The nurse recognizes the presence of Cushing's triad in the patient with which vitals?
A. Increase pulse, irregular respirations, increased BP
B. Decreased pulse, increased respirations, decreased systolic BP
C. Decreased pulse, irregular respiration, widened pulse pressure
D. Increased pulse, decreased respiration, widened pulse pressure
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Chapter 57: Nursing Management: Acute Intracranial Problems
Terms in this set (10)
The nurse recognizes the presence of Cushing's triad in the patient with
a. Increased pulse, irregular respiration, increased BP
b. decreased pulse, irregular respiration, increased pulse pressure
c. increased
pulse, decreased respiration, increased pulse pressure
d. decreased pulse, increased respiration, decreased systolic BP
B. Cushing's triad consists of three vital sign measures that reflect ICP and its effect on the medulla, the hypothalamus, the pons, and the thalamus. Because these structures are very deep, Cushing's triad is usually a late sign of ICP. The signs include an increasing systolic BP with a widening pulse pressure, a bradycardia with a full and bounding pulse, and irregular respirations.
Vasogenic cerebral edema increases ICP by
a. shifting fluid in gray matter
b. altering the endothelial lining of cerebral capillaries
c. leaking molecules from the intracellular fluid to the capillaries
d. altering the osmotic gradient flow inot the intravascular component
B. Altering the endothelial lining of cerebral capillaries
A patient with ICP monitoring has pressure of 12 mm Hg. The nurse understand that this pressure reflects
a. a severe decrease in cerebral perfusion pressure
b. an alteration in the production of CSF
c. the loss of autoregulatory control of ICP
d. a normal balance between brain tissue, blood, and CSF
D. A normal balance between brain tissue, blood, and CSF- normal is 10- 15 mm Hg
The nurse plans care for a 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
B. elevate the head of the bed to 30 degrees
The
nurse is alerted to possible acute subdural hematoma in the patient who
a. has a linear skull fracture crossing a major artery
b. has focal symptoms of brain damage with no recollection of a head injury
c. develops decreased LOC and a headache within 48 hours of head injury
d. has an immediate loss of consciousness with a brief lucid interval followed by decreasing LOC
C. develops decreased LOC and a headache within 48 hours of head injury
During admission of a patient with a severe head injury to the ED, the nurse places highest priority on assessment for
a. patency of of airway
b. presence of a neck injury
c. neurologic status with Glascow Coma Scale
d. CSF leakage from ears and nose
A. Patency of airway is the #1 priority with all head injuries
A patient is suspected of
having a cranial tumor. The signs and symptoms include memory deficits, visual disturbances, weakness of right upper and lower extremities, and personality changes. The nurse recognizes that the tumor is most likely located in the
a. frontal lobe
b. parietal lobe
c. occipital lobe
d. temporal lobe
A. Frontal lobe
Nursing management of a patient with a brain tumor includes (select all that
apply)
a. discussing with the patient methods to control appropriate behavior
b. using diversion techniques to leep the patient stimulated and motivated
c. assisting and supporting the family in understanding any changes in behavior
d. limiting self care activities until the patient has regained maximal physical functioning
e. plan for seizure precautions and teaching the patient and caregiver about antiseizure drugs.
C, E
The nurse on the clinical unit is assigned to four patients. Which patient should she assess first?
a. patient with a skull fracture whose nose is bleeding
b. elderly patient with a stroke who is confused and whose daughter is present
c. patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale
d. patient who had a craniotomy for a brain tumor who is now 3 days postoperative and has had continued
emesis
C. patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale
A nursing measure that is indicated to reduce the potential for seizures and increased ICP in the patient with bacterial meningitis is
a. administering codeine for relief of head and neck pain
b. controlling fever with prescribed drugs and cooling techniques
c. keeping the room darkened and quiet to
minimize environmental stimulation
d. maintaining the patient on strict bed rest with the HOB slightly elevated
B. Controlling fever with prescribed drugs and cooling techniques
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