ICP, head and spinal injury QUESTIONS

ICP, head and spinal injury QUESTIONS Leave the first rating Students also studied Terms in this set (49) Save Med surg Neuro questions 73 terms allenirizarryPreview ICP/head injury NCLEX style questio...50 terms Alix_VanderWiele Preview Psychiatric Mental Health Nursing N...50 terms schwabaccaPreview Nursing 49 terms gra which components are able to adapt to small increases in ICP (select all that apply)

• blood
• skull bone
• brain tissue
• scalp tissue
• cerebrospinal fluid
• blood
• brain tissue
• cerebrospinal fluid

which events causes increased ICP (select all that apply)

• vasodilation
• necrotic tissue edema
• blood vessel compression
• edema from initial brain insult
• brainstem compression and herniation
• vasodilation
• necrotic tissue edema
• edema from initial brain insult

an early sign of increased ICP that the nurse should assess for is?

• Cushing's triad
• unexpected vomiting
• decreased LOC
• dilated pupil with sluggish response to light
• decreased LOC

a patient has ICP monitoring with an intraventricular catheter. what is the priority nursing intervention for the patient?

• aseptic technique to prevent infection
• constant monitoring of ICP waveforms
• removal of CSF to maintain normal ICP
• sampling CSF to determine abnormalities
• aseptic technique to prevent infection

which drug treatment helps to decrease ICP by expanding plasma and the osmotic effect to move fluid?

• O2 administration
• pentobarbital
• mannitol
• dexamethasone
• mannitol

how are the metabolic nutritional needs of the patient with increased ICP best met?

• enteral feedings that are low in sodium
• simple glucose available in D5W IV
• fluid restrictions that promotes a moderate

dehydration

• balanced, essential nutrition in a form that the patient

can tolerate

• balanced, essential nutrition in a form that the patient can tolerate

why is the Glasgow Coma scale used?

• to quickly assess the LOC
• to assess the patient's ability to communicate
• to assess the patient's ability to respond to commands
• to assess the patient's coordination with motor

responses

• to quickly assess the LOC

a patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arms in response to painful stimuli. what should the nurse report as the GCS score?

• 6
• 7
• 9
• 11
• 7

when assessing the body functions of a patient with increased ICP, what should the nurse assess first?

• corneal reflex testing
• pupilllary reaction to light
• extremity strength testing
• circulatory and respiratory status
• circulatory and respiratory status

a patient has a nursing diagnosis o risk for ineffective cerebral tissue perfusion related to cerebral edema. what is an appropriate nursing intervention for the patient

• avoid positioning the patient with neck and hip flexion
• maintain hyperventilation to a PaCO2 of 15-20
• cluster nursing activities to provide periods of

uninterrupted rest

• routinely suction to prevent accumulation of

respiratory secretions

• avoid positioning the patient with neck and hip flexion

the nurse is monitoring a patient of increased ICP following a head injury. what are manifestations of increased ICP (select all that apply)

• fever
• oriented to name only
• narrowing pulse pressure
• right pupil dilated greater that left
• decorticate posturing to painful stimulus
• fever
• oriented to name only
• right pupil dilated greater that left
• decorticate posturing to painful stimulus

the patient comes to the ED with cortical blindness and visual field defects. which type of head injury does the nurse suspect?

• cerebral contusion
• orbital skull fracture
• posterior fossa fracture
• frontal lobe skull fracture
• posterior fossa fracture

the patient has a depressed skull fracture and scalp lacerations with communication to the intracranial cavity.which type of injury should the nurse record?

• linear skull fracture
• depressed skull fracture
• compound skull fracture
• comminuted skull fracture
• compound skull fracture

a patient with a head injury has bloody drainage from the ear. what should the nurse do to determine if CS is present in the drainage?

• examine the tympanic membrane for a tear
• test the fluid for a halo sign on a white dressing
• test the fluid with a glucose-identifying strip
• collect 5mL of fluid in a test tube and send to the lab
• test the fluid for a halo sign on a white dressing

the nurse suspects the presence of an arterial epidural hematoma in the patient who experiences

• failure to regain consciousness following a head injury
• a rapid deterioration of neurologic function within 25-

48 hours folowing head injury

• nonspecific, nonlocalizing progression of alteration in

LOC occurring over weeks to months

• unconsciousness at the time of a head injury with a

brief period of consciousness followed by a decrease in LOC

• unconsciousness at the time of a head injury with a brief period of

consciousness followed by a decrease in LOC when a patient is admitted to the ED following a head injury, what should be the nurse's first priority in management of the patient once a patent airway is confirmed?

• maintain a cervical spine precautions
• monitor for changes in neurologic status
• determine the presence of increased ICP
• establish IV access with a large-bore catheter
• maintain a cervical spine precautions

a 54 year old man is recovering from a skull fracture with a subacute subdural hematoma that caused unconsciousness. he has return of motor control and orientation but appears apathetic and has reduced awareness of his environment. when planning discharge of the patient, what should the nurse explain to the patient and the family

• the patient is likely to have long-term emotional and

mental changes that may require professional help

• continuous improvement in the patient's condition

should occur until he has returned to pretrauma care

• the patients complete recovery may take years and the

family should plan for his long-term dependent care

• role changes in family membranes will be necessary

because the patient will be dependent on his family for care

• the patient is likely to have long-term emotional and mental changes that may

require professional help which cranial surgery would require the patient to learn how to protect the surgical area from trauma?

• burr holes
• craniotomy
• cranioplasty
• craniectomy
• craniectomy