Test 3 Practice Questions
*CVA*: FAST** (1) B = (2) E = (3) F = (4) A = (5) S = (6) T =
(1) Balance - Does the person have a sudden loss of balance? (2) Eyes - Has the person lost vision in one or both eyes? (3) Face - does the face look uneven? - ask them to smile (4) Arm - does one arm drift down? - ask them to raise both arms (5) Speech - Does their speech sound strange? - Ask them to repeat a phrase (6) Time - EVERY SECOND brain cells die. Call 911 at ANY of these signs
*Assessment: Hemorrhagic Stroke* (1) Refer to ____
(1) NIH Stroke Scale
State whether the client / spouse understands or requires further teaching: (1) Client places right arm in shirt sleeve first when getting dressed (2) Spouse states: "It will help my wife's vision if I approach her from the right side" (3) Spouse states: I will talk to the home care aides when they come, to be sure they get all of the care done within the first hour" (4) Client turns head to the right and then to the left before activity or ambulation (5) Client states: I know that I need to call for help when I have to go to the potty (6) Client states: I can skip the stool softener pill if I have a bowel movement each day (7) Client picks up a washcloth with the left hand to wash face
(1) Requires further teaching (2) Understood (3) Requires further teaching (4) Understood (5) Understood (6) Requires Further Teaching (7) Requires Further Teaching
Cushings Triad = Late sign of increased ICP (a) Systolic BP ___ (b) HR ___ (c) Respirations ____
(a) Increases (b) Decrease (c) Irregular
Complications ofIncreased ICP include: DI & SIADH (a) Fluid volume overload (retention) (b) Fluid volume deficit (dehydration)
(a) SIADH (b) DI
Sympathetic or Parasympathetic: (a) Increased HR (b) Constricted Pupils (c) Slowed Digestion (d) Bladder Contraction
(a) Sympathetic (b) Parasympathetic (c) Sympathetic (d) Parasympathetic
Cranial nerves responsible for EOM?
- Oculomotor (III), Trochlear (IV), Abducens (VI)
Name 2 branches of the Autonomic Nervous System
- Sympathetic - Parasympathetic
Other Symptoms of ICP (besides change in LOC) may include:
- headache - vomiting - seizures - pupil changes - speech changes
A blood clot may cause which type of stroke? (1) Ischemic (2) Central (3) Transient (4) Hemorrhagic
1
A patient with aphasia cannot speak but can understand your words. This is called ______ aphasia. (1) Expressive (2) Auditory (3) Reactive (4) Receptive
1
Teach patients with Parkinson's who have a shuffling gait to: 1. Walk with a wide based gait 2. Look at their feet while walking 3. Keep their arms at the side for balance 4. Use a toe-heel placement of the feet
1
Which of the following changes in patient status may cause increased ICP? (1) PaCO2 60 (2) Cerebral Perfusion Pressure (3) HR 104 (4) PaO289%
1
A nurse provides care for a client diagnosed with Parkinson's disease. Which sign does the nurse expect to observe? Select all that apply: 1. Tremors 2. Drooling 3. Constipation 4. Unsteady gait 5. Slow speech patterns
1,2,3,4,5
Normal Glowscow Score
15
4 hrs to an EEG, the nurse will hold which medication? (1) Omezaprole (2) Lorazepam (3) Enoxaparin (4) Lisinopril
2
Late signs of increased ICP include "Cushing's Triad". This includes all of the following EXCEPT: (1) Bradycardia (2) Pinpoint Pupils (3) Systolic HTN (4) Irregular Respirations
2
The earliest sign of increased ICP is: (1) Bradycardia (2) A change in LOC (3) Elevated systolic BP (4) Fever
2
The nurse will monitor which lab values daily for a hospitalized stroke patient who is taking Warfarin? (1) BUN and Creatinine and GFR (2) PT and INR (3) Sodium (4) Platelets
2
Which of the following is MOST concerning? (1) ICP 10 (2) CPP 60 (3) CPP 80 (4) ICP 12
2
How many middle cerebral arteries?
2 (one right & one left)
A client living with Parkinson's disease is completely dependent on others to provide self-care. Which finding is most important for the nurse to address? 1. Tachycardia 2. Drooling 3. Contracture 4. Incontinence
2 - aspiration risk
Increased ICP may affect the _____ cranial nerve, resulting in abnormal pupil size & response (1) Optic (2) Facial (3) Oculomotor (4) Vagus
3
The Glascow Coma Scale (GCS) includes all of the following parameters EXCEPT: (1) Best eye opening response (2) Best motor response (3) Pupillary Response (4) Best verbal response
3
The earliest sign of increased ICP the nurse should assess for includes: 1. Cushing's triad 2. Unexpected vomiting 3. Decreasing LOC 4. Dilated pupil with sluggish response
3
Which of the following is an omnious sign in a patient recently diagnosed with a middle cerebral artery CVA? (1) HR 101 (2) BP 146/86 (3) Rectal Temp 102.9 (4) Tympanic Temp 99.5
3
Which of the following responses is NOT induced by sympathetic nervous system stimulation? (1) Tachycardia (2) Pupillary dilation (3) Bronchiole constriction (4) Slowed peristalsis
3
A contraindication to thrombolytic therapy with Alteplase includes: (1) History of asthma (2) History of glaucoma (3) Diabetic Gastroparesis (4) Recent head injury
4
Act FAST at the 1st sign of a stroke. FAST includes all of the following except: (1) Facial Weakness or Droop (2) Speech Difficulties (3) Arm Weakness (4) Tachycardia
4
An aneurysm or AV malformation may cause which type of stroke? (1) Ischemic (2) Central (3) Embolic (4) Hemorrhagic
4
Which clinical manifestations would the nurse expect to assess in the client diagnosed with Parkinson disease? 1. Nausea, vomiting, diarrhea 2. Polyuria, polydipsia, polyphagia 3. Dysphonia, dysphagia and scanning speech 4. Tremors, rigidity, and bradykinesia (akinesia)
4
Which of the following is NOT a complication associated with increased ICP? (1) Seizures (2) SIADH (3) Diabetes Insipidus (4) Hyperthyroidism
4
Normal ICP
<10 - MAX 15
A client with MS has been admitted to the hospital following an acute exacerbation. When planning the client's care, the nurse addresses the need to enhance the client's bladder control. What aspect of Nursing care is most likely to meet this goal? A. Establish a timed voiding schedule B. Perform intermittent catheterization q6 C. Administer anticholinergic drugs as prescribed D. Avoid foods that change the pH of urine
A
A nurse is performing a neurologic assessment on a client with a left middle cerebralartery ischemic stroke and cannot elicit a gag reflex. What will the nurse consider apriority nursing diagnosis? A. Risk for aspiration B. Risk for falls C. Imbalanced nutrition D. Hypoperfusion
A
Quadraplegia may develop from a spinal cord injury at which level? A. C5 B. T2 C. T7 D. L1
A
The nurse caring for a client diagnosed with Parkinson disease has helped prepare a plan of care that Would include which goal? A. Promoting effective communication B. Controlling diarrhea C. Preventing seizures D. Preventing optic nerve damage
A
The nurse is caring for patient in traction. The patient complains of severe leg pain. Which is the priority nursing action? •A. Check the clients alignment in bed •B. Assess the pin sites for infection •C. Medicate the patient with an analgesic •D. Notify the orthopedic surgeon
A
Which of the following is the priority nursing diagnosis in a patient with seizure disorder? A. Risk for injury related to seizure activity B. Fear related to the possibility of seizures C. Ineffective individual coping related to stresses imposed by epilepsy D. Deficient knowledge related to epilepsy and its control
A
Which pt. is most at risk for developing Meningitis? A. A college freshman who Is living in the cormatory B. An 18-month old child who has not received scheduled immunizations at the last wellness visit C. A middle-aged adult who has recently hospitalized for a total knee replacement D. A high-school football player who travels on a bus to Friday night football games
A
The nurse is caring for a client with increased ICP. The nurse administers mannitol, an osmotic diuretic. 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 signs of: A. Heart failure B. Kidney failure C. Pancreatitis D. Diabetes Insipidus
A promotes the shift of fluid from the intracellular to the intravascular compartment
A patient with a T-5 spinal cord injury should be able to: Select all that apply: A. Feed himself B. Brush his teeth C. Breath independently D. Walk with the assistance of 2 people
A,B,C
After having a stroke, a patient has cognitive deficits. Which deficits are likely to occur as result of the stroke? Select all that apply. A. poor abstract reasoning B. decreased attention span C. short and/or long-term memory loss D. difficulty swallowing E. parasthesias
A,B,C
You're collecting vital signs on a patient with increased ICP. The patient has a GlascowComa Scale score of 4. How will you assess the patient's temperature? Choose all appropriate answers. A. Rectal B. Tympanic C. Temporal D. Oral
A,B,C
A nurse is providing care for a client who is experiencing a tonic-clonic seizure. Which finding is unexpected? Select all that apply. A. Decreased oral secretions B. Padded tongue blade placed inside client's mouth C. Oral airway is used to protect the client airway D. Crash cart is brought into the room
A,B,C,D
SCI complications include - Select all that apply: A. Stress ulcer development B. Atelectasis C. Neurogenic bladder D. Autonomic dysreflexia E. Neurogenic shock
A,B,C,D,E
A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid? A. Coughing B. Sneezing C. Talking D. Valsalva maneuver E. Vomiting F. Keeping the head of the bed between 30- 35 degrees
A,B,D,E
Contraindications for the administration of tissue plasminogen activator (t-PA) include: Select all that apply. A. Subdural hematoma B. Age 17 C. Ischemic stroke D. BP 185/95 E. Lumbar laminectomy 2 months ago F. History of glaucoma G. History of atrial fibrillation
A,B,D,E
The nurse is caring for a patient with a complete transection of C3-4. The patient begins to display symptoms of autonomic dysreflexia. The nurse expects to note: Select all that apply: A.Bradycardia B.Tachycardia C.Hypotension D.Hypertension E.Sweating F.Apprehension G. Headache
A,D,E,F,G
_____ IS THE ENTIRE GOAL OF TRACTION (whether skin or skeletal)
Alignment
A 23 year old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized seizures. Which nursing activity included in the patients care will be best to delegate to the LPN? A. Document the onset, time, nature of seizure and postictal behaviors for all seizures. B. Administer Dilantin 200 mg po C. Teach the patient about the need for good oral hygiene D. Develop a discharge plan including information from the Epilepsy Foundation.
B
A client diagnosed with MS has been admitted to the medical unit for treatment of an exacerbation. Included in the admission orders is Baclofen. What should the nurse identify as an expected outcome of this treatment? A. Increased muscle strength in the upper extremities B. Reduced muscle spasms in the lower extremities C. Decreased severity and duration of Exacerbations D. Reduction in the appearance of new lesions on the MRI
B
A client with Parkinson disease is undergoing a swallowing assessment because the client has been having some difficulty with chewing and swallowing foods. The client's nutritional needs should be met by what method? A.Minced foods and a fluid restriction B.Semisolid food with thick liquids C.Provision of a low-residue diet D.Total parenteral nutrition (TPN)
B
A client with a history of stroke and taking warfarin is brought to the hospital after experiencing fours seizures within an hour. Which prescription does the nurse question? A. Place a helmet on the client B. Phenytoin 100 mg PO C. Insert a peripheral IV D. 4 Liters O2 via nasal cannula
B
A nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure(ICP)? A. Suction the airway every hour and as needed. B. Elevate the head of bed to 30 degrees C. Turn the client every 2 hours D. Maintain a well-lighted room
B
A patient is admitted to the ER with a cord injury at T2. Which of the following findings is of most concern to the nurse? A. SpO2 92% B. HR 42 beats/min C. BP 90/60 D. Loss of motor and sensory function in arms and legs
B
A patient is scheduled for an electroencephalogram (EEG) in the morning. What foodon the patient's tray should the nurse remove prior to the test? A. Orange juice B. Coffee C. Milk D. Eggs
B
A patient with a fracture of the pelvis should be monitored for: •A. Petechiae on the abdomen •B. Changes in urinary output •C. A palpable lump in the buttock •D. An increase in blood pressure
B
Patients with MS often experience diplopia. To treat this, ________ can be used: A. Snellen chart B. Eye patch C. carbmazepine (Tegretol) D. Atropine
B
The nurse is caring for a patient in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is an optimal range of ICP for this patient? A. 9-15 mm B. 3-10 mm C. 20-30 mm D. 25-40 mm
B
The nursing care plan for a client in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis? •A. Loss of sensation to the calf •B. Increased warmth of the calf •C. Decreased circumference of the calf •D. Pale-appearing calf
B
What assessment finding requires immediate intervention if found while a patient is receiving Mannitol? A. ICP of 10 mmHg B. Crackles throughout lung fields C. BP 110/72 D. Patient complains of dry mouth and thirst
B
When preparing to discharge a post stroke client home, the nurse has met with the family and warned them that the client may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? A. unmet physiologic needs B. frustration related to changes in function & communication C. changes in brain activity during sleep and wakefulness D. temporary changes in metabolism
B
Which of the following may indicate impending damage to brain tissue and brain stem damage? A. BP 160/90 B. Temp 103.1 C. HR 104 D. Respirations 10
B
Which patient is most at risk for a spinal cord injury? A. 40 year old male B. 18 year old male C. 24 year old female D. 75 year old female
B
The nurse supervises as a new graduate nurse provides care for an 18 year old client diagnosed with meningococcal meningitis. Which action by the new graduate nurse is incorrect A. The nurse prepares a new bag of Amoxicilln for IV infusion B. The nurse enters the room wearing a gown and gloves C. The nurse tells the client that isolation is needed for 24 hpurs after antibiotics are initiated D. The nurse frequently assesses the clients neurological status
B - Nurse also needs mask, protective eye wear
A nurse in a busy emergency department provides care for many clients who present with contusions, strains, or sprains. What are treatment modalities that are common to all of these musculoskeletal injuries? Select all that apply. •A. Massage •B. Applying ice •C. Compression dressings •D. Resting the affected extremity •E. Corticosteroids •F. Elevating the injured limb B, C, D, F
B, C, D, F
2 symptoms most commonly associated with neurogenic shock include: A.Tachycardia B. Bradycardia C. Hypotension D. Hypertension
B,C
The nurse is caring for a client who is rapidly progressing toward brain death. The nurse should be aware of what cardinal signs of brain death? Select all that apply. A. Absence of pain response B. Apnea C. Coma D. Absence of brain stem reflexes E. Absence of deep tendon reflexes B, C, D
B,C,D
The nurse is setting up the room for a patient who is being admitted for seizure monitoring. Which equipment is appropriate to place in the patient's room? A. Padded tongue blades B. Oxygen tubing and set up C. Suction equipment D. Padded side rails E. Wrist restraints
B,C,D
69 year old patient is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The health care provider suspectes bacterial Menningitis and admits the patient to the ICU. What interventions should the nurse perform? Select All that apply: A. Obtain a blood type and cross-match B. Administer antipyretics as prescribed C. Perform frequent neurologic assessments D. Monitor pain levels and administer analgesics E. Place the patient in droplet precuations
B,C,D,E
BIGGEST WORRY WITH INCREASED ICP =
Brain Herniation
A 33-year-old patient presents with complaints of weakness, incoordination, dizziness, and loss of balance. The patient is hospitalized and diagnosed with MS. Which symptoms are typical of MS? A. Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes B. Flexor spasm, clonus, and negative Babinski's reflex C. Blurred vision, intention tremor, urinary hesitancy D. Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs
C
A client presents to the ED after sustaining a significant blow to the head, near the right ear. The client tells the nurse that something is leaking from his ear. The nurse suspects: A. Depressed skull fracture B. Nasal fracture C. Basilar skull fracture D. Increased ICP
C
A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication? A. acute pain B. sepsis C. bleeding D. seizures
C
A patient who experienced a cerebral hemorrhagic is at risk for developing increased ICP. Which sign is the EARLIEST indicator of this complication? ◦A. Bradycardia ◦B. Decerebrate posturing ◦C. Restlessness ◦D. Unequal pupil size
C
A teenager with a concussion is discharged from the ED and still complaining of a headache. His mother asks if he can take something stronger than acetaminophen at home. Which of the following responses is best? A."your son can take the acetaminophen every 3 hours around the clock" B."stronger medications may lead to vomiting which will increase the intracranial pressure" C."opioid medications are not given with a head injury because they may mask symptoms that indicate worsening of the injury" D."opioid medications are not indicated for a teenager"
C
During the post-operative period, the nurse instructs the patient with an above-the-knee (AKA) amputation that the residual limb should not be routinely elevated because this position promotes: A. Skin irritation and breakdown B. Clot formation at the incision site C. Hip flexion contracture D. Increased risk of wound dehiscence
C
The nurse finds a patient having a tonic clonic seizure. During the seizure, the nurse should take the following action: A. tighten clothing B. insert tongue blade C. protect the patient's head D. restrain the arms
C
The nurse has provided instructions regarding leg exercises for the patient immobilized in skeletal traction of the right leg. The nurse determines the patient needs further teaching when the patient __________: •A. Pulls up on the trapeze bar •B. Performs gluteal stretching exercises •C. Performs active range of motion exercises to the right ankle and knee •D. Performs dorsiflexion and plantar flexion of the right foot
C
The nurse is aware that the preferred drug to administer to a patient in status epilepticus is: A. carbamazepine B. valproate C. lorazepam D. phenobarbital
C
The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority? A. Measuring accurate intake and output B. Providing appropriate pain control C. Maintaining a patent airway D. Performing a swallowing evaluation
C
What is the most common adverse effect associated with anti-seizure drugs? A. Nausea and vomiting B. Headaches C. Sedation D. Hair loss
C
What is the most common adverse effect associated with anti-seizure drugs? A. Nausea and vomiting B. Headaches C. Sedation D. Hair loss
C
When teaching a patient with a seizure disorder about medications, it is most important for the nurse to stress that: A. They should increase the dose if stress is increased B. Most over the counter drugs are safe to take with anti-seizure drugs. C. Stopping the medication abruptly may increase the intensity of seizures D. If gingival hypertrophy occurs, the drugs should be stopped and doctor called.
C
Which patient below is experiencing Cushing's Triad? A. BP 150/112, HR 110, RR 8 B. BP 90/60, HR 80, RR 22 C. BP 200/60, HR 50, RR 8 D. BP 80/40, HR 49, RR 12
C
Your patient, who has a spinal cord injury at T3, states they are experiencing a throbbing headache. What is your NEXT nursing action? A. Perform a bladder scan B. Perform a rectal digital examination C. Assess the patient's blood pressure D. Administer a PRN medication to alleviate pain and provide a dark, calm environment.
C
A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until the femur can be rodded in surgery. For what early complication(s) should the nurse monitor this client? Select all that apply. •A. Systemic infection •B. Complex regional pain syndrome •C. Deep vein thrombosis •D. Compartment syndrome •E. Fat embolism
C, D, E
A client is experiencing dysphagia following a stroke. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing? Select all that apply. A. Offer liquids frequently in small quantities B. Allow optimum physical activity before meals to expedite digestion C. Help the client sit upright when eating D. Encourage the client to eat slowly
C,D
The nurse is reviewing an 80-year-old female client's reports related to the onset of a severe headache, rated at 9 out of 10 on the pain scale, with recent onset. The client denies any visual changes. During a prior visit to the office a few months ago, the client had reported a ground-level fall as a result of falling off a chair and hitting the back of their head. The client had been taken to the emergency department, where imaging was performed with negative results. Complete the following sentence by choosing from the lists of options. The nurse anticipates that the client has developed (choose 1 answer): Chronic subdural hematoma OR Acute subdural hematoma
Chronic Subdural Hematoma
A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms? A. cardiac disease B. migraine headaches C. hypertension D. impaired cerebral circulation
D
A patient is involved in a skiing accident and has no motor or sensory function below T2 upon arrival in the ED. The nurse is aware that: A. The patient has a head injury B. The patient is experiencing neurogenic shock C. The patient has a completely severed spinal cord at T2 D. The patient is experiencing spinal shock
D
A patient with a T5 spinal cord injury suddenly begins sweating profusely in the face and neck. Vital signs reveal HR 48 and BP 170/94. Which is the PRIORITY nursing intervention? A. Administer nifedipine STAT B. Check the patient for a fecal impaction C. Check the patient for bladder distention D. Place the patient in high fowler's position
D
An aneurysm or arterio-venous malformation in the brain may cause which type of stroke? A. Ischemic B. Embolic C. Transient ischemic attach (TIA) D. Hemorrhagic
D
Following a lumbar puncture, the nurse will position the patient: A. With head of bed elevated 30 degrees B. With head of bed elevated 60 degrees C. In prone position for 1 hour D. In flat, supine position
D
The nurse is caring for a client with a brain tumor. What drug would the nurse expect to be prescribed to reduce the edema surrounding the tumor? A. Dextromethorphan B. Furosemide C. Apixaban D. Dexamethasone
D
The nurse is caring for a client with multiple sclerosis (MS). The client tells the nurse the hardest thing To deal with is the fatigue. When teaching the client how to reduce fatigue, what action should the nurse suggest? A. Taking a hot bath at least once a daily B. Avoiding naps during the day C. Increasing the dose of muscle relaxants D. Resting in an air-conditioned room whenever possible
D
The nurse is conducting a focused neurologic assessment and is assessing the client's gag reflex. How should the nurse best perform this aspect of the assessment? A. depress the client's tongue with a sterile tongue depressor B. ask the client to swallow a small quantity of soft food C. observe the client swallowing a small amount of water using a straw D. lightly touch the client's pharynx with a cotton tipped swab
D
The nurse is preparing the patient for an MRI to evaluate a new onset stroke. Which finding in the patient's history would prompt the nurse to notify the health care provider? A. allergy to IV contrast B. chronic indwelling foley catheter C. removal of the gallbladder 3 weeks ago D. placement of a pacemaker 6 months ago
D
The nurse is working with a client who is newly diagnosed with multiple sclerosis (MS). Which explanation about the diagnosis should the nurse provide to the client? A. MS is caused by an unresolved bacterial infection B. MS typically has an acute onset C. MS occurs more frequently in men D. MS is a progressive disease of the nervous system
D
The nurse will prioritize which assessment when administering a muscle relaxer such as baclofen or cyclobenzaprine (Flexeril) to a patient with MS: A. Bradycardia B. Hypotension C. Muscle aches D. Sedation
D
This same client develops chronic issues with swallowing, develops adventitious lung sounds after choking, and fails a swallowing evaluation. The client's nutritional needs should be met by what method? A. Semisolid food with thick liquids B. Pureed food with thick liquids C. Total Parenteral Nutrition (TPN) D. Tube feedings via PEG tube
D
True or False: A thrombolytic medication is appropriate for a patient diagnosed with a CVA secondary to a ruptured brain aneurysm? False
False
______ may also be indicated to control cerebral edema
Fluid Restriction
Fever will ______ ICP
Increase
Where is the reflex center for respiration?
Medulla (brainstem)
Rapid Eye Movement is called ___
Nystagmus
◦Client admitted to the medical unit with a diagnosis of CVA after "feeling funny" at work and falling ◦Medical history: hypertension, high cholesterol, and gastric ulcers ◦Surgical history: left knee replacement and appendectomy ◦Client is alert and oriented x 3, with slurred speech ◦Exhibits left hemiparesis and facial droop ◦BP 162/90, HR 72, RR 18, Temp 98.8 F, O2 saturation 98% on room air ◦Client made comfortable in bed, spouse visiting with client Where will you place the call light?
On the right side of the patient
Assessment of balance - name of test
Romberg
ALL patients involved in MVA, sports injury, diving injury, fall, head trauma >>> consider as _____ until ruled out
SCI
True or False: A complication of an ICP monitor (Ventriculostomy) includes Meningitis
True
True or False: Fever will increase intracranial pressure
True
True or False: An embolic stroke is associated with atrial fibrillation and endocarditis?
True
True or False: Brain damage can continue for hours and days after the initial injury.
True
Would a patient with a T4 injury be able to breath, write, & transfer to a wheelchair? (1) Yes (2) No
Yes
Earliest sign of increased ICP
change in LOC
As ICP increases, CPP _____
decreases
If CSF leak suspected DO NOT ________*** - ex: ___ , ____
insert anything into nose - ex: suction catheter, nasogastric tube