405 Unit 2

What are fixed and dilated pupils a sign of?

Head trauma, which needs immediate intervention

A nurse on the neurologic unit is providing care for a client who has spinal cord injury at the level of C4. When planning the client's care, what aspect of the client's neurologic and functional status should the nurse consider? Inability to use a wheelchair Requires full assistance for elimination Incontinent in bowel movements Unable to swallow liquid and solid food

Requires full assistance for elimination They need help eating but they have no trouble swallowing. Patient can also use a wheel chair

Confusion

DDisorientation, alert but may respond incorrectly to questions

Ischemic stroke

Functional recovery usually plateaus at 6 months, not hemorrhagic.

Lorazepam

drug for anxiety treatment

What are sunset eyes a sign of?

Increased intracranial pressure from hydrocephalus

Naproxen

NSAID to relieve pain

calcium carbonate

calcium supplement + antacid to releive indigestion and heartburn.

Why would we need to increase blood pressure?

Neurogenic shock would decrease bp and heartrate. So transfusion, reposition and ice baths are not indicated interventions.

Why not the others?

THose are not typical restrictions for the condition Urinary cathetirs increase the risk of infection so we want to remove it asap getting the patient up and moving to prevent ulcers

During a client's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help clients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply. Age LOC at time of admission Gender Race National Institutes of Health Stroke Scale (NIHSS) score

Age LOC at time of admission National Institutes of Health Stroke Scale (NIHSS) sc Gender and race are not significant predictors

A client sustained a head injury as a result of trauma. The health care provider has instituted seizure prophylactic measures. The nurse anticipates which specific measures being initiated for this client? Aspiration precautions on day four of injury Anticonvulsant medications on day two of injury Antiemetic medications on day three of injury Intubation and ventilator support on day one of injury

Anticonvulsant medications on day two of injury

The nurse is caring for a client who is rapidly progressing toward brain death. The nurse should be aware of what cardinal sign(s) of brain death? Select all that apply. Absence of deep tendon reflexes Apnea Absence of brain stem reflexes Absence of pain response Coma

Apnea Absence of brain stem reflexes Coma Absence of reflex or pain are not necessarily indicative of brain death

The nurse is reviewing the medication administration record of a client who possesses numerous risk factors for stroke. Which of the client's medications carries the greatest potential for reducing her risk of stroke? Lorazepam 1 mg SL b.i.d. PRN Calcium carbonate 1,000 mg PO b.i.d. Aspirin 81 mg PO o.d. Naproxen 250 PO b.i.d.

Aspirin 81 mg PO o.d. relieves pain, colds, headaches, and reduce pain/swelling.

A 10-month-old infant is brought to the emergency department by the parents after they found the infant face down in the bathtub. The parent states, "I just left the bathroom to answer the phone. When I came back, I found my infant." Which nursing action is priority? Determine how long the client was face down in the water Start cardiopulmonary resuscitative measures Assess the client's respiratory rate Apply a heart monitor to the client

Assess the client's respiratory rate Submersion, hypoxia is the primary concern. Assessment of airways nad breathing are priority. Start off with this and the other actions can be done.

A nurse has received an unconscious client with a traumatic brain injury (TBI). The nurse is concerned about the client's skin integrity and implements interventions to prevent pressure injuries. Which action should the nurse implement during the shift? Assisting the client to get out of bed to a chair four times a day. Turning and repositioning the client every 6 hours Providing skin care with barrier care ointments once a day Assessing all body surfaces and documenting skin integrity every 8 hours

Assessing all body surfaces and documenting skin integrity every 8 hours

A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client? Third-spacing and hyperthermia Tachycardia and agitation Bradycardia and hypertension Respiratory distress and projectile vomiting

Bradycardia and hypertension Autonomic dysreflexia is characterized by pounding headache, profuse sweating, nasal congestion, and goosebumps, bradycardia and hypertension. So it does not result in vomiting, tachyvardia or third spacing

What is Reye syndrome characterized by?

Brain swelling, liver failure, and death in hours if treatment is not initiated. As a result, intracranial pressure could increase, liver enzymes could rise. Blood glucose levels and protein in urine are not typical of this disease

Why assess all body surfaces?

Clients with TBI often require assistance in turning and positioning because of immobility or unconsciousness. Prolonged pressure on the tissues decreases circulation and leads to tissue necrosis. Specific nursing measures include the following: Assessing all body surfaces and documenting skin integrity every 8 hours. Turning and repositioning the client should occur every 2 hours. Skin care should be done every 4 hours and includes more than applying an ointment. Other interventions include keeping the skin dry, offloading bony prominences and with pillows or wedge devices. Since this client is unconscious; assisting the client to get out of bed needs his/her cooperation which is not possible. It should also be three times a day and not four.

Why anticonvulsants and not other drugs?

Clients with head injury are at an increased risk for posttraumatic seizures. Posttraumatic seizures are classified as immediate (within 24 hours after injury), early (within 1 to 7 days after injury), or late (more than 7 days after injury). Seizure prophylaxis is the practice of administering anticonvulsant medications to clients with head injury to prevent seizures. It is important to prevent posttraumatic seizures, especially in the immediate and early phases of recovery, because seizures may increase ICP and decrease oxygenation. All of the other interventions are not part of the seizure prophylactic protocol nor have a specific timeline of administration.

Which is a nonmodifiable risk factor for ischemic stroke? Smoking Hyperlipidemia Gender Atrial fibrillation

Gender, this cannot be changed unlike the others lol

The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipate administering to halt the seizure immediately? Oral lorazepam Intravenous diazepam Intravenous phenobarbital Oral phenytoin

Intravenous diazepam Oral medications are not given during seizures. Diazepam and lorazepam help stop seizures. Phenobarbital are given to maintain a seizure free state post seizure

During class, a student states, "I didn't think children could have strokes. I thought this only occurred in older adults." When responding to the student, what would be most important for the instructor to integrate into the response? The signs and symptoms in children are different from an adult. Ischemic strokes are more common than hemorrhagic strokes. Strokes in children often have an identifiable cause. Research has identified specific treatments for children.

Ischemic strokes are more common than hemorrhagic strokes. Cause of strokes are often unknown, usually similar to those in adults. Children are usually excluded from these studies Signs and symtoms are usually similar

Which of the following is accurate regarding a hemorrhagic stroke? Main presenting symptom is an "exploding headache." One of the main presenting symptoms is numbness or weakness of the face. It is caused by a large-artery thrombosis. Functional recovery usually plateaus at 6 months.

Main presenting symptom is an "exploding headache." However, it is also true that it may be caused by a large artery thrombosis and may have presenting symptoms of numbness in the face

The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client? Maintain bed in Trendelenburg position. Maintain head of bed (HOB) elevated at 30 to 45 degrees. Position the client supine. Position client in prone position.

Maintain head of bed (HOB) elevated at 30 to 45 degrees. Other alignments woukd actually be dangerous for ICP

Coma

No arousal even with painful stimuli

A client is suspected of having had a stroke. Which is the initial diagnostic test for a stroke? Carotid Doppler Transcranial Doppler studies Electrocardiography Noncontrast computed tomography

Noncontrast computed tomography (CT SCAN) Further diagnosis would use the carotid doppler, electrocardiogram, and transcranial doppler.

The nurse assesses a child's level of consciousness, noting that the child falls asleep unless he is stimulated. What is the child's level of consciousness? Obtunded Coma Stupor Confusion

Obtunded -limited response to the environment and falls asleep ubkess stimulation is provided

Stupor

Only respond to vigorous stimulation

The nurse is caring for a client recovering from an ischemic stroke. What intervention(s) best addresses potential complications after an ischemic stroke? Select all that apply. Limiting intake of insoluble fiber, carbohydrates, and simple sugars. Providing frequent small meals rather than three larger meals Encourage the client to stay in bed and assist with turning and repositioning. Keeping a urinary catheter in place for the full duration of recovery. Teaching the client to perform deep breathing and coughing exercises.

Providing frequent small meals rather than three larger meals Teaching the client to perform deep breathing and coughing exercises.

A 16-year-old boy reports to the school nurse with headaches and a stiff neck. Which sign or symptom would alert the nurse that the child may have bacterial meningitis? Sunset eyes Sunlight is "too bright" Frequent urination Fixed and dilated pupils

Sunlight is "too bright" Light intolerance is a symptom of bacterial meningitis.

A child is in the emergency department with a head injury obtained in a motor vehicle crash. The glascow coma scale assessment is rated at 10 (3 eye opening, 3 motor, 4 verbal). How should the nurse interpret these findings? The child's eyes open spontaneously, able to localize pain and uses inappropriate words The child's eyes open to speech, is able to obey commands but is confused The child's eyes open to verbal stimuli, is confused and flexes with painful stimuli The child's eyes open to pain, opens to extension and says incomprehensible words

The child's eyes open to verbal stimuli, is confused and flexes with painful stimuli The glascow coma scale is a widely used tool for assessing the extent of brain injury and prognosis. The scores are based on eye opening, motor response and verbal response. The perfect score is 15. The lower the score the more severe the injury and prognosis. Scores for a severe head injury are 8 or less. A moderate head injury scores between 9-12 points and a mild head injury scores between 13 and 15. With a score of 10 this child would be classified as having a moderate head injury. For answer B the eyes open spontaneously (4), localizes pain (5) and uses incomprehensive words(2) for a total score of 11.For answer C the eyes open to speech (3), uses inappropriate words (2) and has flexion withdrawal (4) for a total score of 9. For answer D the eyes open to pain (2) extremities open to extension (2) and uses incomprehensible words (2) for a score of 6.

A 13-year-old was brought to the ED after being hit in the head by a baseball and is subsequently diagnosed with a concussion. Which assessment finding would rule out discharging the client? The client's speech is slightly slurred. The client reports pain at the site where the ball hits his head. The client reports a headache. The client is visibly fatigued.

The client's speech is slightly slurred. Sign of possibly serious trauma/ Locailize pain, headache and fatigue are consistent with concussion

A group of students are reviewing information about head injuries in children. The students demonstrate understanding of this information when they identify what as the most common type of skull fracture in children? Basilar Linear Depressed Diastatic

Linear The most common type of skull fracture in children is a linear skull fracture, which can result from minor head injuries. Other, less common types of skull fractures in children include depressed, diastatic, and basilar.

The nurse is admitting a client to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this client's admission orders? Select all that apply. MRI Cerebral angiography Cranial radiography Transcranial Doppler flow study Electromyography (EMG)

MRI Cerebral angiography Transcranial Doppler flow study MRI provides tissue contrast. Angigraphy may be used to stud a tumors blood supply. Transcranial doppler flow studies are used to evaluate blood flow within intracranial blood blessels. Cranial radiography would not be good for seeing a mass and emg woud not be ordered prior to surgery

The nurse planning the care of a client with head injuries is addressing the client's nursing diagnosis of "sleep deprivation." What action should the nurse implement? Ensure that the client does not sleep during the day. Administer a benzodiazepine at bedtime each night. Cluster overnight nursing activities to minimize disturbances. Do not disturb the client between 2200 and 0600.

Cluster overnight nursing activities to minimize disturbances. To allow the client longer times of uninterrupted sleep and rest, the nurse can group nursing care activities so that the client is disturbed less frequently. However, it is impractical and unsafe to provide no care for an 8-hour period. The use of benzodiazepines should be avoided.

A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the emergency department (ED). The nurse should first gauge the client's LOC on the results of what diagnostic tool? Cranial nerve function Monro-Kellie hypothesis Glasgow Coma scale Mental status examination

Glasgow Coma scale because it is an indicator of neurologic function which is perfect for LOC Mental status and cranial nerve examiniation would not be priority for LOC And MonroKellie hypothesis states that because f the limited space for expansion within the skull, an increase in any one ofthe components causes a change in volume in the rest.

The nurse is caring for a client with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the client may be experiencing increased brain compression causing brain stem damage? Tachycardia Hyperthermia Hypertension Bradypnea

Hyperthermia Rationale: Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic BP, and widening pulse pressure. As brain compression increases, respirations become rapid, BP may decrease, and the pulse slows further. A rapid rise in body temperature is regarded as unfavorable. Hyperthermia increases the metabolic demands of the brain and may indicate brain stem damage.

The nurse caring for a client with a spinal cord injury notes that the client is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action? Increase the frequency of ROM exercises. Collaborate with the physical therapist and immobilize the client's extremities temporarily. Educate the client about the importance of frequent position changes. Limit the amount of assistance provided with ADLs.

Increase the frequency of ROM exercises. Rationale: To prevent disuse syndrome, ROM exercises must be provided at least four times a day, and care is taken to stretch the Achilles tendon with exercises. The client is repositioned frequently and is maintained in proper body alignment whether in bed or in a wheelchair. The client must be repositioned by caregivers, not just taught about repositioning. It is inappropriate to limit assistance for the sole purpose of preventing disuse syndrome.

The nurse is caring for a child hospitalized with Reye syndrome who is in the acute stage of the illness. The nurse would assess the child most carefully for what finding? A presence of protein in the urine An increase in the blood glucose level A decrease in the liver enzymes Indications of increased intracranial pressure

Indications of increased intracranial pressure

A hospitalized child is scheduled for magnetic resonance imaging (MRI) with contrast. What nursing intervention(s) will the nurse complete to ensure safety during the examination? Select all that apply. Place child in clothing with no metal Review any prescriptions for sedation Connect the child to a heart monitor Assess the IV site for patency Assess for a latex allergy

Place child in clothing with no metal Review any prescriptions for sedation Assess the IV site for patency When preparing a child for an MRI procedure, it is important the child and parent are aware of the test procedure. No metal can be used in the MRI scanner room so all clothing, jewelry, etc. need to be removed before testing. IV contrast may be used so the IV needs to be patent and in good working order. If the child is to be sedated the nurse should review the sedation prescription and identify any discrepancies before the child goes for the examination. If the child is to be sedated a heart monitor will be used, but it is not necessary for the nurse on the unit to connect the child. A special monitor compatible with the MRI scanner will be used. If sedated the child may also receive oxygen just as a prevention because the exam take a long time in a confined space. Having a latex allergy is not a contraindication for receiving gadolinium, the MRI contrast used during testing.

Why deep breath/cough and small frequent meals?

Pneumonia is a potential complication after stroke, so we want the patient to do this to prevent infection. Small frequent meals prevent the chances of aspiration

The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action? Place the client in the Trendelenburg position. Prepare for interventions to increase the client's BP. Prepare to transfuse packed red blood cells. Prepare an ice bath to lower core body temperature.

Prepare for interventions to increase the client's BP.

The nurse caring for a client in a persistent vegetative state is regularly assessing for potential complications. The nurse should assess for which complications? Select all that apply. Pressure ulcers Venous thromboembolism Contractures Pneumonia Hemorrhage

Pressure ulcers Venous thromboembolism Contractures Pneumonia Vegetation does not directly correlate to heightened risk for hemorrhage.

Frequent urination is a sign of?

Type 1 arnold chari malformation

Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply. Intelligence Muscle strength Verbal response Eye opening Motor response

Verbal response Eye opening Motor response rated 3-15 Intelligence/muscle is not measured herre