Exam 1
Normal ICP range
5-15 mm, Hg
A client with a head injury is being monitored for increased intracranial pressure, his blood pressure is 90/60 mm Hg and the ICP is 15 mmHg, therfore his cervral perfusion pressure is
52 mm Hg
client with head injury is being monitored for increased intracranial pressure, ICP his blood pressure is 90/60 mm Hg and the icp is 15 mm Hg, therefore his cerebral perfusion pressure is
52 mm Hg
a pt with ICP monitoring has pressure of 12 mm Hg, the nurse understand that this pressure reflects
A normal balance between brain tissue, blood, and CSF- normal is 10- 15 mm Hg
a pt with increased ICP is bein monitored in the ICU with a fiberoptic catheter which order is a priority for you
Administer the prescribed mannitol (Osmitrol).
a pt admitted with a head injury has admission vital signs of temperature 98.6 bp 128/68, pulse 110, and respirations 26, which of these vital signs , if taken 1 hour after admission, will be of most concern to the nurse
Blood pressure 156/60, pulse 60, respirations 14
Which option is the most sensitive indication of increased ICP
CHange in the level of consciousness (LOC)
when assessing a pt with a head injury, the nurse recognizes that teh earliest indication of increased intracranial pressure is
Change in level of consciousness (LOC)
you are alerted to a possible acute subdural hematoma in the pt who
Develops decreased level of consciousness and a headache within 48 hrs of a head injury
a nurse is teaching family members of a client with a concussion about the early signs of increased cranial pressure, ICP which of the following would the nurse cite as early signs of ICP
Headache and vomiting, Headache and vomiting are early signs of increased ICP,
which option indicates a sign of Cushigns traid, an indication of increased intracranial pressure
Heart rate decreases from 75 to 55 beats/minute
Whether Mr. synders tumor is benign or malignant, it will eventually cause an increase in intracranial pressure. Signs and symptoms of increasing ICP include all the following except:
Increased pulse rate, drop in blood pressure
A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity ( inability to flex the neck forward due to rigidity of the neck muscles), and projectile vomiting. The nurse knows that lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances?
Intracranial pressure is increased - sudden remocal of CSF results in pressures lower in the lumbar region than the brain and favors herniation of the brain, therefore, LP is contraindicated with increased ICP. vomiting may be caused by reason other than ICP, so Lp is not stricly contraindicated. LP may be performed on a client needing medchanical ventilation.
a pt with a head injury has an arterial blood pressure is 92/50 mm Hg and an intracranial pressure of 18 mm Hg. which action by the nurse is appropriate
Notify the health care provider aboud the assessments
During admission of a patient with a severe head injury to the emergency department the nurse places the highest priority on assessment for a. Patency of airway b. Presence of neck injury c. Neurologic status with Glasgow coma scale d. Cerebrospinal fluid leakage from the ears or nose
Patency of airway is the #1 priority with all head injuries
a pt with a suspected closed head injury has bloody nasal drainage. you suspect that this pt has a cerebrospinal fluid leak when observing which of the following.
a halo sign on the nasal drip pad. , the blood coalesces into the center within a few minutes, and a yellowish ring of CSF encircles the blood, giving a halo effect. The presence of glucose is unreliable for determining the presence of CSF because blood also contains glucose.
The pt has rhinorrhea after a head injury. what action should you take?
a loose collection pad may be place under the nose. The concern is whether it is spinal fluid, which is determined by a test for glucose or the halo or ring sign.
the pt has rhinorrhea after a head injury what action should you take
a loose collection pad may be placed under the nose
a pt being monitored has an ICP pressure of 12 mm. you understand that this pressure reflects
a normal balance between brain tissue, blood, and cerebrospinal fluid. normal ICP ranges 5-15
Successful achievement of patient outcomes for the patient with cranial surgery would be best indicated by the a. ability to return home in 6 days b. ability to meet all self-care needs c. acceptance of residual neurologic deficits d. absence of signs and symptoms of increased ICP
absence of signs and symptoms of increased ICP
a pt with possible cerebral edema has a serum sodium level of 115 mEq/l a decreasing level of consciousness and complains of a headache. all of the following orders have been received. which one should the nurse accomplish first.
administer 5% hypertonic saline intravenously
a pt has ICP monitoring iwth an intraventricular catheter. a priority nursing intervention for the pt is
aspetic technique to prevent infection
A pt admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse "I have a pounding headache and I feel sick to my stomach. which action should the nurse ake first.
assess the blood pressure.
a pt admitted iwth dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, I have a pounding headache and I feel sick to my stomach which action should the nurse take first
assess the blood pressure. assessed immediatelty in a pt with an injury at the T6 level or higher, who complains of a headache to determine wheter autonmoic dysrefelxia is occuring.
which nursing action has the highest priority for a pt who was admitted 16 hts previously with a C5 spinal cord injury.
assessment of respiratory rate and effort
Which nursing action will the home health nurse include in the plan of care for a pt with paraplegia at the T4 level in order to prevent autonomic dysreflexia?
assist in planning a prescribed bowel program
Which nursing action will the home health nurse include in the plan of care for a pt with paraplegia at T4 level in order to prevent autonomic dysreflexia
assist in planning a prescribed bowel program.
a pt has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema, an appropriate nursing intervention for the pt is
avoiding positioning the pt with neck and hip flexion.
A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema. An appropriate nursing intervention for the patient is
avoidng positioning the pt with a neck and hip flexion - nursing care activites that increase ICP include hip and neck Flexion, suctionoing, clustering care avtivities, and noxious stimuli, they should be avoided or performed as little as possible in the pt with increased ICP. lowering the PaCO2 below 20 mm Hg can cause ischemia and worsening of ICP, paco2 should be maintained at 30 to 35 mm Hg,
The patient has rhinorrhea after a head injury. What action should you take?
b - a loose collection pad may be placed under teh nose. do not place a dressign in teh nasal cavity, and nothing should be placed inside the nostril. there is no need to cultrue the drainage. teh concern is wherther it is spinal fluid, which is determined by a test for glucose or the halo or ring sign.
metabolic and nutritional needs of the pt with increased ICP are best met with
balanced, essential nutrition in a form that the pt can tolerate
when teaching seniors at a community recreation center, which information will teh nurse included about ways to prevent fractures
buy shoes that provide good support and are comforable to wear.
Following a cauda equina spinal cord injury, which action will the nurse include in the plan of care?
cateterize pt every 3 -4 hrs.
When assessing a pt with a head injury the nurse recognizes that the earliest indication of increased intracranial pressure is
chagne in level of consciousness
The nurse notes that a pt with a head injury has a clear nasal drainage, the most appropriate nursing action for this finding is to
check the nasal drainage for glucose with a dextrostik or testape. it the drainage is cerebrospinal fluid, leakage from a dural tear, glucose will be present. dural teat increases the risk for infections like meningitits, avoid blowing the nose.
When assessing the body funciton of a pt with increased ICP, the nurse should initially assess
circulatory and respiratory status
an adult client is brought to the emergency department due to a motor vehicle accident. while monitoring the client, the nurse begins to suspect increased intracranial pressure ICP, when
client is orientated when aroused from sleep and goes back to sleep immediately
indicates a decrease in teh level of consciousness, which is the primary sign of increased ICP
client is orientd when aroused from sleep and goes back to sleep immediately
An adult is brought to the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse? A. rebound abdominal tenderness B. diminished bilateral breath sounds C. rub pain with deep inspiration D. nausea with projectile vomiting
client is oriented when aroused from sleep and goes back to sleep immediately behavior indicates a decrease in level of consiousness, which is the primary sign of increased ICP
An adult client is brought to the emergency department due to a motor vehicle accident. While monitoring the client, the nurse begins to suspect increased intracranial pressure, ICP, when:
client is oriented when aroused from sleep and goes back to sleep immediately. behavior indicates a decrease in level of consviousness which is the primary sign of increased ICP
THe nurse recognizes the presence of Cushings traid in the pt with
decreased pulse, irregular respiration, increased pulse pressure
The earliest signs of increased ICP the nurse should assess for include
decreasing level of consciousness
which finding in a pt with a spinal cord tumor is most important for the nurse to report to the health care provider.
decreasing sensation and ability to move the legs.
a 38 yeaer old pt has returned home following rehabilitation for spinal cord in home care nurse notes the spouse is performing many of the activities that the pt has been managing unassisted during rehabilitation. the most appropriate action by the nurse time is to
develop a plan to increase the pt indepedndence in consulation wiht the pt. and the spouse.
you plan care for the pt with increased ICP iwth the knowledge that the best way to position the pt is to
elevate the head of the bed to 30 degrees
You plan care for the patient with increased ICP with the knowledge that the best way to position the patient is to A. keep the head of the bed flat. B. elevate the head of the bed to 30 degrees. C. maintain patient on the left side with the head supported on a pillow. D. use a continuous-rotation bed to continuously change patient position.
elevate the head of the bed to 30 degrees.
You are providing care for a pt who has been admitted to the hospital with a head injury who requires regular neurologic vital signs which assessments are components of the pts score on the Glasgow Coma Scale
eye opening best verbal response best motor respons
symptoms of ICP
fixed and dilated pupils are symptoms
the Nurse will explain to patient who has a T2 spinal cord transection injury that
function of both arms should be retained.
the nurse is positioning the client with increased intracranial pressure. which of the following positions would the nurse avoid?
head turned to the side. the head of the client with increased cranial pressure should be positioned so the head is in a neutral midline position.
A nurse is positioning a client with increased ICP. Which position would the nurse avoid?
head turned to the side. the head of the client with increased cranial pressure should be positioned so the head is in a neutral midline position. the head of the bed should be raised to 30 to 45 defreees.
A nurse is teaching family members of a client with a concussion about the early signs of increased cranial pressure, ICP which of the following would the nurse cite as early signs of ICP
headache and vomiting. headache and vomiting are early signs of increased ICP.
The nurse is admitting a pt with a neck fracture at the C6 level to intensive care unit. Which assesment finding indicate neurogenic shock.
hypotension, bradycarida, and warm pink extremities.
a pt has a systemic blood pressure of 120/60 mm Hg and intracranial pressure of 24 mm Hg. the nurse determines that the cerebral perfusion pressure of this pt indicates
impaired brain blood flow
Whether Mr. Synder's tumor is benign or malignant, it will eventually cause an increase in intracranial pressure (ICP). Signs and symptoms of increasing ICP include ALL of the following EXCEPT:
increased pulse rate, drop in blood pressure as ICP increases, pulse rate decreased, and blood pressure increases. as ICP continues to increase, vital sigsn vary considerably.
Whether Mr. synders tumor is benign or malignant, it will eventually cause an increase in intracranial pressure. signs and symptoms of increasing ICp include ALL of the following except
increased pulse rate, drop in blood pressure,
an adult client with a severe head injury Is being monitored by the nurse for increase intracranial pressure. which finding would be the most indicative indication of increased ICP
increased restlessness restlessness indicates a lack of oxygen to the brain stem which imparis the reticular activating system
Which of the following signs of increased intracranial pressure would appear first after head trauma?
increased restlessness. resltessness indicates a lack of oxygen to the brain stem which impairs the reticular activating system.
The nurse is caring for a client with increased intracranial pressure, iCP. the nurse would note which of the following trends in vital signs if the ICP is rising?
increasin temperature, decreasing pulse, decreasing resp, increasing blood pressure.
The nurse is caring for a client with increased intracranial pressure, ICP. The nurse would note which of the following trends in vital signs if the ICP is rising?
increasing temp, decreasing pulse, decreasing respirations, increasing blood pressure change in vitals signs may be a late sign of increased ICP.
The nurse is caring for a client with increased intracranial pressure, ICP. The nurse would note which of the following trends in vital signs if the ICP is rising?
increasing temperature, decreasing pusle, decreasing respirations, increasin blood pressure a chane in vital signs may be late sign of incerased ICP.
a pt wit paraplegia resulting from a T9 spinal cord injury has neurogenic reflexic bladder. which action will the nurse include in the plan of care?
instruct the pt how to self catheterize pts bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate methog is to avoid incontinence by emptying the bladder at regular intervals through intermittetent cateterization.
A client admitted to the hospital with a subarachnoid hemorrhage has complaints of sever headache nuchal rigidity(inability to flex the neck forward due to rigidity of the neck muscles) and projectile vomiting, the nurse knows that lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances.
intracranial pressure is increased
A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nurchal rigidity (inability to flex the neck forward due to rigidity of the neck muscles,) and projectile vomiting. the nurse knows that lumbar puncture would be contraindicated in this client in which of the following circumstances?
intracranial pressure is increased
a pt with paraplegia resulting from a T9 spinal cord injury has a neurogenic refelxic bladder. Which action will the nurse include in the plan of care?
intsruct the pt how to self catheterize
The female client admitted to an acute care facility after a car accident develops signs and symptons of increased intracranial pressure the client is intubated and placed on mechanical ventilation to help reduce ICP. to prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning?
lidocaine (Xylocaine)
The female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure. the client is intubated and placed on mechanical ventilation to help reduce ICP. to prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning.
lidocaine (xylocaine) - administering lidocaine via endotracheal tube may minimize elevations in ICp caused by suctioning. although mannitol and furosemid may be given to reduce ICP, therye administered parenterally, not endotracheally.
when a pt is admitted to the emergency department following a head injury, the nurse first priority in management of the pt once a pt airway is confirmed is
maintaining cervical spine precautions
When a pt is admitted to the Ed following a head injury the nurse firsy priority in management of the pt once a pt airway is confimed is
maintaining cervical spine precautions.
which nursing action should be implemented in the care of a pt who is experiencing increased ICP
monitor fluid and electrolyte status astutely
a 33 year old pt with a T4 spinal cord injury asks the nurse whether he will ne able to sexually active. which initial respons by the nurse is best?
mulitple options are available to maintain secuality after spinal cord injury
A 33 year old pat with T4 spinal cord injury asks the nurse whether he will be able to be sexually active. which initial response by the nurse is best?
mulitple options are available to maintain sexuality after spinal cord injury. sexuality will be change by the pt spinal cord injury therer are options for expression of sexuality and for fertility.
During admission of a patient with a severe head injury to the ED, the nurse places highest priority on assessment for
patency of airway is the #1 prioiry with all head injuries.
During admission of a patient with a severe head injury to the emergency department the nurse places the highest priority on assessment for a. Patency of airway b. Presence of neck injury c. Neurologic status with Glasgow coma scale d. Cerebrospinal fluid leakage from the ears or nose
patency of airway is the #1 priority with all head injuries
the nurse on the clinical unit assigned to four pt, which pt should she assess first
patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale
While the nurse performs ROM on an unconscious patient with increased ICP, the patient experiences severe decerebrate posturing reflexes. The nurse should a. use restraints to protect the patient from injury b. administer CNS depressants to lightly sedate the patient c. perform the exercises less frequently because posturing can increase ICP d. continue the exercises because they are necessary to maintain musculoskeletal function
perform the exercises less frequently because posturing can increase ICP
a pt has an incomplete left spinal cord lesion at the level of T7, resulting in Brown squared syndrome. which nursing action should be included in the plan of care?
postitioning the pt left leg when turning the pt.
later signs of intracranial pressure include which of the following
projectile vomiting may occur with increased pressure on the reflex center in the medulla
Later signs of intracranial pressure include whic of the following
projectile vomiting may ovvur with increased pressure on the reflex center in the medulla.
For an adult client with a suspected increased intracranial pressure (ICP), a most appropriate respiratory goal would be:
promote CO2 elimination , the goal of treatment would be to prevent acidemia by eliminating CO2. that is beacause an acid environoment in the brain causes cerbral vessels to dilate and therfore increases ICP. preventiong respiratory alkalosis and lowerign arterial pH could raise acid levels.
For an adult client with a suspected increased intracranial pressure, a most appropriate respiratory goal would be
promote CO2 elinination
When the nurse is developing a rehabilitation plan for a patient with a C6 spinal cord injury, an appropriate patient goal is that the patient will be able to _____________
push a manual wheelchair on a flat surface.
A pt who had a C7 spinal cord injury a week ago has a weak cough effort and audible rhonchi. the initial intervention by the nurse should be to
push upward on the epigastic area as the pts coughs.
a pt who had a C7 spinal cord injury a wk ago has a weak cough effort and audible rhonchi. the initial intervention by the nurse should be to
push upward on the epigastric area as the patient coughs cough effort is poor, the intitial action should be to use assisted coughing techniques to improve the ability to mobilze secretions administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia.
Later signs of intracranial pressure include whic of the following
repeaeted vomiting increased pressure caused by bleeding or swelling within the skull can damage delicate brain tisuse and may become life threatening.
a nurse in the ed is observing a 4 yr old child for signs of increased intracranial pressure after a fall from a bicycle which resulted in a head trauma. which of the following signs or symptoms would be cause for concern.
repeated vomiting
a nurse in the ed is observing a 4 yr old child with signs of increased intracranial pressure after a fall from a bicycle which resulted in a head trauma. which of the following signs and symptoms would be cause for concern.
repeated vomiting
a 20 yr old pt who sustained a T2 spinal cord injury 10 days ago angrily tells I want to be transferred to a hospital where the nurses know what they are doing. which response by the nurse is best.
requst that the pt provide input for the plan of care.
a pt. with a head injury has bloody drainage from the ear to determine whether CSF is present in the drainage the nurse
tests the fluid for a halo sign on a white dressing
A pt with increased ICP has mannitol prescribed. which option is the best indication that the drug is achieving he desired therapeutic effects.
the LOC improves is the most sensitive indicator of ICP ,
a 54 yo man is recovering from a skull fracture iwth a subacute subdural hematoma. he has return of motor control and orientation but appears apathetic and has reduced awareness of his environment. when planning discharge or the pt, the nurse explains to the pt and the family that
the patient is likely to have long term emotional and mental changes that may require continued professional help
a 39 yr pt is bein evaluated for a possible spinal cord tumor. which finding by the nurse requires the most immediate action
the pt has a new onset weakness of both legs.
when caring for a pt who has had a head injury, which assessment information is of most concern to the nurse,
the pt is more difficult to arouse.
a client with a subdural hematoma was given mannitol to decrease intracranial pressure. which of the following result would best show the mannitol was effective?
to promote osmotic diureses to reduce ICP mannitol promotes osmotic diuresis by increasing teh pressure gradlent, drawing fluid from intracellular to intravascular spaces.
a client with a subdural hematoma (a collection of blood on the brains surface beneath the skull, becomes restless and confused, with dilation of the ipsilateral pupil. the physician order mannitol for which of the following reasons
to promote osmotic diuresis to reduce ICP mannitol promotes osmotic diureses by increasing the pressure gradlent, drawing fluid from intracellulat to intravascular spaces.
The nurse suspects the presence of an arterial epidural hematoterm-85ma in the pt who experiences
unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC
when caring for a pt who experienced a T2 spinal cord transection 24 hrs ago, which collaborative and nursing actions will the nurse included in the plan of care.
urinary catheter care continuous cardiac monitoring maintain a warm room temperature administration of H2 blockers