NCLEX increased ICP quiz

NCLEX increased ICP quiz Leave the first rating Students also studied Terms in this set (24) Science MedicineNursing Save Ch 56 Acute Intracranial Problems 92 terms lebeauing_blogg Preview Chapter 56 Acute Intracranial Probl...193 terms SenobePreview NUR 4766 - Exam 2 Review 110 terms corrine5616Preview AQ Ne 50 terms jord Which data, obtained during the nurse's assessment of the patient, indicates that the patient in the neurologic intensive care unit with an increased intracranial pressure (ICP) is deteriorating?Presence of fixed unresponsive pupils Which intervention would the nurse implement when a patient, receiving treatment for viral meningitis since last week, arrives at the hospital reporting a persistent severe headache?Inform the patient that headaches can occur after recovery.When the unlicensed assistive personnel (UAP) reports the vital signs (VS) of a patient with with a suspected brain injury as temperature = 101.6 F orally, heart rate = 58 beats/minute, respiratory rate = 14 breaths/minute, and BP = 162/48 mm Hg, which action would the nurse implement first?Compare the current VS to recorded baseline VS Which outcome would the nurse anticipate after administering a high dose of prescribed barbiturates to the patient with an increased ICP?Barbiturates decrease the level of cerebral metabolism After assessing the breathing patterns of four assigned patients, which patient would the nurse suspect of having a lesion in the medulla of the brain?The patient with cluster breathing.

The patient admitted with a closed head injury is awake but lethargic, and the baseline vital signs include a BP of 120/80 mm Hg, pulse of 78 beats/minute, and respirations of 20 breaths/min. Which findings indicate deterioration of the patient's condition two hours later?BP is 160/74 mm Hg, pulse is 52 beats/min, and respirations are 10 breaths/min When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/min, and respirations 24 breaths/minute, which subsequent vital signs would the nurse report immediately to the health care provider?BP 172/54 mm Hg, pulse 58 beats/minute, respirations 10 breaths/minute When providing a community safety presentation, which disorder would the nurse include as a possible cause for a patient's increased intracranial pressure?Subdural hematoma When performing the prescribed intermittent drainage of cerebrospinal fluid (CSF) from a previously inserted ventriculostomy system, in which order would the intensive care unit nurse drain the fluid?

• Obtain the intracranial pressure (ICP) and determine whether the pressure is

above the prescribed level.

• Open the ventriculostomy system when ICP is greater than the prescribed

pressure

• Allow the CSF to drain for two to three minutes into the collection bag.
• Close the stopcock to return the ventriculostomy to a closed position.

When assessing a patient's intracranial pressure (ICP) after they sustained a head trauma, which normative value would the nurse utilize to compare the assessment data?

• to 15 mm Hg

Which interventions would the nurse implement to prevent injury to the patient with an increased intracranial pressure (ICP) and a decreased level of consciousness in the intensive care unit? Select all that apply.

• Consider administering light sedation agents
• Observe the skin area under the restraints
• Use effective restraints in an agitated patient

Which interventions would the nurse implement to promote optimal outcomes for the patient with an increased intracranial pressure (ICP)? Select all that apply.

• Maintain fluid balance and assess osmolality
• Maintain intubation and mechanical ventilation
• Elevate the head of the bed to 30 degrees with the head in a neutral position

Which intervention would the nurse implement as the priority when providing care for a patient with a ventriculostomy to measure increased intracranial pressures (ICP) caused by a brain tumor?Use strict aseptic technique with all procedural dressing changes.Which clinical manifestation would the nurse report immediately to the health care provider when providing care for a patient with a traumatic brain injury and an increased intracranial pressure (ICP)?Urine output of 1000 mL in one hour For the patient who sustained a head trauma and has an increased intracranial pressure, which cranial nerve (CN) would the nurse assess to determine the patient's papillary response?CN III - oculomotor

Which clinical manifestations would the nurse monitor to assess the development of increasing intracranial pressures in a patient who sustained a head injury and has a baseline Glasgow Coma Scale (GCS) score of 14?Increased systolic BP, decreased pulse, widening pulse pressure, GCS score of 4 Which clinical manifestations would the nurse identify when assessing a patient for intracranial pressure (ICP) changes secondary to a malfunctioning ventricular shunt?Select all that apply.

• Blurred vision
• Headache and vomiting
• Decreased level of consciousness

The nurse reviews the laboratory results of a patient with a cerebral inflammatory condition and notes that glucose was absent in the patient's cerebrospinal fluid. The nurse recognizes that the finding is consistent with which condition?Brain abscess Which components would the nurse assess when using the Glasgow Coma Scale (GCS) to assess a patient who sustained a head injury and subsequently developed an increased intracranial pressure?Speaking, responding to stimuli, and following verbal commands.Which factors would the nurse consider prior to repositioning a patient with an increased intracranial pressure (ICP)? Select all that apply.

• Take care to prevent extreme neck flexion of patients.
• Adjust body position to decrease ICP
• Follow protocol standards to maintain a head-up position for the patient

Which interventions would the nurse implement to avoid complications associated with the corticosteroid treatment prescribed for a patient with an increased intracranial pressure (ICP)? Select all that apply.

• Monitor fluid intake and sodium levels regularly
• Perform blood glucose monitoring at least every six hours
• Initiate concurrent treatment with antacids or proton pump inhibitors.

Which inflammatory condition would the nurse associate to the common cause of acute nonepidemic encephalitis?Herpes simplex virus encephalitis After receiving preprocedural instructions, which patient statement demonstrates an understanding of a scheduled ventriculostomy?"It will directly measure the pressure within the ventricles of my brain." Which term would the nurse use to document a patient who is comatose from a head injury and displays flexion of the arms, wrists, and fingers, as well as adduction of the upper extremeties?Decorticate posturing.