Module 6 - Neuro Flashcards
While caring for a client with a closed head injury, the nurse assesses the client to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102°F. To reduce the risk of increased intracranial pressure (ICP) in this client, what is the priority?
Maintain neutral head alignment and avoid extreme hip flexion
Ensure adequate periods of rest between nursing interventions
Reduce ambient room temperature and administer antipyretics
Insert an oral airway and monitor respiratory rate and depth
Reduce ambient room temperature and administer antipyretics
A nurse is caring for a mechanically ventilated client with a sustained intracranial pressure (ICP) of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse?
Elevate the patient’s head of the bed 30 degrees
Apply bilateral heel protectors after repositioning
Provide rest periods between nursing interventions
Hyperoxygenate during endotracheal suctioning
Provide rest periods between nursing interventions
The nurse is caring for a client 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the client to be more lethargic than the previous hour with a blood pressure of 85/50 mm Hg, heart rate 110 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5°F. Which provider prescription should the nurse institute first?
Decadron 20 mg intravenous push every 4 hours
500 mL albumin infusion intravenously
Blood cultures (2 specimens) for temperature >101°F
Acetaminophen (Tylenol) 650 mg per rectum
500 mL albumin infusion intravenously
A nurse care for a client in the ED with a suspected cervical spine injury. What is the priority nursing action?
Prepare for immediate endotracheal intubation
Remove cervical collar upon arrival to the ED
Keep the neck in the hyperextended position
Maintain proper head and neck alignment
Maintain proper head and neck alignment
A nurse is caring for a client from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses: blood pressure 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse?
Notify the provider of the patient’s blood pressure
Assess for a kinked urinary catheter and assess for bowel impaction
Administer acetaminophen as ordered for the headache
Encourage the patient to take slow, deep breaths.
Assess for a kinked urinary catheter and assess for bowel impaction
A nurse is caring for a client with bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse?
Implement droplet precautions upon admission
Dispose of all bloody dressings in biohazard bags
Scrub the hub of all central line ports before use
Wash hands thoroughly before leaving the room
Implement droplet precautions upon admission
A nurse is caring for a client who has a diminished level of consciousness on mechanical ventilation. While performing endotracheal suctioning, the client reaches up in an attempt to grab the suction catheter. What is the best interpretation by the nurse?
The patient is exhibiting extension posturing
The patient is exhibiting purposeful movement
The patient is exhibiting flexion posturing
The patient is withdrawing to stimulation
The patient is exhibiting purposeful movement
A nurse assesses a client with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action?
Support bony prominences with padding
Increase supplemental oxygen delivery
Monitor the patient’s airway patency
Elevate the head of the client’s bed
MOnitor patients airway patency
A nurse is caring for a client who was hit on the head with a hammer. The client was unconscious at the scene briefly but is now conscious upon arrival at the emergency department with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority action of the nurse?
Notify the provider
Continue to monitor the client
Stimulate the client hourly
Lower the head of the bed
Notify the provider
A nurse is caring for a mechanically ventilated client admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a client with this type of injury?
pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg
You Answered
pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg
pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg
pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg
pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg
A client with a head injury has an intracranial pressure (ICP) of 18 mm Hg. The blood pressure is 144/90 mm Hg and mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)?
54 mm Hg
72 mm Hg
90 mm Hg
126 mm Hg
90 mm Hg
A nurse is caring for a client who sustained a closed head injury. After insertion of a ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which order should the nurse institute first?
Mannitol 1 g intravenous
Seizure precautions
Portable chest x-ray
Ancef 1 g intravenous
Mannitol 1 g intravenous
A nurse is caring for a client with a new onset of slurred speech and right-sided weakness. What is the priority nursing action?
Assess the patient’s general orientation
Determine the time of symptom onset
Determine the patient’s drug allergies
Assess for the presence of a headache
Determine the time
After receiving the handoff report from the day shift charge nurse, which client should the evening charge nurse assess first?
A client with meningitis complaining of photophobia
A mechanically ventilated client with a GCS of 6
A client with bacterial meningitis on droplet precautions
A client with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F
A client with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F
