Nursing Care: Complex Intracranial & Neurologic Alterations

Drag the nursing diagnosis next to the set of actions that best addresses that problem.​

1. Decreased intracranial adaptive capacity 2. Altered perfusion 3. Impaired airway clearance 4. Altered gas exchange

The nurse is evaluating Angela's response to the immediate actions that were performed. Indicate whether each nursing goal below was met or not met with these initial actions.

1. Not Met 2. Met 3. Met 4. Met

Place the nursing actions in order from the highest priority to the lowest priority.

1. Reposition the head 2. Obtain an airway 3. Artificially ventilate 4. Administer oxygen 5. Administer blood pressure 6. Elevate the head

In a client with a head injury, drag the nursing goal to the matching nursing actions that are most appropriate.

1. The client maintains a normal bowel routine. 2. The skin remains free of urinary or fecal moisture. 3. The skin remains intact. 4. The albumin blood levels are maintained above 3.5 g/dl. 5. The client maintains a temperature between 97.8ºF and 99.8ºF. 6. The client maintains muscle mass.

Drag the following nursing diagnoses to match the most appropriate nursing actions.​

1.Decreased intracranial adaptive capacity 2.Ineffective thermoregulation 3.Pain 4.Reduced cardiac output 5.Altered gas exchange 6.Constipation

A client has a mean arterial pressure of 120 mm Hg with an intracranial pressure of 42 mm Hg. What is the calculated cerebral perfusion pressure?​

78 mm Hg

The Arizona Department of Health received a $1 million dollar grant to implement strategies for reducing the number of spinal cord injuries in the state. In determining funding, which type of prevention should the public health nurse recommend that would affect most people?

More seatbelt use and vehicle speed reduction strategies​

Drag the following nursing diagnoses to match the corresponding nursing evaluation goal.​

Acute confusion -The client is alert and oriented to person, place, time, and situation.​ Decreased intracranial adaptive capacity -The Glasgow coma scale score is 15​. Ineffective thermoregulation - The client maintains an oral temperature between 97.8ºF (36.6ºC) and 99.8ºF (37.7ºC). Impaired memory -The client can describe short- and long-term memories. Altered perfusion -The client has no symptoms of decreased cerebral perfusion. Impaired mobility -The client has normal reflexes and moves all extremities. Pain -The client verbalizes a manageable pain level.

Drag the causes of primary intracranial regulation problems into the "primary issues" box, and secondary issues that can appear in the "secondary issues" box.​

Altered intracranial regulation can cause these primary issues. Brain perfusion problems​ Temperature control problems Altered level of consciousness Confusion Memory problems​ As a result, these secondary issues can arise. Urinary retention or incontinence​ Reduced nutrition intake​ Complications of tissue integrity (skin breakdown)​Complications of immobility (muscle atrophy) ​Breathing, airway, and oxygenation problems​ Bowel retention or incontinence

Jesse is admitted to the emergency department after a fall from a second-story balcony. He states that he is unable to move both lower extremities. His vital signs are stable, and he has had no urine output for the past 6 hours. Suddenly, he starts to experience symptoms of cold clammy skin from mid-chest down. Vitals signs:T: 96.8ºF (36.0ºC)BP: 145/86P: 50R: 14 Which nursing action is most appropriate?​

Appropriate Actions Insert a straight catheter as ordered.​ Inappropriate Actions Sit the head of the bed to 30 degrees.​ Turn the client to the right side.​ Give morphine 2 mg intravenous (IV) as ordered for pain.

When intracranial pressure is significantly elevated, what symptoms might the nurse expect? Select all that apply.

Bradycardia Increased systolic blood pressure with decreased diastolic blood pressure Irregular breathing

Select the priority nursing diagnoses in the left column, and the assessment cues that support each diagnosis in the right column.

Decreased intracranial adaptive capacity Reduced level of consciousness Cranial nerve abnormalities Impaired airway clearance No breathing Altered gas exchange Low oxygen saturation Decreased respirations

For each category, click to specify the client history information that is pertinent when seeing a client with altered intracranial regulation?

Dyslipidemia​ Concussion​ Bacterial Meningitis Lumbar laminectomy​ Cerebral vascular disease​ Smoking history: 20 pack years Aspirin 81 mg daily​

The nurse reports that the client is experiencing a reduced level of consciousness. Which tool is used to measure and record the level of consciousness?​

Glasgow coma scale (GCS)​

Based on the assessment findings, for which complications should the nurse monitor? Select all that apply.​

Respiratory arrest Increased intracranial pressure

The nurse is caring for Angela Everheart, a 57-year-old female brought to the emergency department (ED). Review the electronic health record (EHR) and answer the question below.​ Click to specify the pertinent nursing assessment findings and Glasgow coma scale score.​ Select that all apply.

decerebrate posturing dilated and unequal 180/60 45 0 unable to attain GCS: 1, 1, 2