Cardiac Nclex

Question 2 See full question36sReport this Question 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 Maintaining aseptic technique with an intraventricular catheter Encouraging deep breathing and coughing every 2 hours Frequent oral care

Controlling fever is an important intervention for a client with increased ICP because fevers can cause an increase in cerebral metabolism and can lead to cerebral edema. Antipyretics are appropriate to control a fever. It is imperative that the nurse use aseptic technique when caring for the intraventricular catheter because of its risk for infection. Oral care should be provided frequently because the client is likely to be placed on a fluid restriction and will have dry mucous membranes. A nondrying oral rinse may be used. Coughing should be discouraged in a client with increased ICP because it increases intrathoracic pressure, and thus ICP. Unless contraindicated, the head of the bed should be elevated to 30 to 45 degrees and in a neutral position to allow for venous drainage.

Question 5 See full question21sReport this Question The nurse is caring for a client with a traumatic brain injury and experiencing increased intracranial pressure. The nurse has administered mannitol, an osmotic diuretic, as ordered. This medication promotes the shift of fluid from the intracellular to the intravascular compartment. Therefore, it is necessary for the nurse to continually assess for which of the following?

Correct response: Heart failure Explanation: It is possible for the client to have a fluid overload that creates such an increased workload for the heart that it fails.

Question 1 See full question36sReport this Question A patient having an acute stroke with no other significant medical disorders has a blood glucose level of 420 mg/dL. What significance does the hyperglycemia have for this patient?

This is significant for poor neurologic outcomes. Explanation: Hyperglycemia has been associated with poor neurologic outcomes in acute stroke and should be treated if the blood glucose is above 140 mg/dL

Question 4 See full question20sReport this Question 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?

Correct response: Administer acetaminophen per orders. Explanation: The nurse needs to control the fever by administering the ordered acetaminophen as the priority action. An increase in the client's temperature can lead to increased cerebral metabolic demands and poor outcomes if not properly treated. The nurse should always inspect the equipment to ensure that it is working properly, but this is not the priority because there is no indication of equipment failure. The nurse should provide ventriculostomy care, but this is not the priority as there is an elevated temperature. Because the client has an elevated temperature, the nurse should assess for signs and symptoms of infection, but only after treating the elevated temperature.

Question 3 See full question10sReport this Question 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?

Correct response: Flaccid Explanation: LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response (Barlow, 2012). The patient's responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive (see Chapter 68). An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate (Fig. 66-1; see also Chapter 65). The most severe neurologic impairment results in flaccidity. The motor response cannot be elicited or assessed when the patient has been administered pharmacologic paralyzing agents (i.e., neuromuscular blocking agents).