Adult health -Chapter 45: Nursing Management: Patients With Neurologic Trauma
A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? Lactated Ringer's When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes? 30-degree head elevation Which condition occurs when blood collects between the dura mater and arachnoid membrane? Subdural hematoma
A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? Lactated Ringer's When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes? 30-degree head elevation Which condition occurs when blood collects between the dura mater and arachnoid membrane? Subdural hematoma
The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury? It results from initial damage to the brain from the traumatic event. Which are characteristics of autonomic dysreflexia? severe hypertension, slow heart rate, pounding headache, sweating
The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury? It results from initial damage to the brain from the traumatic event. Which are characteristics of autonomic dysreflexia? severe hypertension, slow heart rate, pounding headache, sweating
A nurse observes an abnormal posture response in an unconscious patient. She documents "extension and outward rotation of the upper extremities and plantar flexion of the feet." She is aware that this posture is a clinical indicator of which of the following? Decerebrate positioning implying severe dysfunction and brain pathology A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin? immediately What is one of the earliest signs of increased ICP? decreased level of consciousness (LOC)
A nurse observes an abnormal posture response in an unconscious patient. She documents "extension and outward rotation of the upper extremities and plantar flexion of the feet." She is aware that this posture is a clinical indicator of which of the following? Decerebrate positioning implying severe dysfunction and brain pathology A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin? immediately What is one of the earliest signs of increased ICP? decreased level of consciousness (LOC)
The nurse is discussing spinal cord injury (SCI) at a health fair at a local high school. The nurse relays that the most common cause of SCI is Motor vehicle crashes A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following? Monro-Kellie A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP? Keep the client's neck in a neutral position (no flexing).
The nurse is discussing spinal cord injury (SCI) at a health fair at a local high school. The nurse relays that the most common cause of SCI is Motor vehicle crashes A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following? Monro-Kellie A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP? Keep the client's neck in a neutral position (no flexing).