1.When the nurse is assessing a client with suspected increased intracranial pressure, the nurse is aware that which of the following is true in clients with increased intracranial pressure?
A. In pressure autoregulation, stretch receptors within small blood vessels of the brain cause smooth muscle of the arterioles to dilate.
B. Autoregulatory mechanisms have a great ability to maintain cerebral blood flow.
C. Interruption of the cerebral blood flow leads to ischemia and disruption of the cerebral metabolism
D. The relationship between the volume of the intracranial components and intracranial pressure is known as vasodilation
Answer: C
2.The nurse is assessing a 10-year-old client's level of consciousness in the emergency department. Which of the following would be important questions to ask the parent? (Select all that apply.)
A. “Has the child ever had a brain tumor or shunt?”
B. “Has the child been sick?”
C. “Has the child been huffing (ingesting) any household products?”
D. “Does the child have animals at home?”
E. “Has the child had recent head trauma?”
Answer: A, B, C, E
3. A client with cerebral edema is prescribed intravenous mannitol (Osmitrol). In planning care for this client, the nurse recognizes which of the following as the purpose of administering mannitol?
A. To decrease the osmolarity of the blood, thereby drawing water out of edematous brain tissue and into the vascular system for elimination via the kidneys
B. To act on the renal tubule to promote dieresis
C. To manage seizure activity associated with increased intracranial pressure (ICP)
D. To increase the osmolarity of the blood, thereby drawing water out of edematous brain tissue and into the vascular system for elimination via the kidneys
Answer: D
4. When providing care to a client with increased intracranial pressure (ICP) requiring mechanical ventilation, the nurse is aware that which of the following can increase intracranial pressure?
A. Partial pressure of arterial carbon dioxide of about 35 mmHg
B. Hyperventilation
C. Oxygenation with a partial pressure of arterial oxygen at about 100 mmHg
D. Hypoxemia and hypercapnia
Answer: D
5. The nurse establishes a diagnosis of Ineffective Tissue Perfusion: Cerebral for a client with increased intracranial pressure (ICP). Which of the following interventions would not be included in the client's plan of care?
A. Provide a quiet environment, limiting noxious stimuli.
B. Assess for bladder distention and bowel constipation.
C. Preoxygenate mechanically ventilated client with 100% oxygen before suctioning
D. Cluster nursing care
Answer: D
Activity Intolerance related to Imbalance between oxygen supply or delivery and demand
I: Assess patient ability to perform ADLs
R: Influences choice of interventions and needed assistance
I: Monitor vital sign (Blood Pressure, pulse, and respirations) during and after activity
R: Cardiopulmonary manifestations result from attempts by the heart and lungs to supply adequate amounts of oxygen to the tissues
I: Suggest client change position slowly; monitor for dizziness.
R: Postural hypotension or cerebral hypoxia may cause dizziness, fainting, and increased risk of injury.
Risk For Ineffective Tissue Perfusion: peripheral, renal, GI, cardiopulmonary, or central r/t hypovolemia, decreased arterial flow & cerebral edema
I: Assess each area for signs of decreased tissue perfusion
R: Early detection facilitates prompt, effective treatment
I: Monitor vital signs for optimal cardiac output
R: Adequate perfusion to vital organs is essential. A mean arterial blood pressure of at least 60 mmHg is essential to maintain perfusion
I: Administer fluids and blood products as ordered
R: Aids in maintaining adequate circulating volume to prevent irreversible ischemic damage
What medications do you take for an INR of 4?
The patient would be taking warfarin/Coumadin (anticoagulant)
I: Note clt report of pain in specific areas whether diffuse, increasing or localized.
R: Can help ID bleeding into tissues, organs, or body cavities.
I: Review laboratory data
R: To determine needed dosage changes or pt management issues requiring monitoring and/or modification.
I: Prepare pt for or assist with diagnostic tests
R: to determine presence of injuries or disorders that could cause internal bleeding.
A. In pressure autoregulation, stretch receptors within small blood vessels of the brain cause smooth muscle of the arterioles to dilate.
B. Autoregulatory mechanisms have a great ability to maintain cerebral blood flow.
C. Interruption of the cerebral blood flow leads to ischemia and disruption of the cerebral metabolism
D. The relationship between the volume of the intracranial components and intracranial pressure is known as vasodilation
Answer: C
2.The nurse is assessing a 10-year-old client's level of consciousness in the emergency department. Which of the following would be important questions to ask the parent? (Select all that apply.)
A. “Has the child ever had a brain tumor or shunt?”
B. “Has the child been sick?”
C. “Has the child been huffing (ingesting) any household products?”
D. “Does the child have animals at home?”
E. “Has the child had recent head trauma?”
Answer: A, B, C, E
3. A client with cerebral edema is prescribed intravenous mannitol (Osmitrol). In planning care for this client, the nurse recognizes which of the following as the purpose of administering mannitol?
A. To decrease the osmolarity of the blood, thereby drawing water out of edematous brain tissue and into the vascular system for elimination via the kidneys
B. To act on the renal tubule to promote dieresis
C. To manage seizure activity associated with increased intracranial pressure (ICP)
D. To increase the osmolarity of the blood, thereby drawing water out of edematous brain tissue and into the vascular system for elimination via the kidneys
Answer: D
4. When providing care to a client with increased intracranial pressure (ICP) requiring mechanical ventilation, the nurse is aware that which of the following can increase intracranial pressure?
A. Partial pressure of arterial carbon dioxide of about 35 mmHg
B. Hyperventilation
C. Oxygenation with a partial pressure of arterial oxygen at about 100 mmHg
D. Hypoxemia and hypercapnia
Answer: D
5. The nurse establishes a diagnosis of Ineffective Tissue Perfusion: Cerebral for a client with increased intracranial pressure (ICP). Which of the following interventions would not be included in the client's plan of care?
A. Provide a quiet environment, limiting noxious stimuli.
B. Assess for bladder distention and bowel constipation.
C. Preoxygenate mechanically ventilated client with 100% oxygen before suctioning
D. Cluster nursing care
Answer: D
Activity Intolerance related to Imbalance between oxygen supply or delivery and demand
I: Assess patient ability to perform ADLs
R: Influences choice of interventions and needed assistance
I: Monitor vital sign (Blood Pressure, pulse, and respirations) during and after activity
R: Cardiopulmonary manifestations result from attempts by the heart and lungs to supply adequate amounts of oxygen to the tissues
I: Suggest client change position slowly; monitor for dizziness.
R: Postural hypotension or cerebral hypoxia may cause dizziness, fainting, and increased risk of injury.
Risk For Ineffective Tissue Perfusion: peripheral, renal, GI, cardiopulmonary, or central r/t hypovolemia, decreased arterial flow & cerebral edema
I: Assess each area for signs of decreased tissue perfusion
R: Early detection facilitates prompt, effective treatment
I: Monitor vital signs for optimal cardiac output
R: Adequate perfusion to vital organs is essential. A mean arterial blood pressure of at least 60 mmHg is essential to maintain perfusion
I: Administer fluids and blood products as ordered
R: Aids in maintaining adequate circulating volume to prevent irreversible ischemic damage
What medications do you take for an INR of 4?
The patient would be taking warfarin/Coumadin (anticoagulant)
I: Note clt report of pain in specific areas whether diffuse, increasing or localized.
R: Can help ID bleeding into tissues, organs, or body cavities.
I: Review laboratory data
R: To determine needed dosage changes or pt management issues requiring monitoring and/or modification.
I: Prepare pt for or assist with diagnostic tests
R: to determine presence of injuries or disorders that could cause internal bleeding.
