neuro practice questions (ch 14)

The nurse is educating the family of a patient admitted with acute hemorrhagic stroke due to an arteriovenous malformation. Which statement indicates understanding of the education? - "he was born with the AV malformation" - "his anticoagulant medications increased his risk of developing the malformation" - "the vessels in his brain have too many protein deposits on them" - "it's rare that this event occurred in a male"

"he was born with the AV malformation"

Which statement about cerebral oxygen monitoring shows understanding of the information? - "the jugular vein oxygen saturation monitor is inserted through the jugular vein into the white matter of the brain" - "a partial pressure of oxygen probe can be inserted into damaged portions of the brain to measure global oxygenation" - "a jugular vein oxygen saturation less than 70% indicates cerebral ischemia" - "the partial pressure of oxygen within brain tissue should be greater than 20 mmHg"

"the partial pressure of oxygen within brain tissue should be greater than 20 mmHg"

A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (Select all that apply). - headache - dilated pupils - bradycardia - decorticate positioning - hypotension

- headache - dilated pupils - bradycardia - decorticate positioning

Which nursing intervention would the nurse include in the plan of care for a patient with ischemic stroke who will be receiving rt-PA treatment? Select all that apply. One, some, or all responses may be correct. - place invasive lines prior to administering rt-PA - hold other anticoagulants for 48 hours after administration of rt-PA - maintain systolic BP at less than 185 mmHg - closely monitor for signs of intracranial hemorrhage - perform neurological assessments every 2 hours

- place invasive lines prior to administering rt-PA - maintain systolic BP at less than 185 mmHg - closely monitor for signs of intracranial hemorrhage

The pons contains the nuclei for which cranial nerve? Select all that apply. One, some, or all responses may be correct. - oculomotor - glossopharyngeal - trigeminal - facial - vestibulocochlear - accessory

- trigeminal - facial - vestibulocochlear

Which factor increases the risk of status epilepticus? Select all that apply. One, some, or all responses may be correct. - withdrawal from habitual use of alcohol - azotemia - hyponatremia - infection - sudden increase of antiepileptic drugs

- withdrawal from habitual use of alcohol - azotemia - hyponatremia - infection

The primary care provider has opted to treat a patient with a complete spinal cord injury with glucocorticoids. The orders are for 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/hour for 23 hours. What is the total 24-hour dose for the 70-kg patient? - 2478 mg - 5000 mg - 10,794 mg - 12,750 mg

10,794 mg

While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse? - both pressures are high - both pressures are low - ICP is high; CPP is normal - ICP is high; CPP is low

ICP is high; CPP is normal

Which patient being cared for in the emergency department should the charge nurse evaluate first? - an ischemic stroke patient with a BP of 190/100 mmHg - an alert patient with a subdural bleed who is complaining of a headache - a patient with a GCS score of 15 on 3 liter nasal cannula - a patient with a complete spinal injury at the C5 dermatome level

a patient with a complete spinal injury at the C5 dermatome level

Which type of seizure involves an area on both sides of the brain at the onset? - generalized motor - focal non-motor - unknown onset - focal to bilateral

generalized motor

The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which order should the nurse institute first? - mannitol 1 g IV - seizure precautions - portable chest xray - acnef 1 g IV

mannitol 1 g IV

Which assessment finding indicates the resolution of spinal shock? - bradycardia - hypothermia - +3 deep tendon reflexes - return of sensory function

+3 deep tendon reflexes

Which spinal nerves are assessed with the triceps reflex? - C5-C6 - L2-L4 - C7-C8 - S1-S2

C7-C8

The primary care provider orders fosphenytoin, 1.5 g intravenous (IV) loading dose for a 75-kg patient in status epilepticus. What is the most important action by the nurse? - contact the primary care provider to discuss the order - administer the drug at a slow infusion rate - mix medication with 0.9% normal saline - administer via central line

administer the drug at a slow infusion rate

The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action? - open the patient's mouth and insert a padded tongue blade - insert an NG tube and connect to continuous wall suction - assist the patient to the floor and provide soft head support - restrain the patient's extremities until the seizure subsides

assist the patient to the floor and provide soft head support

The nurse is caring for a patient who received a gunshot wound to the side of the head. Which concern is most worrisome for the nurse? - brain damage - infection - bleeding - shearing forces

brain damage (high-velocity penetrating wounds, such as those from gunshot wounds, cause many paths and shockwaves that create extensive brain damage)

Which clinical manifestation indicates an early central herniation? - cheyne-stokes respirations - increased muscle tone - positive babinski reflex - fixed and dilated pupils

cheyne-stokes respirations (are an early indicator of central herniation due to the downward shift of the cerebral hemispheres)

The nurse is preparing to admit a patient for bacterial meningitis. Which precaution would the nurse include in the plan of care? - contact - droplet - airborne - blood borne

droplet

Which change would the nurse expect in a patient that is in phase 1 of status epilepticus? - hypertension - hypoglycemia - hypopyrexia - metabolic alkalosis

hypertension

Which type of stroke occurs from small arterial vessel occlusion? - hemorrhagic - cryptogenic - lacunar - cardioembolic

lacunar

The nurse inserts an intravenous line in a patient experiencing acute stroke. Which type of fluid would the nurse anticipate administering? - D5 normal saline - D5 1/2 normal saline - normal saline - 0.45% normal saline

normal saline

Which cerebral lobe is responsible for visual processing? - frontal - occipital - temporal - parietal

occipital

The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse? - hyper oxygenate during endotracheal suctioning - elevate the patient's head of the bed to 30 degrees - apply bilateral heel protectors after repositioning - provide rest periods between nursing interventions

provide rest periods between nursing interventions

The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an intravenous (IV) line, which order should the nurse implement first? - obtain a stat portable chest xray - obtain stat serum electrolytes - administer lorazepam - administer phenytoin

administer lorazepam

The nurse would encourage meningitis vaccination for which population? - infants - toddlers - adolescents - middle aged adults

adolescents

The nurse is caring for a patient admitted to the ED following a fall from a 10-foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left nare. What is the most appropriate nursing action? - maintain neutral head position - apply a small nasal drip pad - monitor airway latency - insert bilateral ear plugs

apply a small nasal drip pad

How would the nurse assess the spinal accessory cranial nerve? - ask the patient to shrug their shoulders - have the patient stick their tongue out - observe the patient's ability to puff their cheeks - evaluate pupil size and shape

ask the patient to shrug their shoulders

The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is reporting a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse? - notify the physician of the patient's blood pressure - administer acetaminophen as ordered for the headache - assess for a kinked urinary catheter and assess for bowel impaction - encourage the patient to take slow, deep breaths

assess for a kinked urinary catheter and assess for bowel impaction

When caring for a patient who underwent a craniotomy four hours ago, which finding would prompt the nurse to immediately contact the healthcare provider? - high fever and uncontrolled headache - generalized body aches - loss of lean muscle mass - constipation and weakness

high fever and uncontrolled headache (may indicate infection or the formation of a brain abscess and should be reported)

Which intracranial pressure monitoring device would be best for a patient who requires cerebrospinal fluid drainage? - intraventricular catheter - subarachnoid screw - epidural transducer - parenchymal fiberoptic catheter

intraventricular catheter (can be used for intracranial pressuring monitoring and can also be used for drainage of cerebrospinal fluid)

Which substance does not cross the blood-brain barrier? - water - oxygen - glucose - protein

protein

A patient presents to the emergency room with stiff neck, photophobia, and pain behind the eyes. In triage, the patient states "this is the worst headache of my life!" Which condition would the nurse suspect? - ischemic stroke - arteriovenous malformation - hemorrhagic stroke - subarachnoid hemorrhage

subarachnoid hemorrhage (a patient with a subarachnoid hemorrhage would have irritation of the meninges, causing stiff neck, photophobia, and pain behind the eyes)

Which cranial nerve would the nurse assess by observing for bilateral blink? - trigeminal - auditory - trochlear - hypoglossal

trigeminal

The nurse is caring for a patient with a concussion after a fall from a ladder. Which patient statement indicates understanding of the diagnosis? - "the injury occurred distal to the site of impact" - "concussions heal quickly but cause lasting effects" - "with concussions, the neurological deficits are usually reversible" - "my concussion has caused a deep laceration of brain tissue"

"with concussions, the neurological deficits are usually reversible"

Which reflex, if noted in an adult, would indicate neurological dysfunction? Select all that apply. One, some, or all responses may be correct. - babinski - suck - snout - palmar - palmomental

- babinski - suck - snout - palmar - palmomental

The nurse would consider which metabolic response to traumatic brain injuries when developing a plan of care addressing nutrition? - increase of lean muscle mass - hypometabolism - accelerated catabolism - decreased nitrogen loss

accelerated catabolism (TBIs lead to accelerated catabolism, which depletes energy stores)

A patient presents with a right-sided spinal cord injury. Which manifestation would indicate the patient is experiencing Brown-Séquard syndrome? - loss of pain sensation on the left side - incomplete loss of motor function on the right side - intact sensation to vibration on the right side - total loss of reflex activity on both sides

loss of pain sensation on the left side

The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action? - pad all bony prominences - monitor blood pressure - use proper hand washing - maintain body temperature

monitor blood pressure

The nurse assesses a patient with a skull fracture and notes a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action? - support bony prominences with padding - increase supplemental oxygen delivery - monitor the patient's airway patency - elevate the head of the patient's bed

monitor the patient's airway patency

The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action? - notify the primary care provider immediately - stimulate the patient hourly - elevate the head of the bed - continue to monitor the patient

notify the primary care provider immediately

In which situation would the parasympathetic nervous system be activated? - being chased by a bear - relaxing on the couch - taking an exam - performing cardiopulmonary resuscitation

relaxing on the couch

A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg.; blood pressure is 144/90 mm Hg, and mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)? - 54 mmHg - 72 mmHg - 90 mmHg - 126 mmHg

90 mmHg

Which change would decrease the cerebral perfusion pressure? - increased systemic blood pressure - increased contractility - decreased mean arterial pressure - decreased intracranial pressure

decreased mean arterial pressure

The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury? - pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg - pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg - pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg - pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg

pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg

While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient's left naris. What is the best nursing action? - have the patient blow the nose until clear - suction the left nares until the drainage clears - place a nasal drip pad under the nose - insert bilateral cotton nasal packing

place a nasal drip pad under the nose

Which statement describes cerebral veins? - include a thick muscular layer - empty blood into cerebral arteries - play a role in absorption of CSF - form the circle of willis (ring of vessels connecting anterior and posterior circulations of the brain)

play a role in absorption of CSF

A patient with a complete spinal cord lesion at which level would require long-term mechanical ventilation? - C2 - C5 - T6 - L3

C2

The nurse is caring for a patient who is experiencing vasospasm after treatment of an aneurysmal subarachnoid hemorrhage. Which intervention would the nurse implement? - administer a loop diuretic - closely monitor for fever - hold enteral nutrition - encourage ambulation

closely monitor for fever

The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action? - keep the neck in the hyperextended position - maintain proper head and neck alignment - remove cervical collar upon arrival to the ED - prepare for immediate endotracheal intubation

maintain proper head and neck alignment

The nurse is caring for a patient who underwent endovascular treatment of a cerebral aneurysm two days ago. The patient asks the nurse how the aneurysm was treated. How would the nurse respond? - "the surgeon occluded the neck of the aneurysm with a metal clip" - "the physician placed coils into the aneurysm sac to occlude the aneurysm" - "fibrin foam and muscle were wrapped around the neck of the aneurysm to prevent thrombosis" - "the aneurysm was removed, and the vessels were resected"

"the physician placed coils into the aneurysm sac to occlude the aneurysm" (an endovascular approach involves the placement of coils into the aneurysm sac to occlude the aneurysm from the feeder vessel with thrombosis)

What topic would the nurse provide education about to decrease the risk of stroke from large artery atherosclerosis? Select all that apply. One, some, or all responses may be correct. - control of hypertension - smoking cessation - healthy diet - glucose control - avoiding head injury

- control of hypertension - smoking cessation - healthy diet - glucose control

Which structure comprises part of the subdural space? Select all that apply. One, some, or all responses may be correct. - skull - dura mater - pia mater - spinal cord - arachnoid mater

- dura mater - arachnoid mater

The nurse is caring for a patient with a traumatic brain injury. Which patient problem would the nurse closely monitor for? Select all that apply. One, some, or all responses may be correct. - dysphagia - fever - headache - constipation - altered communication

- dysphagia - fever - headache - constipation - altered communication

Which diagnostic test is most accurate when assessing for bacterial meningitis? - CT scan of the brain - blood cultures - CSF analysis - MRI study of the brain

CSF analysis (gold standard and most accurate way to assess for diagnosis of bacterial meningitis)

In an unconscious patient, eye movements are tested by the oculocephalic response. Which statements regarding the testing of this reflex are true? (Select all that apply.) - increased ICP is a contraindication to the assessment of this reflex - presence of cervical injuries is a contraindication to the assessment of this reflex - eye movement in the same direction as the head when turned indicates an intact reflex - eye movement in the opposite direction as the head when turned indicates an intact reflex - doll's eyes present indicate brainstem activity - doll's eyes absent indicate a disruption in normal brainstem processing

- increased ICP is a contraindication to the assessment of this reflex - presence of cervical injuries is a contraindication to the assessment of this reflex - eye movement in the opposite direction as the head when turned indicates an intact reflex - doll's eyes present indicate brainstem activity - doll's eyes absent indicate a disruption in normal brainstem processing

The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patient's plan of care? (Select all that apply.) - make frequent neurological assessments - restrain affected limb to prevent injury - maintain MAP < 130 mmHg - prepare for thrombolytic administration - maintain CO2 level at 50 mmHg

- make frequent neurological assessments - maintain MAP < 130 mmHg

The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patient's plan of care? (Select all that apply.) - make frequent neurological assessments - restrain affected limb to prevent injury - maintain SBP < 220 mmHg and DBP < 120 mmHg - prepare for thrombolytic administration - maintain CO2 level at 50 mmHg

- make frequent neurological assessments - maintain SBP < 220 mmHg and DBP < 120 mmHg

The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5° F. Which order should the nurse institute first? - blood cultures (2 specimens) for temperature > 101 F - decadron 20 mg IV push q 4 hours - 500 mL albumin infusion IV - acetaminophen 650 mg per rectum

500 mL albumin infusion IV

The nurse is caring for a patient with an intracranial pressure ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol, which assessment finding by the nurse requires further action? - CVP of 2 mmHg - CPP of 70 mmHg - GCS score of 5 - ICP of 10 mmHg

CVP of 2 mmHg

After receiving the hand-off report from the day shift charge nurse, which patient should the evening charge nurse assess first? - a patient with bacterial meningitis on droplet precautions - a mechanically ventilated patient with a GCS of 6 - a patient with meningitis complaining of photophobia - a patient with an ICP of 20 mmHg and an oral temperature of 104 F

a patient with an ICP of 20 mmHg and an oral temperature of 104 F

The nurse completes an assessment of motor function and documents a score of 4. Which finding indicates a score of 4? - moves the limb but unable to raise the extremity off the bed - flicker of movement in the limb is felt or seen - able to lift the extremity off the bed and maintain the position against resistance - able to lift the extremity off the bed but has difficulty resisting the examiner

able to lift the extremity off the bed but has difficulty resisting the examiner

The nurse is to administer 100 mg phenytoin intravenous (IV). Vital signs assessed by the nurse include blood pressure 90/60 mm Hg, heart rate 52 beats/min, respiratory rate 18 breaths/min, and oxygen saturation (SpO2) 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the best action by the nurse? - administer over 2 minutes - mix medications with 0.9% normal saline - administer via central line - administer over 5 minutes

administer over 5 minutes

The nurse is preparing to administer a routine dose of phenytoin. The primary care provider orders phenytoin 500 mg intravenous every 6 hours. What is the best action by the nurse? - administer with 0.9% normal saline IV - assess cardiac rhythm - administer over 2 minutes - contact the primary care provider to discuss the order

contact the primary care provider to discuss the order

What response would the nurse expect to see when hyperventilating a patient with acute increased intracranial pressure? - increased cerebral perfusion pressure - decreased intracranial pressure - increased PaCO2 - cerebral vasodilation

decreased intracranial pressure (hyperventilation decreases intracranial pressure but should only be used for short periods when acute neurological deterioration is occurring)

The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness. What is the priority nursing action to assure effective care? - determine the time of symptom onset - determine the patient's drug allergies - assess for the presence of a headache - assess the patient's general orientation

determine the time of symptom onset

The nurse is caring for a patient who has experienced a 7-minute anoxic state during a cardiac arrest. Which finding would the nurse expect? - edema within cerebral cells - increased electrical activity - alkalosis of the extracellular environment - increased storage of glucose

edema within cerebral cells (when cell membrane integrity is lost, extracellular fluid flows into the cell and causes cerebral cell edema)

Which monitoring device would the nurse use to assess the effects of sedation and neuromuscular blocking medications? - hemodynamic - pulse oximetry - electroencephalographic - bispectral index

electroencephalographic (provides recordings of electrical activity in the brain and can be used to assess the effects of sedation and neuromuscular blocking medications)

Which side effect would the nurse monitor for when administering an osmotic diuretic (ex: mannitol) to a patient with increased intracranial pressure? - hypertension - electrolyte imbalance - bradycardia - gastric distension

electrolyte imbalance

Which nursing intervention may increase intracranial pressure? - positioning the patient at a 30 degree angle - endotracheal suctioning - emptying an indwelling urinary catheter - applying compression stockings

endotracheal suctioning (causes hypoxia, which increases intracranial pressure)

The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5° F. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patient's plan of care? - frequent neuro assessments - frequent oropharyngeal suctioning - side to side position changes - range of motion to extremities

frequent neuro assessments

A patient with a T1 spinal cord injury is admitted to the intensive care unit (ICU). The nurse will teach the patient and family that - use of the shoulders will be preserved - full function of the patient's arms will be retained - total loss of respiratory function may occur temporarily - elevations in heart rate are common with this type of injury

full function of the patient's arms will be retained

When completing the National Institutes of Health Stroke Scale, how would the nurse assess for limb ataxia? - ask the patient to notify the examiner when they feel a pinprick - have the patient perform the finger-nose-finger and heel-shin tests - ask the patient to hold their leg at a 30 degree angle while supine - have the patient raise their eyebrows, close their eyes, and show their teeth

have the patient perform the finger-nose-finger and heel-shin tests

The nurse is caring for a patient admitted with bacterial meningitis. Vital signsassessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min, oxygen saturation (SpO2) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5° F. What is the priority nursing action? - implement seizure precautions - maintain bed rest at all times - elevate the head of the bed to 30 degrees - keep lights dim at all times

implement seizure precautions

The nurse, caring for a patient following a subarachnoid hemorrhage, begins a nicardipine infusion. Baseline blood pressure assessed by the nurse is 170/100 mm Hg. Five minutes after beginning the infusion at 5 mg/hr, the nurse assesses the patient's blood pressure to be 160/90 mm Hg. What is the best action by the nurse? - stop the infusion for 5 minutes - begin weaning the infusion - notify the physician of the BP - increase the dose by 2.5 mg/hr

increase the dose by 2.5 mg/hr

The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow? - no effect on cerebral blood flow (PaCO2 of 60 mmHg is normal) - increased cerebral blood volume due to vessel dilation - decreased cerebral blood volume due to vessel constriction - altered cerebral spinal fluid production and reabsorption

increased cerebral blood volume due to vessel dilation

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority? - risk for impairment of tissue integrity caused by paralysis - altered patterns of urinary elimination caused by quadriplegia - altered family and individual coping caused by the extent of trauma - ineffective airway clearance caused by high cervical spinal cord injury

ineffective airway clearance caused by high cervical spinal cord injury

The nurse is caring for a patient with rhinorrhea of cerebrospinal fluid due to a dural tear and basilar skull fracture. Which action would the nurse include in the plan of care? - place a piece of cotton inside of the nose to stop the drainage - ask the patient to blow their nose every hour - insert gastric tubes through the mouth instead of the nose - closely observe the patient for redness around the neck

insert gastric tubes through the mouth instead of the nose

The nurse is preparing to endotracheal suction a patient with increased intracranial pressure. Which intervention would the nurse include? - avoid preoxygenating the patient - limit each suction pass to 20 seconds of less - maintain the head in a neutral position - closely monitor for pupillary changes

maintain the head in a neutral position (the head should be maintained in a neutral position during suctioning; this positioning increases perfusion to the brain)

While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102° F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what are the priority nursing actions? - maintain neutral head alignment and avoid extreme hip flexion - insert an oral airway and monitor respiratory rate and depth - insert an oral airway and monitor respiratory rate and depth - ensure adequate periods of rest between nursing interventions - reduce ambient room temperature and administer antipyretics

reduce ambient room temperature and administer antipyretics