exams 1-4 cont. Flashcards
the nurse is admitting a client diagnosed with primary adrenal cortex insufficiency (addison’s) which clinical manifestations should the nurse expect to assess?
bronze pigmentation hypotension and anorexia
The nurse is developing a plan of care for the client diagnosed with acquired immunodeficiency syndrome (aids) who has developed an infection in the adrenal gland. Which client problem is highest priority ?altered body imageactivity intoleranceimpaired copingfluid volume deficit
fluid volume deficit
the nurse is planning the care of a client diagnosed with Addison’s . which intervention should be included ?
administer steroid medications
The client is admitted to rule out cushing’s syndrome. Which laboratory tests should the nurse anticipate being ordered?
plasma levels of ACTH and cortisol
The client has developed iatrogenic cushing’s disease. Which statement is the scientific rationale for the development of this diagnosis.the client has an autoimmune problem causing the destruction of the adrenal cortexthe client has been taking steroid medications for an extended period for another disease processthe client has a pituitary gland tumor causing the adrenal glands to produce to much cortisolthe client has developed an adrenal gland problem for which the healthy care provider does not have an explanation
The client has been taking steroid medications for an extended period for another disease process
The nurse is performing discharge teaching for a client diagnosed with cushing’s disease. which statement by the client demonstrates an understanding of the instructionsI will be sure to notify my health care provider if i start to run a feverbefore I stop taking the prednisone, I will be taught how to taper it offIf i get weak and shaky, I need to eat some hard candy or drink some juiceIt is fine if I continue to participate in weekend games of tackle football
I will be sure to notify my health care provider if i start to run a fever
The charge nurse of an intensive care unit is making assignments for the night shift. Which client should be assigned to the most experienced intensive care nurse ?The client diagnosed with respiratory failure who is on a ventilator and requires frequent sedationThe client diagnosed with lung cancer and iatrogenic cushing’s disease with ABGs of PH 7.35 PaO2 88, Paco2 44, and HCo322The client diagnosed with Addison’s disease who is lethargic and has a BP of 80/45, P 124 and R28The client diagnosed with hyperthyroidism who has undergone a thyroidectomy two days ago and has a negative trousseau’s sign
The client diagnosed with Addison’s disease who is lethargic and has a BP of 80/45, P 124 and R28
The nurse writes a problem of “altered body image” for a 34 year old client diagnosed with Cushing’s disease. Which intervention should be implemented
Use therapeutic communication to allow the client to discuss feelings
The client diagnosed with Addison’s disease is admitted to the ER after a day at the lake. The client is lethargic, forgetful, and weak. Which intervention should the nurse implement.
Start an IV with an 18 gauge needle and infuse NS rapidly
The nurse manager of a medical surgical unit is asked to determine if the unit should adopt a new care delivery system. Which behavior is an example of an autocratic style of leadership?call a meeting and educate the staff on the new delivery system being used. organize a committee to investigate the various types of delivery systemswait until another unit has implemented the new system and see if it works outdiscuss with the nursing staff if a new delivery system should be adopted
call a meeting and educate the staff on the new delivery system being used.
The client diagnosed with cushing’s disease has undergone a unilateral adrenalectomy. Which discharge instructions should the nurse discuss with the client?Call a meeting and educate the staff on the new delivery system being usedorganize a committee to investigate the various types of delivery systemswait until another unit has implemented the new system and see if it works outdiscuss with the nursing staff if a new delivery system should be adopted.
wait until another unit has implemented the new system and see if it works out
The client diagnosed with a pituitary timor developed syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should the nurse implement?
assess for N/V and weigh daily
The nurse is admitting a client to the neurological intensive care unit who is postoperative transsphenoidal hypophysectomy. which data warrant immediate intervention?The client is alert to name but is unable to tell the nurse the locationthe client has an output of 2500 ml since surgery and an intake of 1,000 mlthe clients vital signs are 97.6,88,20,130/80The client has a 3 cm amount of dark red drainage on the turban dressing
the client has an output of 2500 ml since surgery and an intake of 1,000 ml
which laboratory value should be monitored by the nurse for the client diagnosed with diabetes insipidus
serum sodium
the nurse i discharging a client diagnosed with diabetes insipid us. which statement made by the client warrants further interventioni will keep a list of my medications in my wallet and wear a medic alert braceleti should take my medication in the morning and leave it refrigerated at homei should weigh myself every morning and record any weight gainIf I develop a tightness in my chest, I will call my health care provider
i should take my medication in the morning and leave it refrigerated at home
the client is admitted to the medical unit with a diagnosis of rule out diabetes insipidus. Which instructions should the nurse teach regarding a fluid deprivation test?
The client will be NPO and vital signs and weights will be done hourly until the end of the test
The nurse is caring for clients on a medical floor . Which client should be assessed first.the client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who has a weight gain of 1.5 pounds since yesterdaythe client diagnosed with a pituitary timor who has developed diabetes insipid us and has an intake of 1500 and an output of 1600 in the last 8 hrs.The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who is having muscle twitchingthe client diagnosed with diabetes insipid us who is complaining of feeling tired after having to get up at night
The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who is having muscle twitching
The nurse is planning the care of a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should be implemented? Select all that applyRestrict fluids per health care provider orderassess level of consciousness every 2 hoursprovide an atmosphere of stimulationmonitor urine and serum osmolalityweigh the client every 3 days
Restrict fluids per health care provider orderassess level of consciousness every 2 hoursmonitor urine and serum osmolality
The nurse is caring for a client diagnosed with Diabetes insipid us. Which intervention should be implemented
assess tissue turgor every four hours
The UAP complains to the nurse she has filled the water pitcher four times during the shift for a client diagnosed with a closed head injury and the client has asked for the pitcher to be filled again. Which intervention should the nurse implement first
assess the client for polyuria and polydipsia
The nurse is admitting a client diagnosed with syndrome of inappropriate antidiurectic hormone (SIADH). Which clinical manifestations should be reported to the health care provider Serum sodium of 112 and a headacheserum potassium of 5.0 and a heightened awarenessserum calcium of 10 and tented tissue turgorserum magnesium of 1.2 and large urinary output
Serum sodium of 112 and a headache
The male client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) secondary to cancer of the lung tells the nurse he wants to discontinue the fluid restriction and does not care if he dies. Which action by the nurse is an example of the ethical principle of autonomy
notify the health care provider of the clients wishes and give the client fluids as desired
The client is diagnosed with hypothyroidism. Which signs/symptoms should the nurse expect the client to exhibit?
complaints of extreme fatigue and hair loss
The nurse identifies the client problem risk for imbalanced body temperature for the client diagnosed with hypothyroidism. Which intervention should be included in the plan of care
discourage the use of an electric blanket
the client diagnosed with hypothyroidism is prescribed the thyroid hormone levothyroxine (synthroid) which assessment data indicate the medication has been effective
the clients temperature is WNL
Which nursing intervention should be included in the plan of care for the client diagnosed with hyperthyroidism
provide 6 small well balanced meals a day
The client is admitted to the ICU diagnosed with myxedema coma. Which assessment data warrant immediate intervention by the nurse serum glucose of 74pulse ox reading of 90%telemetry reading showing sinus bradycardiathe client is lethargic and sleeps all the time
pulse ox reading of 90%
Which medication order should the nurse question in the client diagnosed with untreated hypothyroidism
sedatives
which statement made by the client makes the nurse suspect the client is experiencing hyperthyroidismi just don’t seem to have any appetite anymorei have a bowel movement about every 3-4 daysmy skin is really becoming dry and coursei have noticed all my collars are getting tighter
i have noticed all my collars are getting tighter
The 68 year old client diagnosed with hyperthyroidism is being treated with radioactive iodine therapy. Which interventions should the nurse discuss with the client
explain it will take up to a month for symptoms of hyperthyroidism to subside
The nurse is teaching the client diagnosed with hyperthyroidism. Which information should be taught to the client? Select all that applyNotify the HCP if a 3 lb weight loss occurs in 2 daysdiscuss ways to cope with the emotional labilitynotify the HCP if taking over the counter medscarry a medical identification card or braceletteach how to take thyroid medications correctly
Notify the HCP if a 3 lb weight loss occurs in 2 daysdiscuss ways to cope with the emotional labilitynotify the HCP if taking over the counter medscarry a medical identification card or bracelet
The nurse is providing an in service on thyroid disorders. Once of the attendees asks the nurse why don’t the people in the united states get goiters as often? Which statement by the nurse is the best responseit is because of the screening techniques used in the USit is a genetic predisposition rare in the North AmericansThe medications available in the US decrease goitersIodized salt helps prevent the development of goiters in the US
Iodized salt helps prevent the development of goiters in the US
The nurse is preparing to administer the following medications. Which med should the nurse question administering
the loop diuretic to the client with a potassium level of 3.3
Which signs/symptoms should make the nurse suspect the client is experiencing a thyroid storm
hyperpyrexia and extreme tachycardia
Problems in the hypothalamus that change the function of the anterior pituitary land result in which condition
secondary pituitary dysfunction
Which are hormones produced and secreted by the anterior pituitary gland (select all that apply)Growth Hormone ProlactinThyrotropin (TSH)serotoninGonadotropins (FSH and LH)epinephrine
Growth Hormone ProlactinThyrotropin (TSH)Gonadotropins (FSH and LH)
a malfunctioning posterior pituitary gland can result in which disorders (select all that apply)hypothyroidismaltered sexual functionDiabetes insipidusgrowth retardationsyndrome of inappropriate antidiuretic hormone (SIADH)
Diabetes insipidussyndrome of inappropriate antidiuretic hormone (SIADH)
a malfunctioning anterior pituitary gland can result in which disorders (select all that apply)pituitary hypo functionpituitary hyper functiondiabetes insipidushypothyroidismosteoporosis
pituitary hypo functionpituitary hyper functionhypothyroidismosteoporosis
The assessment findings of a male patient with anterior pituitary tumor include reports of changes in secondary sex characteristics such as episodes of impotence and decreased libido. The nurse explains to the patient that these findings are a result of overproduction of which hormone
PRL inhibiting secretion of gonadotropins
a patient with PRL secreting tumor is likely to be treated with which medication
dopamine agonists
a patient is prescribed bromocriptine mesylate (parlodel). which information does the nurse teach the patient (select all that apply) get up slowly from a lying positiontake medication on an empty stomachtake daily for purposes of raising GH levels to reduce symptom of acromegalybegin therapy with a maintenance level dosereport watery nasal discharge to the health care provider immediately
get up slowly from a lying positionreport watery nasal discharge to the health care provider immediately
Patients diagnosed with an anterior pituitary tumor can have symptoms of acromegaly or gigantism. These symptoms are a result of overproduction of which hormone
GH
The nurse is performing an assessment of an adult patient with new onset acromegaly. What does the nurse expect to find
thickened lips
When analyzing laboratory values, the nurse expects to find which value as a direct result of overproduction of GH
hyperglycemia
In caring for a patient with hyperpituitarism, which symptoms does the nurse expect the patient to report (select all that apply) joint painvisual disturbanceschanges in menstruationdecreased libidoheadache
joint painvisual disturbanceschanges in menstruationdecreased libidoheadache
a deficiency of which anterior pituitary hormones is considered life threatening (select all that apply)GHmelanocyte stimulating hormone (MSH)PRLTSHACTH
TSHACTH
Which statements about the etiology of hypopituitarism are correct? (select all that apply)dysfunction can result from radiation treatment to the head or braindysfunction can result from infection or a brain tumorinfarction following systemic shock can result in hypopituitarismsevere malnutrition and body fat depletion can depress pituitary gland functionThere is always an underlying cause of hypopituitarism
dysfunction can result from radiation treatment to the head or braindysfunction can result from infection or a brain tumorinfarction following systemic shock can result in hypopituitarismsevere malnutrition and body fat depletion can depress pituitary gland function
which statement about hormone replacement therapy for hypopituitarism is correct.
testosterone replacement therapy is contraindicated in men with prostate cancer
a femal patient has been prescribed hormone replacement therapy. What does the nurse instruct the patient to do regarding this therapy
take measures to reduce risk for hypertension and thrombosis
A patient requires 100 g. of oral glucose for suppression testing and GH levels are measured serially for 120 minutes. The results of the suppression testing are abnormal. The nurse assesses for the signs and symptoms of which endocrine disorder
hyperpituitarism
a patioent is recovering from a transsphenoidal hypophysectomy. What postoperative nursing interventions apply to this patient (select all that apply)vigorous coughing and deep breathing exercisesinstruction on the use of a soft bristled toothbrush for brushing the teethstrict monitoring of fluid balancehourly neurologic checks for first 24 hoursinstructing the patient to alert the nurse regarding postnasal drip
strict monitoring of fluid balancehourly neurologic checks for first 24 hoursinstructing the patient to alert the nurse regarding postnasal drip
Following a hupophysectomy the patient requires instruction on hormone replacement for which hormones (select all that apply)cortisolthyroidgonadalvasopressinPRL
cortisolthyroidgonadalvasopressin
After a hypophysectomy, home care monitoring by the nurse includes assessing which factors (select all that apply)hypoglycemiabowel habitspossible leakage of csf24 hour intake of fluids and urine output24 hour diet recallactivity level
bowel habitspossible leakage of csf24 hour intake of fluids and urine output24 hour diet recallactivity level
Postoperative care for a patient who has had a transsphenoidal hypophysectomy includes which intervention
testing nasal drainage for glucose to determine whether it contains CSF
While caring for a post op patient following a transphenoidal hypophysectomy, the nurse observes nasal drainage that is clear with yellow color at the edge. This halo sign is indicative of which condition
drainage of CSF from the patients nose
A patient with hpophysectomy can post op experience transient diabetes insipidus Which manifestation alerts the nurse to this problem
output much greater than intake
The action of ADH influences normal kidney function by stimulating which mechanism
distal nephron tubules ad collecting ducts to reabsorb water
What is the disorder that results from a deficiency of vasopressin (ADH) from the posterior pituitary gland called
diabetes insipidus
Which statements about diabetes insipid us are accurate (select all that apply)it is caused by ADH deficiencyIt is characterized by a decrease in urinationUrine output of greater that 4 L/24 hours is the first diagnostic indication the water loss increases plasma osmolaritynephrogenic DI can be caused by lithium (eskalith)
It is caused by ADH deficiencyUrine output of greater that 4 L/24 hours is the first diagnostic indication the water loss increases plasma osmolarity
What does the nurse instruct patients with permanent DI to do (select all that apply)continue vasopressin therapy until symptoms disappearmonitor for recurrence of polydipsia and polyuriamonitor and record weight dailycheck urine specific gravity three times a weekwear a medical alert bracelet
monitor for recurrence of polydipsia and polyuriamonitor and record weight dailywear a medical alert bracelet
A patient uses desmopressin acetate metered dose spray as a replacement hormone for ADH. Which is an indication for another dose ( select all that apply) excessive urinationspecific gravity of 1.003dark concentrated urineedema in the legsdecreased urination
excessive urinationspecific gravity of 1.003
The nurse is caring for a patient with DI. What is the priority goal of collaborative care
correct the water metabolism problem
Which medications are used to treat DI (select all that apply)chlorpropamide (diabinese)desmopressin acetate (DDAVP) lithium (Eskalith)Vasopressin (Pitressin)Demeclocycline (declomycin)
chlorpropamide (diabinese)desmopressin acetate (DDAVP) Vasopressin (Pitressin)
Which patients history puts him or her at risk for developing SIADH?
58 year old with metastatic lung or breast cancer
which statement about the pathophysiology of SIADH is correct
water retention results in dilution hyponatremia and expanded extracellular fluid (ECF) volume
Which statement about the etiology and incidence of SIADH is correct
demeclocycline may be used to treat SIADH
The effect of increased ADH in the blood results in which effect on the kidney
tubular reabsorption of water increases
In SIADH as a result of water retention from excess ADH which laboratory value does the nurse expect to find (select all that apply)increased urine osmolality (increased sodium in urine)elevated serum sodium levelincreased specific gravity ( concentrated urine)decreased serum osmolaritydecreased urine specific gravity
increased urine osmolality (increased sodium in urine)increased specific gravity ( concentrated urine)decreased serum osmolarity
Which nursing intervention is the priority for a patient with SIADH
restrict fluid intake
Which type of IV fluid does the nurse use to treat a patient with SIADH when the serum sodium level is very low
3% normal saline
In addition to IV fluids a patient with SIADH is on a fluid restriction as low as 500 to 600 /24 hours. Indicate the serum and urine results that demonstrate effectiveness of this treatment by writing increases or decreases for each item belowurine specific gravity resultsserum sodium resultsurine output
urine specific gravity results (dec)serum sodium results (inc.)urine output (inc.)
which medications are used in SIADH to promote water excretion without causing sodium loss (select all that apply)Tolvaptan (samsca)demeclocycline (declomycin)furosemide (lasix)conivaptan (vaprisol)spironolactone (aldactone)
Tolvaptan (samsca)conivaptan (vaprisol)
Which statement about pheochromocytoma is correct
it is a catecholamine producing tumor
A patient in the emergency department is diagnosed with possible pheochromocytoma. What is the priority nursing intervention for this patient
monitor blood pressure for severe hypertension
the nurse expects to perform which diagnostic test for pheochromocytoma
24 hour urine collection for vanillylmandelic acid (VMA)
Which intervention applies to a patine with pheochromocytoma
instruct not to smoke or drink coffee
which intervention is contraindicated for a patient with pheochromocytoma
palpating the abdomen
which diuretic is ordered by the health care provider to treat hyperaldosteronism
spironolactone ( aldactone)
which statement about hyperaldosteronism is correct
hypokalemia and hypertension are the main issues
when diagnosed with cushing syndrome the manifestations are most likely related to an excess production of which hormone
cortisol from the adrenal cortex
what is the most common cause of endogenous hypercortisolism or cushing syndrome
hyperplasia of the adrenal cortex
Which are the physical findings of cushing’s syndrome? (select all that apply)moon faced appearancedecreased amount of body hairbarrel chesttruncal obesitycoarse facial featuresthin easily damaged skinexcessive sweatingextremity muscle wasting
moon faced appearancetruncal obesitythin easily damaged skinextremity muscle wasting
When assessing a patient with cushing’s syndrome, what does the nurse expect to find
hypertension
which lab findings does the nurse expect to find with cushing’s syndrome (select all that apply)decreased serum sodiumincreased serum glucoseincreased serum sodiumincreased serum potassiumdecreased serum potassium
increased serum glucoseincreased serum sodiumdecreased serum potassium
the nurse determines a priority patient problem of altered self concept in a female patient with cushion’s syndrome who expresses concern about the changes in her general appearance. What is the expected outcome for this patient
to verbalize an understanding that treatment will reverse many of the problems
Mitotane (lysodren)
adrenal vytotoxic agent used for inoperable adrenal tumors
aminoglutethimide (cytadren)
adrenal enzyme inhibitor that decreases cortisol production
cyproheptadine (periactin)
interferes with ACTH production
a patient is scheduled for bilateral adrenalectomy. Before surgery, steroids are to be given. Which is the reasoning behind the administration of this drug
to compensate for sudden lack of adrenal hormones following surgery
The nurse is teaching a patient being discharged after bilateral adrenalectomy. What medication information does the nurse emphasize in the teaching plan
the patient should learn how to give himself an intramuscular injection of hydrocortisone
which statement about a patient with hyperaldosteronism after a successful unilateral adrenalectomy is correct
glucocorticoid replacement therapy is temporary
which are causes for decreased production of adrenocortical steroids (select all that apply) inadequate secretion of ACTHDysfunction of hypothalamic pituitary control mechanismadrenal gland dysfuctioncancerAIDS
inadequate secretion of ACTHDysfunction of hypothalamic pituitary control mechanismadrenal gland dysfuctioncancerAIDS
which patient is at risk for developing secondary adrenal insufficiency
patient who suddenly stops taking high dose steroid therapy
An ACTH stimulation test is the most definitive test for which disorder
adrenal insufficiency
which interventions are necessary for a patient with acute adrenal insufficiency ( addisonian crisis) (select all that apply)IV infusion of normal salineIV infusion of 3% salinehourly glucose monitoringinsulin administrationIV potassium therapy
IV infusion of normal salinehourly glucose monitoringinsulin administration
a patient in the ER who reports lethargy, muscle weakness, nausea, vomiting , and weight loss over the past weeks is diagnosed with addisonian crisis (acute adrenal insufficiency) which drugs does the nurse expect to administer to this patient
solu-coref IV along with IM injections of hydrocortisone
The nurse determines that the administration of hydrocortisone for Addisonian crisis is effective when which assessment is made
lethargy improving; patient alert and oriented
which nursing intervention is a preventive measure for adrenocortical insufficiency
reducing high dose glucocorticoid doses gradually
The nurse should instruct a patient who is taking hydrocortisone to report which symptoms to the health care provider for possible dose adjustment (select all that apply)rapid weight gainround facefluid retentionGI irritationUrinary incontinence
rapid weight gainround facefluid retention
The nurse determines that the patient in acute adrenal insufficiency is responding favorably to treatment when
the patient appears alert and oriented
when assessing a patient who is returned to the surgical unit following a thyroidectomy. the nurse would be most concerned if the patient
makes harsh, vibratory sounds when she breathes
an IV hydrocortisone treatment is started for a patient being taken to surgery for a bilateral adrenalectomy. The nurse explains to the patient that this is done to
provide substances to respond to stress after removal of the adrenal glands
a priority nursing intervention for a patient with primary adrenal cortex dysfunction would be to
monitor vital signs and the patients physiologic response to stress
signs and symptoms of hyperthyroidism
weight loss with increased appetiteincreased HR, palpitationsphotophobiamanic behaviordyspnea with or without exertioninsomniaincreased stoolscorneal ulcersirritabilityfine, soft, silky, body hairincreased libidoheat intolerance, warm skindiaphoresistremors
signs and symptoms of hypothyroidism
constipationdecreased libidocold intolerancefatigue, increased sleepingimpaired memoryfacial puffinessweight gaindry, coarse, brittle hair
which assessment finding should trigger a more detailed assessment of the patients endocrine system
changes in hair texture and distribution
which is a possible outcome for a patient experiencing an age related decrease in antidiurectic hormone
diluted urine and dehydration
a patient diagnosed with small cell lung cancer might present with endocrine symptoms consistent with
syndrome of inappropriate antidiurectic hormone (SIADH)
what is a priority question to ask a patient with a hypopituitary tumor
have you noticed a change in your libidohave you experienced a change in growth with your facial hair have you had an unexpected weight loss
which patient with cushing’s disease is at greatest risk for developing heart failure
42 year old with a serum creatinine level of 3.7 mg/dl
which factor is a hallmark assessment finding that signifies hyperthyroidism
heat intolerance
which factor is a main assessment finding that signifies hypothyroidism
cold intolerance
which sign/symptom is one of the first indicators of hyperthyroidism that is often noticed by the patient
vision changes or tiring of the eyes
which laboratory result is consistent with a diagnosis of hyperthyroidism
increased serum T3 and T4
the lab results for a 53 year old patient indicate a low T3 level and elevated TSH. What do these results indicate
hypothyroidism
the clinical manifestations of hyperthyroidism are known as which condition
thyrotoxiocosis
what is the most common cause of hyperthyroidism
grave’s disease
the nurse assessing a patient palpates enlargement of the thyroid gland, along with noticeable swelling of the neck. How does the nurse interpret the finding
Goiter
The nurse is assessing a patient diagnosed with hyperthyroidism and observes dry, waxy swelling of the front surfaces of the lower legs. How does the nurse interpret this finding
pretibial myxedema
which statement best describes globe lag in a patient with hyperthyroidism
upper eyelid pulls back faster than the eyeball when the patient gazes upward
the nurse is assessing a patient with graves disease and observes an abnormal protrusion of both eyeballs. how does the nurse document this assessment finding
exophthalmos
which statements about hyperthyroidism are accurate (select all that apply)it is most commonly caused by Grave’s diseaseit can be caused by overuse of thyroid replacement medicationit occurs more often in men between the ages of 20-40weight gain is a common manifestationserum T3 and T4 results will be elevated
it is most commonly caused by Grave’s diseaseit can be caused by overuse of thyroid replacement medicationserum T3 and T4 results will be elevated
the nurse is providing instructions to a patient taking levothyroixine (synthroid). When does the nurse tell the patient to take this medication
on an empty stomach
the nurse is providing instructions to a patient who is taking the antithyroid med propylthiouracil (PTU). The nurse instructs the patient to notify the health care provider immediately if which s/s occurs
dark colored urine
a patent who has been diagnosed with Graves disease is going to receive radioactive iodine (RAI) in the oral for of 131I. What does the nurse teach the patient about how this drug works
it destroys the tissue that produces thyroid hormones
A patient who has been diagnosed with Graves disease is to receive radioactive iodine (RAI) in the oral form of 131 I as treatment. What instructions does the nurse include in the teaching plan about preventing radiation exposure to others (select all that apply)do not share a toilet with others for 2 week after treatmentflush the toilet threw times after each usewash clothing separately from others in the householdlimit contact with pregnant women infants and childrendo not use a laxative within 2 weeks of having the treatment
do not share a toilet with others for 2 week after treatmentflush the toilet threw times after each usewash clothing separately from others in the householdlimit contact with pregnant women infants and children
which statements about hyperthyroidism are accurate (select all that apply)it occurs more often in womenit can be caused by iodine deficiencyweight loss is a common manifestationit can be caused by autoimmune thyroid destructionmyxedema coma is a rare but serious complication
it occurs more often in womenit can be caused by iodine deficiencyit can be caused by autoimmune thyroid destructionmyxedema coma is a rare but serious complication
the nurse is assessing a patient with a diagnosis of hashimoto’s disease. what are the primary manifestations of this disease (select all that apply)dysphagiapainless enlargement of the thyroid glandpainful enlargement of the thyroid glandweight lossintolerance to heat
dysphagiapainless enlargement of the thyroid gland
lab findings of elevated T3 and T4 decrease TSH and high thyrotropin receptor antibody titer indicate which condition
graves disease
uncommon; usually occurs with large follicular carcinomas
thyroid carcinoma
T3 and T4 secretion increased before destruction of gland. hyperthyroid state usually transient
thyroiditis (radiation induced)
autoimmune disease antibodies bind to TSH receptors and rep them activated increasing the size of the gland and increasing the production of thyroid hormones
graves disease
multiple thyroid nodules resulting in thryoid hyperfunction
toxic multinodular goiter
pituitary adenoma resulting in excessive TSH secretion
pituitary hyperthyroidism
after a visit to the heath care providers office a patient is diagnosed with general thyroid enlargement and elevated thyroid hormone level. This is an indication of which condition
hyperthyroidism and goiter
which condition is a life threatening emergency and serious complication of untreated or poorly treated hypothyroidism
myxedema com
a patient with exophthalmose from hyperthyroidism reports dry eyes especially in the morning. The nurse teaches the patient to perform which intervention to help correct this problem
tape the eyes closed with nonallergenic tape
which factors are considered to be triggers for thyroid storm (select all that apply)infectioncold tempsvigorous palpation of a goiterpregnancyextremely warm temps
infectionvigorous palpation of a goiterpregnancy
a patient has the following assessment findings; elevated TSH level , low T3 and T4 level difficulty with memory, lethargy, and muscle stiffness. These are clinical manifestations of which disorder
hypothyroidism
a patient has been prescribed thyroid hormone for treatment of hypothyroidism . Within what time frame does the patient expect improvement in mental awareness with this treatment
2 weeks
which signs and symptoms are assessment findings indicative of thyroid storm (select all that apply)abdominal pain and nauseahypothermiafevertachycardiaelevated systolic blood pressure bradycardia
abdominal pain and nauseafevertachycardiaelevated systolic blood pressure
management of the patient with hyperthyroidism focuses on which goals (select all that apply)blocking the effects of excessive thyroid secretiontreating the s/s the patient experiencesestablishing euthyroid functionpreventing spread of the diseasemaintaining an environment of reduced stimulation
blocking the effects of excessive thyroid secretiontreating the s/s the patient experiencesestablishing euthyroid functionmaintaining an environment of reduced stimulation
which are preoperative instructions for a patient having thyroid surgery (select all that apply)teach postop restrictions such as no coughing and deep breathing exercises to prevent strain on the suture lineteach the moving and turning technique of manually supporting the head and avoiding neck extension to minimize strain on the suture lineinform the patient that hoarseness for a few days after surgery is usually the result of a breathing tube used during surgeryhumidification of air may be helpful to promote expectoration of secretions. suctioning may also be usedclarify any questions regarding placement of incision complications and post op carea supine position and lying flat will be maintained post op to avoid strain on the suture lineteach the patient to report immediately any respiratory difficulty tingling around the lips or fingers, or muscular twitchinga drain may be present in the incision. all drainage and dressings will be monitored closely for 24 hours
teach the moving and turning technique of manually supporting the head and avoiding neck extension to minimize strain on the suture lineinform the patient that hoarseness for a few days after surgery is usually the result of a breathing tube used during surgeryhumidification of air may be helpful to promote expectoration of secretions. suctioning may also be usedclarify any questions regarding placement of incision complications and post op careteach the patient to report immediately any respiratory difficulty tingling around the lips or fingers, or muscular twitchinga drain may be present in the incision. all drainage and dressings will be monitored closely for 24 hours
the nurse is preparing for a patient to return from thyroid surgery. What priority equipment does the nurse ensure immediately available? (select all that apply)tracheostomy equipmentcalcium gluconate or calcium chloride for IV administrationhumidified oxygensuction equipmentsandbags
tracheostomy equipmentcalcium gluconate or calcium chloride for IV administrationhumidified oxygensuction equipmentsandbags
after a thyroidectomy, a patient reports tingling around the mouth and muscle twitching. Which complication do these assessment findings indicate to the nurse
hypocalcemia
the nurse assesses a patient post thyroidectomy for laryngeal nerve damage. which findings indicate this complication (select all that apply)dyspneasore throathoarsenessweak voicedry cough
hoarsenessweak voice
after hospitalization for myxedema a patient is prescribed thyroid replacement medication. which statement by the patient demonstrates a caret understanding of this therapy?
Ill be taking thyroid medication for the rest of my life
which statements about thyroiditis are accurate (select all that apply)it is an inflammation of the thyroid glandHashimoto’s disease is the most common typeit always resolves with antibiotic therapythere are three types: acute, subacute, and chronicthe patient must take thyroid hormones
it is an inflammation of the thyroid glandHashimoto’s disease is the most common typethere are three types: acute, subacute, and chronicthe patient must take thyroid hormones
which statements about acute thyroiditis are accurate (select all that apply)it is caused by a bacterial infection of the thyroid glandit is treated with antibiotic therapyit results from a viral infection of the thyroid glandsubtotal thyroidectomy is a form of treatment manifestations include neck tenderness fever and dysphagia
it is caused by a bacterial infection of the thyroid glandit is treated with antibiotic therapymanifestations include neck tenderness fever and dysphagia
serum calcium levels are maintained by which hormone
parathryroid hormone (PTH)
PTH production
raises calcium levels
calcitonin production
lowers calcium levels
Bone changes in the older adult are often seen with endocrine dysfunction and increased secretion of which substance
PTH
In addition to regulation of calcium levels PTH and calcitonin regulate the circulating blood levels of which substance
phosphate
a patient has a positive Trousseau’s or Chvosteks sign resulting from Hypoparathyroidism. What condition does this assessment finding indicate
hypophosphatemia
which food does the nurse instruct a patient with hypoparathyroidism to avoid
fresh fruit
a patient with continuous spasms of the muscles is diagnosed with hypoparathyroidism . The muscle spasms are a clinical manifestation of which condition
tetany
causes of hypoparathyroidism
removal of the thyroid gland parathyroidectomy
causes of hyperparathyroidism
chronic kidney diseasevitamin D deficiencyneck traumacarcinoma of the lung kidney or GI tract producing PTH like substance
a patient has hyperparathyroidism and high levels of serum calcium. Which initial treatment does the nurse prepare to administer to the patient
force fluids (intravenous or oral) and administer lasix
which are assessment findings of hypocalcemia (select all that apply)numbness and tingling around the mouthmuscle crampingmental status changes including irritability fever tachycardia
numbness and tingling around the mouthmuscle crampingmental status changes including irritability
which medication therapies does the nurse expect patient with hypoparathyroidism to receive (select all that apply)calcium chloridecalcium gluconatecalcitrolmagnesium sulfateergocalciferol
calcium chloridecalcium gluconatecalcitrolmagnesium sulfateergocalciferol
discharge planning for a patient with chronic hypoparathyroidism include which instructions (select all that apply)prescribed medications must be taken for the patient’s entire lifeeat foods low in vitamin D and high inphophoruseat foods high in calcium but low in phosphorusafter several weeks, medications can be discontinuedkidney stones are no longer a risk to the patient
prescribed medications must be taken for the patient’s entire lifeeat foods high in calcium but low in phosphorus
in older adults assessment findings of fatigue altered thought processes, dry skin and constipation are often mistaken for signs of aging rather than assessment findings for which endocrine disorder
hypothyroidism
which conditions may precipitate myexedema coma (select all that apply)rapid withdrawal of thyroid medicationvitamin D deficiencyuntreated hypothyroidismsurgeryexcessive exosure to iodine
rapid withdrawal of thyroid medicationuntreated hypothyroidismsurgery
interpersonal or domestic violence
a pattern of coercive behavior in which one person attempts to control another through threats or actual use of physical violence, sexual assault and/or verbal and psychological abuse.
what is one of the most common causes of injury to women
battering
what has changed over the years as far as domestic violence
Increased awareness, ability to obtain help, and more readily available information have helped in raising the rate of reporting.Increasing incidence of men reporting victimization at the hands of women.
effects of family violence
•It isolates the person being abused and robs inner strength, self-worth and the ability to make personal choices. Often people experiencing abuse begin to feel responsible for the abuse.••It traumatizes children, destroying their ability to feel safe in the world and causing them to feel responsible for the abuse.
effect on children with domestic violence
–Development adversely affectedEnergy needed to accomplish developmental tasks successfully goesto coping with family violence
effect on adolescents domestic violence
–Poorer coping and social skills–Higher incidence of dissociativeidentity disorder–Poorer impulse control
secondary effects of violence
•Anxiety•Depression•Suicidal ideation
Types of maltreatment
•Physical violence: infliction of physical pain or bodily harm•Sexual violence: any form of sexual contact or exposure without consent•Emotional violence: infliction of mental anguish; threatening, humiliating, intimidating, isolating behavior•Physical neglect: failure to provide medical, dental, or psychiatric care as needed•Developmental neglect: failure to provide nurturing and stimulation needed to ensure meeting developmental milestones•Educational neglect: depriving a child of an education•Economic maltreatment: illegal or improper exploitation of funds or other resources for own person gain or withholding of support
actual occurence of violence requires
1.Perpetrator2.Vulnerable person3.Crisis situation
characteristic of perpetrator
•Their needs are more important than the needs of others•Extreme pathological jealousy•May control family finances•Likely to abuse alcohol or drugs•Poor social skills, relationship with partner enmeshed and codependent
characteristics of vunerable person (partner)
•Legal marriage or pregnancy may initiate or increase violence•Greatest risk for violence when partner attempts to leave relationship
characteristics of a vunerable person (child)
•Younger than 3 years•Perceived as different•Product of an unwanted pregnancy•Premature•Prolonged illness
characteristics of a vulnerable person (elderly)
•Poor mental or physical health•Dependent on perpetrator•Female, older than 75 years, white, living with a relative•Daughter is caring for elderly father who abused her when she was a child•Elderly woman cared for by husband who has abused her in the past
what is a crisis situation
•Situation that puts stress on a family with a violent member
cycle of violence
•Process of escalation/de-escalationTension-building stageAttempts to reduce tension by both partnersAcute battering stageHoneymoon stageTension builds and cycle continues
phase I (tension building phase)
•Abuser:–Demonstrates increased tension by lashing out at victim/minor battering–Has increased fear of abandonment, jealousy, possessiveness–Interprets victim’s withdrawal as rejection -> more angerVictim: Becomes nurturing & compliant to prevent escalation Often accepts abuse as legitimate Denies own anger/rationalizes abuser’s behavior Increased battering -> decreased ability to cope -> withdrawal
phase II (acute battering incident)
•Abuser:–Justifies behavior to self – wants to “just teach a lesson” -> severe battering–Cannot understand what happened, doesn’t know how control was lost–Often minimizes severity of batteringVictim: May intentionally provoke abuser’s behavior because tension of Phase I has become unbearable Knows from experience that once acute phase is over things will be better Beating is severe & victim can often describe violence in detail, dissociating self from own body Help is sought if severe injury, victim fears for own life or severe injury/death to children
PHASE III: Calm, Loving, Respite (Honeymoon)
•Abuser:–Loving, kind, contrite–Promises to never repeat behavior–Begs forgiveness, fears losing victim so attempts to charm–Believes can control behavior & now that “lesson has been taught”, victim will not “act up” again–Plays on victim’s feelings of guilt for having “provoked” the incidentVictim: Desperately wants to believe abuse won’t happen again Relives dream of “ideal” love & chooses to believe that the “ideal” is really what is shared with abuser This loving phase becomes victim’s perception of relationship Victim bases staying in the relationship on this “magical” ideal phase.
Which rationale best explains why a nurse needs to be aware of feelings while working with a family experiencing family violence?a.Self-awareness protects one’s own mental health.b.Strong negative feelings interfere with assessment and judgment.c.Strong positive feelings lead to underinvolvement with the victim.d.Positive feelings promote the development of sympathy for patients.
b.Strong negative feelings interfere with assessment and judgment.
A person at the emergency department reports severe headaches. The individual isaccompanied by a spouse who insists on staying in the room during the examination and answering all questions. The patient avoids eye contact, has a sad affect, and has slumped shoulders. A concussion is diagnosed. Assessment of which additional problem haspriority?a.Risk of domestic abuseb.Phobia of crowded placesc.Major depressiond.Migraine headaches
a.Risk of domestic abuse
A married individual has recently been absent from work for 3-day periods on several occasions. Each time, the individual returned to work wearing dark glasses. Facial and body bruises were apparent. The assessment priority when the occupational health nurse interviews the patient is:a.interpersonal relationships.b.work responsibilities.c.socialization skills.d.physical injuries.
d.physical injuries.
A patient has a history of physical violence against family when frustrated and then periods of remorse after each outburst. The plan of care would be considered successful when the patient:a.expresses frustration verbally instead of physically.b.agrees to seek counseling.c.explains the rationale for behaviors to the victim.d.identifies three personal strengths.
a.expresses frustration verbally instead of physically.
A woman was grabbed by a man as she walked home from work. The attacker put a gun to her head, taped her mouth, tied her hands, took her to a remote location, and raped her. When she was found she was taken to the emergency department, where she received care. Which aspect of this crisis produced the greatest amount of psychological trauma?a.The threat to her lifeb.The memory of the eventc.The physical pain experiencedd.The collection of evidence
a.The threat to her life
A patient was abducted and raped at gunpoint by an unknown assailant. Which assessment finding best indicates the patient is in the acute phase of the Rape-trauma syndrome?a.Confusion and disbeliefb.Flashbacks and dreamsc.Decreased motor activityd.Fears and phobias
a.Confusion and disbelief
When an emergency department nurse teaches a victim of Rape-trauma syndrome about reactions that may be experienced during the long-term phase, which symptoms should be included? (More than one answer is correct.)a.Flashbacks, dreamsb.Decreased motor activityc.Development of fears and phobiasd.Feelings of numbnesse.Syncopal episodes
a.Flashbacks, dreamsc.Development of fears and phobiasd.Feelings of numbness
The nervous system consists of
Central nervous system Peripheral nervous system Autonomic nervous system
The neuron is
the structural and functional unit of the nervous system. Neurons initiate and transmit impulses to other neurons.
The neuron’s function
Composed of an axon and one or more dendrites. Axon transmits impulses away from the cell body to dendrites of other neurons or directly to the cell bodies of other neurons. Dendrites receive impulses and conduct them toward the nerve cell body.
Neuron’s have both a
sensory and motor components
synapse
is the junction between neurons where an impulse is transmitted.
axon
long branch, transmits impulses
dendrites
receive impulses from other neurons
synapse
bridge between the axon and dendrites
neurotransmitters
are chemical agents involved in transmission of the impulse across the synapse.you need these in order for the impulses to go over the bridge.
Myelin Sheath
sheath is a wrapping of a fatty material that protects and insulates the nerve fibers and enhances the speed of impulse conduction.
Afferent Neuron
sensory neuron that transmits impulses from the peripheral receptors to the Central Nervous System (CNS).
Efferent Neuron
is a motor neuron that conducts impulses from the CNS to the muscles and glands.
Myelin Sheath
acts like a wire. has the copper on the inside and a rubber coating that protects it. When that plastic coating breakdown, the wire doesn’t work. Same things happen to a myelin sheath. Sometimes if its not a lot of damage, it can repair itself, but if there is too much damage, then it will bot be able to be repaired.
internuncial neurons
( interneurons) are connecting links between afferent and efferent neurons.
central nervous system is composed of
brain and spinal cord
the brain is composed of
cerebrum, corpus callosum, basal ganglia, Diencephalon, brainstem, cerebellum
how do neurons work
the afferent neuron reports to the brain that there is something wrong. The brain then reports to the efferent neuron to physically change the situation. i.e. if your hand is on a hot stove, the afferent neuron reports this to the brain and then the brain tells the efferent neuron to remove your hand.
internuncial neurons
the links between the afferent and efferent neurons
cerebrum
outermost area is the cortex Has two hemispheres Each hemisphere is divided into four lobes ( frontal, Parietal, Temporal and Occipital )
corpus callosum
large fiber tract that connects the two hemispheres
basal ganglia
islands of gray matter within white matter of cerebrum that regulate and integrate motor activity originating in the cerebal cortex. Part of the extrapyramidal system.
diencephalon
the connecting part of the brain between the cerebrum and the brain stem. It contains the: a. Thalamus b. Hypothalamus
brainstem
contains midbrain, pons and medulla oblongatarespiratory, vasomotor, and cardiac type functions
cerebellum
coordinates muscle tone and movements and maintains equilibriumissues in cerebellum causes ataxia, unsteady gait, surroundings.
frontal lobe
motor function, intellectual function, personality, injury to this lobe changes a person’s personality . Broca’s area is located in the frontal lobe. This is the motorized speech area. Allows us to speak and say what we want to say, be able to communicate. If there is a lesion on the frontal lobe, it causes aphasia and issues with expression through speech.
parietal lobe
sensory stimulation, sensation, touch, pressure, takes info coming in and makes sense of it .
temporal lobe
sensory stimulation, hearing, auditory, receptive, it contains wernicke’s area. This is the sensory speech area. Helps us to understand what someone is saying to us and what is written. If someone has a lesion on wernicke’s area, it causes issues with reception of what we say to them. It’s like we are speaking gibberish.
Occipital Lobe
everything associated with vision. this is where basal ganglia is located. These regulate motor activity that originates in the cerebral cortex. Parkinson’s is caused from this area
spinal cord
Serves as a connecting link between the brain and the peripheryExtends from foramen magnum to the second lumbar vertebra.Ascending tracts are sensory pathwaysDescending tracts are motor pathways
cerebrospinal fluid
Surrounds brain and spinal cordOffers protection by functioning as a shock absorberAllows fluid shifts from the cranial cavity to the spinal cavityCarries nutrients to and from the nerve cellstoo much CSF causes ICP, hydrocephaluscertain things cause CSF leakage. Its very clear color. It is very high in glucose when tested.
what is distinct of CSF
The center is clear and the rest is like a yellow halo coming out around it. you can see this if you catch it on a gauze pad
vascular supply of the CNS
Two internal carotid arteries anteriorlyTwo vertebral arteries leading to basilar artery posteriorlyThese arteries communicate at the base of the brain through the Circle of WillisAnterior, Middle and Posterior cerebral arteries are the main arteries for distributing blood to each hemisphere of the brainBrainstem and Cerebellum are supplied by branches of the vertebral and basilar arteriesVenous blood drains into dural sinuses then into internal jugular veins
peripheral nervous system
Spinal Nerves- 31 pairs carry impulses to and from the spinal cord. Each nerve is attached to spinal cord by two roots:
two roots of the peripheral nervous system are
dorsal posterior root, and the ventral anterior root
Dorsal posterior root
contains afferent sensory nerves
ventral anterior root
contains efferent motor nerve fibers
cranial nerves
12 pairs that carry impulses to and from the brain. Have sensory, motor or mixed functions.
The 12 cranial nerves
I Olfactory: Sensory-carries impulses for sense of smellII Optic: Sensory-carries impulses for visionIII Oculomotor: Motor-muscles for pupillary constriction, elevation of upper eyelid; 4 out of 6 extraocular movementsIV Trochlear: Motor-muscles for downward, inward movement of the eyeV Trigeminal: Mixed-impulses from face, surface of eyes (corneal reflex); muscles controlling masticationVI Abducens: Motor- muscles for lateral deviation of eyeVII Facial: Mixed- impulses for taste from anterior tongue; muscles for facial movementVIII Acoustic: Sensory-impulses for hearing (cochlear division) and balance (vestibular division)IX Glossopharyngeal: Mixed-impulse for sensation to posterior tongue and pharynx ; muscles for movement of soft pharynx (elevation) and swallowing X Vagus: Mixed- impulses for sensation to lower pharynx and larynx; muscles for movement of soft palate, pharynx, and larynx XI Spinal accessory: Motor-movement of sternomastoid muscles and upper trapezius muscles XII Hypoglossal: Motor-movement of tongue
autonomic nervous system
Part of peripheral nervous systemIncludes those peripheral nerves (both cranial and spinal) that regulate functions occurring automatically in the bodyRegulates smooth muscle, cardiac muscle, and glands.Components: Sympathetic and Parasympathetic
neurological exam
Mental Status Exam (Cerebral Function) Appearance and behavior Level of Consciousness Intellectual Function Emotional Status Thought Content Language and SpeechCranial NervesCerebellar FunctionMotor FunctionsSensory FunctionsReflexes
five point level of consciousness scale
1 Alert: Normal mental activity, aware, mentally functional2 Obtunded/Drowsy: Sleepy, very short attention span, can respond appropriately if aroused3 Stupor: Apathetic, slow moving, blank expression, staring, aroused only by vigorous stimuli4 Light coma: Not oriented to time, place or person. Aroused only by painful stimuli- response is only a grunt or grimace or withdrawal from pain5 Deep Coma: No response except decerebrate or decorticate posture
decerebrate posturing
Decerebrate posture is an abnormal body posture that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backwards. The muscles are tightened and held rigidly. This type of posturing usually means there has been severe damage to the brain.
decorticate posturing
Decorticate posture is an abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held out straight. The arms are bent in toward the body and the wrists and fingers are bent and held on the chest.This type of posturing is a sign of severe damage in the brain. People who have this condition should get medical attention right away.
pupil reaction and eye movement
Observe size, shape and equality of pupils (note size in millimeters)Test reaction to light—pupillary constrictionCorneal ReflexOculocephalic Reflex
motor function
Test movement of extremitiesTest muscle strength MOTOR SCALE5/5 moves against gravity and resistance4/5 moves against moderate resistance3/5 moves against gravity only2/5 moves but not against gravity1/5 muscle contracts-no movement0/5 no visible or palpable movement
parasympathetic nervous system
acetocholine
sympathetic nervous system
norepinephrine
abnormal respiratory movements
Cheyne-StokesCentral Neurogenic HyperventilationApneustic BreathingCluster BreathingAtaxic BreathingGasping BreathingDepressed Breathing
first assessment in neuro
patient answering questions appropriately, or are they way off
Second assessment in neuro
does there body language and facial expressions congruent with what they are saying
third assessment neuro
hows there speech clear slurred, normal rate and rhythm
fourth assessment neuro
do they answer you completely
fifth assessment neuro
how is there appearance, are they neat and dressed appropriately for the weather, for their age
sixth assessment neuro
how do they interact, are they angry, hostile, euphoric, do they answer you and treat you appropriately
neuro health history, presenting problem
Behavior changes, memory loss, mood changes, nervousness or anxiety, Headache, seizures, syncope, vertigo, Loss of consciousness, speech problems Vision, smell or motor problems, sensory problems
diagnostic procedures for neuro
Xrays Computed Tomographic Scan (CT scan) Positron Emission Tomographic Scan (Pet scan) Magnetic Resonance Imaging (MRI) Carotid Doppler Studies Cerebral Angiography Myelogram Lumbar Puncture
Increased Intracranial Pressure Pathophysiology
Increase in brain tissue, vascular tissue, and cerebral spinal fluid volume can cause an increase in pressure within the cranial cavityIncrease ICP can be caused by tumors, abscesses, hemorrage, edema, hydrocephalus, inflammationUntreated can lead to displacement of brain tissue (herniation)
sixth assessment of neuro
is the patient hallucinating, or seeing things
Compensatory Mechanisms with Increased ICP
Cerebral blood flow decreases causing inadequate tissue perfusion.Leads to increased PCO2 and decreased PO2Triggers vasodilation and more cerebral edemaCan lead to herniation and death
assessment findings of ICP
Change in level of consciousnessChanges in vital signs - widening pulse pressure - pulse bounding and slows - abnormal respiratory patterns - Elevated temperaturePupillary changesMotor/Sensory abnormalitiesHeadache, projectile vomiting, hiccuping, papilledema
medical management of ICP
Goals: Treat cause, control seizures and other complicationsMaintain fluid and electrolyte balanceSurgical intervention if neededCorticosteroidsOsmotic diuretics, systemic diureticsFluid restrictionBarbituates, analgesicsAirway management
nursing care for ICP
Maintain patent airway and adequate ventilationMonitor vital signs and neuro checksMaintain fluid balanceProper positioningPrevent further increases in ICPMonitor I&O carefullyPrevent complications of immobilityGive medications as orderedAssist with ICP monitoringCare of patient with hyperthermia
