MED SURG EXAM 2 - CH 61
For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to:
Promote carbon dioxide elimination
Cerebral edema peaks at which time point after intracranial surgery?
24 hours
A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)?
Admin stool softener
The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention?
Administer corticosteroids as ordered.
The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action?
Administer medications at exact intervals ordered.
Which is a late sign of increased intracranial pressure (ICP)?
Altered respiratory patterns
A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply.
Bradycardia, bradypnea, HTN
The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop?
Damage to the optic nerve
A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP?
Decerebrate posturing and loss of corneal reflex
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:
Diminished responsiveness
A patient has been diagnosed with myasthenia gravis. The nurse documents the initial and most common manifestation of:
Diplopia
The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began?
Drooping eyelids
Which activity should be avoided in clients with increased intracranial pressure (ICP)?
Enemas
A patient has a severe neurologic impairment from a head trauma. What does the nurse recognize is the type of posturing that occurs with the most severe neurologic impairment?
Flaccid
During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect?
Gingival hyperplasia
A client is demonstrating an altered level of consciousness from a traumatic brain injury. Which assessment will the nurse use as a sensitive indicator of neurologic function?
Glasgow Coma Scale
Following a transsphenoidal hypophysectomy, a nurse should assess a client for which condition?
Hypocortisolism
The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy?
Increased ICP is 12 mm Hg
Which is the priority nursing diagnosis when caring for a client with increased ICP who has an intraventricular catheter?
Ineffective cerebral tissue perfusion
A nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what complication of ICP monitoring?
Infection
A client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure?
Lethargy
After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question?
Performing a lumbar puncture
When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP?
Rising blood pressure and bradycardia
A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value?
The CPP is low
Which method is used to help reduce intracranial pressure?
Using a cervical collar
A client suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure?
Vasodilation
A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms?
Vasopressin