Nursing Care: Complex Intracranial & Neurologic Alterations

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

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

1.Acute confusion The client is alert and oriented to person, place, time, and situation.​ 2.Decreased intracranial adaptive capacity The Glasgow coma scale score is 15​. 3.Ineffective thermoregulation- The client maintains an oral temperature between 97.8ºF (36.6ºC) and 99.8ºF (37.7ºC). 4.Impaired memory The client can describe short- and long-term memories. 5.Altered perfusion The client has no symptoms of decreased cerebral perfusion. 6.Impaired mobility The client has normal reflexes and moves all extremities. 7.Pain-The client verbalizes a manageable pain level.

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

1.Decreased intracranial adaptive capacity Elevate the head of the bed above 30 degrees.​ Administer diuretics as prescribed.​ Administer corticosteroids as prescribed.​ 2.Ineffective thermoregulation Provide a cooling or warming blanket. 3.Pain Administer pain medication as prescribed.​ Use the transcutaneous electrical nerve stimulation (TENS) unit as prescribed.​ 4.Reduced cardiac output Administer fluids as prescribed.​ Administer blood pressure-elevating medications.​​ 5.Altered gas exchange Administer oxygen as prescribed.​ Administer ventilation if needed. 6.Constipation Administer stool softeners.​ Increase fluid intake.​ Administer laxatives if needed and prescribed.​

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

78 mmHg

Prioritizing Hypotheses Select three priority nursing diagnoses based on the client's presentation.​

Altered gas exchange​ Decreased intracranial adaptive capacity​ Impaired airway clearance​

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)​

Generating Solutions For each intervention listed in the first column, select whether it is indicated or not indicated for proper client care.

Indicated Elevate the head of the bed above 30 degrees. ​ Assist with cerebral spinal fluid catheter insertion and drainage. Administer blood pressure-decreasing medications. ​ Administer oxygen as prescribed. ​ not indicated Place client in Trendelenburg. ​ Administer morphine as prescribed for pain. ​ Suction airway vigorously. ​

Jesse (he/him/his) 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: 96.8 ºF (36.0 ºC)BP: 145/86P: 50R: 14 Which nursing action is most appropriate?​

Insert a straight catheter as ordered.

Analyzing Cues For each symptom listed in the first column, choose a condition associated with the symptoms. There may be more than one condition with the associated symptoms.

Migraine Severe headache ​ Nausea ​ Autonomic Dysreflexia Severe headache ​ Nausea ​ Flushing or sweating ​ Bradycardia ​ Impaired movement ​ Increased Intracranial Pressure Severe headache ​ Nausea ​ Slow and/or irregular respirations ​ Bradycardia ​ Impaired movement ​

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

Taking Action Based on the nurse's assessment, which of the following actions should the nurse take immediately? Select all that apply.

Place non-rebreather mask with 15L of oxygen on client​ Notify rapid response team​ Start intravenous line​

Evaluating Outcomes 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.

not met met met met

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

primary issues: Brain perfusion problems ​Temperature control problems Altered level of consciousness Memory problems​ secondary issues: skin breakdown muscle atrophy Reduced nutrition intake​

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

the client maintains a normal bowel routine -Administer stool softeners. -Administer laxatives if needed and ordered. the skin remains free of urinary or fecal moisture -Provide bed padding and frequent sheet changes. -Administer barrier creams as ordered. the skin remains intact -Frequent turning and moving. the blood albumin levels are maintained above 3.5 -Provide dietary consultation. -Administer tube feedings. the client maintains a temp. between 36.5-37.6C -Provide a cooling or warming blanket. the client maintains muscle mass -Encourage active or passive range of motion exercises. -Consult with physical therapy.

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.

unequal dilated pupil on the right side, widening systolic and diastolic blood pressure, bradycardia, irregular respirations of 8, and oxygen saturation of 84%. decerebrate posturing GCS:1,1,2