indicated.

A young adult is admitted to the hospital with a head injury and possible temporal skull fracture sustained in a motorcycle accident. On admission, the client was conscious but lethargic; vital signs included temperature 99°F (37°C), pulse 100 bpm, respirations 18 breaths/min, and blood pressure 130/70 mm Hg. The nurse should report which changes, if they occur, to the health care provider (HCP)? Select all that apply. a. increasing diastolic blood pressure b. decreasing urinary output c. widening pulse pressure d. decreasing systolic blood pressure e. tachycardia f. bradycardia

f. bradycardia c. widening pulse pressure Explanation: The nurse should immediately report changes that indicate increasing intracranial pressure (ICP): bradycardia, increasing systolic pressure, and widening pulse pressure. As ICP increases and the brain becomes more compressed, respirations become rapid, BP decreases, and the pulse slows further; these are very ominous signs. Decreased arterial BP and tachycardia can indicate bleeding elsewhere in the body. Decreasing urinary output indicates decreased tissue perfusion. The nurse monitors changes and notifies the HCP if trends continue.

When a client with thrombocytopenia has a severe headache, what does the nurse interpret that this may indicate? a. sinus congestion b. stress of the disease c. cerebral bleeding d. migraine headache

C. cerebral bleeding Explanation: When the platelet count is very low, red blood cells leak out of the blood vessels and into the tissue. If the blood pressure is elevated and the platelet count falls to less than 15,000/µl (15 X 109/L), internal bleeding in the brain can occur. A severe headache occurs from meningeal irritation when blood leaks out of the cerebral vasculature. When a client has thrombocytopenia, the nurse should always assess for cerebral bleeding by checking vital signs and performing neurologic checks. Headaches can be caused by stress, migraines, and sinus congestion. However, the concern here is the risk of internal bleeding into the brain.