Chapter 61 Review

The earliest sign of increased ICP is _____

a change in level of consciousness (LOC)

A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus related to a traumatic brain injury. The nurse identifies that an hourly output of which volume over 2 hours may be a positive indicator? a. 50 to 100 mL/hr b. 100 to 150 mL/hr c. 150 to 200 mL/hr d. more than 200 mL/hr

a. 50 to 100 mL/hr

A nurse caring for a patient with head trauma will be monitoring the patient for cushing triad. Which are identified symptoms associated with Cushing triad that the nurse documents? SATA a. bradycardia b. bradypnea c. hypertension d. tachycardia e. pupillary constriction

a. bradycardia b. bradypnea c. hypertension

The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54, and crackles in the bases of the lungs. Which situation does the nurse expect is occurring? a. increased ICP b. excerbation of uncontrolled hypertension c. infection d. increase in cerebral perfusion pressure

a. increased ICP

The nurse is called to attend to a patient having a tonic-clonic seizure in the waiting area. Which nursing interventions are provided for this patient? SATA a. loosening constrictive clothing b. opening the patient's jaw and inserting a mouth gag c. positioning the patient on their side with head flexed forward d. providing privacy e. restraining the patient to avoid self-injury

a. loosening constrictive clothing c. positioning the patient on their side with head flexed forward d. providing privacy

The nurse is caring for a patient in the neurologic ICU who sustained head trauma in a physical altercation. Which optimal range does the nurse identify for this patient? a. 8 to 15 mm hg b. 0 to 10 mm hg c. 20 to 30 mm hg d. 25 to 40 mm hg

b. 0 to 10 mm hg

Three primary complications of increased ICP is ____

brain hernation in death

A patient is admitted to the hospital with an ICP reading of 20 mm hg and a mean arterial pressure of 90 mm hg. Which is the calculated cerebral perfusion pressure? a. 50 mm hg b. 60 mm hg c. 70 mm hg d. 80 mm hg

c. 70 mm hg

The nurse assess the patient's LOC using the Glasgow Coma Scale. Which score indicates severe impairment of neurologic function? a. decerebrate b. decorticate c. flaccid d, rigid

c. flaccid

The nurse is educating a patient with a seizure disorder. Which nutritional approach for seizure management would be beneficial for this patient? a. low in fat b. restricts protein to 10% oof daily caloric intake c. high in protein and low in carbohydrate d. at least 50% carbohydrate

c. high in protein and low in carbohydrate

The nurse is caring for a patient with ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer as prescribed? a. glycerin b. isoboride c. mannitol d. urea

c. mannitol

When educating a patient about the use of anticonvulsant medication, what will the nurse inform the patient is a result of long-term use of the medication in women? a. anemia b. osteoarthritis c. osteoporosis d. obesity

c. osteoporosis

A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. Which pharmacologic therapy will the nurse be administering to this patient as prescribed to control symptoms? a. mannitol b. furosemide (lasix) c. vasopressin d. phenobarbital

c. vasopressin

Nursing postoperative management includes detecting and reducing ___ relieving ___, preventing ____ and monitoring ____and ____

cerebral edema; relieving pain; seizures; increased ICP; neurologic status

The leading cause of seizures in the older adult is ____

cerebrovascular disease

The nurse is caring for a patient with a traumatic brain injury. Which does the nurse identify as the earliest sign of serious impairment of brain and circulation related to increasing ICP? a. a bounding pulse b. bradycardia c. hypertension d.lethargy and stupor

d. lethargy and stupor

The nurse is caring for a patient with an altered level of consciousness. Which is the first priority of treatment for this patient? a. assessment of pupillary light reflexes b. determination of the cause c. positioning to prevent complications d. maintenance of a patent airway

d. maintenance of a patent airway

A patient 3 days postoperative from a crainotomy informs the nurse "I feel something trickling down the back of my throat and I taste something salty" Which priority action does the nurse initiate? a. give the patient some mouthwash to gargle with b. request an antihistamine for the postnasal drip c. ask the patient to cough and observe the sputum color and consistency d. notify the health care provider of a possible cerebrospinal fluid leak

d. notify the health care provider of a possible cerebrospinal fluid leak

A patient has a lesion affecting the pons, resulting in paralysis and the inability to speak, but has the vertical eye movements and lid elevation. This patient is suffering from _____

locked-in syndrome

Three major potential complications in a patient with a depressed level of consciousness are ____, ____, and ____

pneumonia, aspiration, and respiratory failure

A major potential complication of epilepsy is ____

status epilepticus