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chap 66 prep U questions
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chap 66 prep U questionsA client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must
implement interventions to help control intracranial pressure (ICP). Which of the
following are appropriate interventions to help control ICP? - ANS-Keep the client's neck
in a neutral position (no flexing).
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? - ANS-Lethargy
A client is receiving hypothermic treatment for uncontrolled fever related to increased
intracranial pressure (ICP). Which assessment finding requires immediate intervention?
- ANS-Shivering
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? - ANS-vasodilation
A client with a head injury is being monitored for increased intracranial pressure (ICP).
His blood pressure is 90/60 mm Hg and the ICP is 18 mm Hg; therefore his cerebral
perfusion pressure (CPP) is: - ANS-52 mm Hg.
60x2= 120
120 +90 =210
210/ 3= 70 mm hg (map)
70-18 = 52 mmhg
(MAP- ICP = CPP
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? - ANS-Decerebrate posturing and loss of corneal reflex
A client with a traumatic brain injury has developed increased intracranial pressure
resulting in diabetes insipidus. The expected treatment would consist of which of the
following? - ANS-Vasopressin therapy
, A client with a traumatic brain injury has developed increased intracranial pressure
resulting in diabetes insipidus. While assessing the client, the nurse expects which of
the following findings? - ANS-Excessive urine output and decreased urine osmolality
A client with a traumatic brain injury is showing early signs of increasing intracranial
pressure (ICP). While planning care for this client, what would be the priority expected
outcome? - ANS-Airway
A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of
40 mm Hg. How should the nurse interpret the CPP value? - ANS-The CPP is
low.Explanation:
The normal CPP is 70 to 100 mm Hg.
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. - ANS-Bradycardia
Bradypnea
Hypertension
A nurse is assessing a client who has been in a motor vehicle collision. The client
directly and accurately answers questions. The nurse notes a contusion to the client's
forehead; the client reports a headache. Assessing the client's pupils, what reaction
would confirm increasing intracranial pressure? - ANS-unequal response
A nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The
nurse should be alert for what complication of ICP monitoring? - ANS-Infection
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of
increased ICP include: - ANS-diminished responsiveness.
A nurse working on a medical-surgical floor walks into a patient's room to find the
patient with an altered level of consciousness (LOC). Which of the following actions
would be the first priority? - ANS-Maintenance of a patent airway
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? - ANS-Flaccid
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