neurve

Question 1

Level of consciousness (A& – A vs , oriented vs confused )
Restlessness
Dizziness
Vision changes
Pupil changes
Vital signs
Pain
Peripheral oxygen saturation (S p O2)
Paresthesias
Weakness
Paralysis
Seizures
Respiratory status
Swallowing

Answer 1

Aneurysm

Question 2

Risk for Ineffective Cerebral Tissue Perfusion
Ineffective Airway Clearance
Risk for Injury
Impaired Physical Mobility
Imbalanced Nutrition
Disturbed Sensory Perception
Risk for Impaired Skin Integrity
Incontinence (Bowel or Overflow Urinary or Functional Urinary)
Self-Care Deficit (Bathing, Dressing, Feeding, Toileting)
Impaired Verbal Communication
Acute or Chronic Confusion
Risk for Falls
Deficient Knowledge
Risk for Caregiver Role Strain

Answer 2

Aneurysm

Question 4

Risk for Ineffective Cerebral Tissue Perfusion

Answer 4

Monitor
Neurological status
Vital signs
S p O 2
Blood glucose
Coagulation studies
Medication effects
Report changes.
Keep head of bed up 20 to 30 degrees.
Monitor medication effects.

Question 5

Ineffective Airway Clearance

Answer 5

Monitor lung sounds, cough, respirations.
Position to maintain open airway.
Encourage to cough and deep breathe.
Suction as needed.
Monitor sounds on ventilator
resporotologist

Question 6

Risk for Injury

Answer 6

Monitor neurological status and report changes.
Monitor for hemorrhage.
Administer anticonvulsant as ordered.
Implement seizure precautions.
Assist with transfers and ambulation.
Rigidity
Within reach/lowest position
Call for help
Sitter
Antislipary
Anticipate the pt’s needs

Question 7

Impaired Physical Mobility

Answer 7

Refer to physical therapy, occupational therapy.
Consider constraint therapy.
Maintain good body alignment.
Perform range-of-motion exercises.
Mobilize: Chair or ambulate.
Turn every 2 hours.

Question 8

Imbalanced Nutrition

Answer 8

Keep nothing by mouth (N P O) until swallowing evaluated.
Perform dysphagia screen.
Try sips of water.
Request speech therapist swallowing evaluation.
Implement aspiration precautions.
Consider tube feeding if necessary.

Question 9

Disturbed Sensory Perception

Answer 9

Assess for sensory deficits – no cold/heat treatment.
Teach patient to scan environment
Protect skin – clean and dry.

Question 10

Risk for Impaired Skin Integrity

Answer 10

Monitor skin for breakdown.
Keep perineal area clean and dry.
Use barrier cream as needed.
Turn patient every 2 hours.
Use lift sheet to reposition.
Consider pressure-reducing mattress.

Question 11

Incontinence

Answer 11

Monitor for incontinence.
Determine usual elimination patterns.
Provide assistance with toileting schedule.
Respond quickly to requests for help.
Water intake – the more concentrated, the more burning

Question 12

Self-Care Deficit

Answer 12

Assess ability to perform activities of daily living.
Encourage independence.
Place objects in reach.
Provide assistive devices.
Assist to learn use of nondominant side.
Involve and educate family.

Question 13

Impaired Verbal Communication

Answer 13

Assess verbal ability.
Consult speech pathologist.
Answer call light in person.
Listen patiently.
Provide communication aids.
Keep communication appropriate.
Don’t assume patient does not understand.

Question 14

Acute or Chronic Confusion

Answer 14

Monitor changes in thought processes.
Place calendars, and clocks in environment.
Reduce stressors.
Maintain patient’s usual routines.
Communicate slowly and clearly.
Involve family.

Question 15

Risk for Falls

Answer 15

Perform fall risk assessment.
Instruct to ask for help to get up.
Keep call light within reach.
Provide frequent toileting.
Avoid restraints.

Question 16

Deficient Knowledge

Answer 16

Explain what happened to patient.
Explain tests and procedures.
Orient patient and family to setting.
Provide instruction for care at home.
Evaluate need for home nursing.

Question 17

Risk for Caregiver Role Strain

Answer 17

Assess impact of patient’s needs on caregiver.
Assist caregiver to identify resources.
Consult social worker or case manager.
Consider skilled nursing facility as needed.