Week 5 THURS

Question 1

What is a priority nursing intervention for a pt who is unconscious?

Answer 1

maintain pt airway

Question 2

During an active seizure the nurse should?

Answer 2

place client on their side, remove dangerous objects, and protect their head

Question 3

What intervention should the nurse implement to prevent increases in ICP?

Answer 3

Elevate HOB 30 degrees

Question 4

What is the earliest sign of increased ICP?

Answer 4

Change in LOC

Question 5

A client is sitting in a chair and begins having a tonic-clonic seizure. What is the most appropriate nursing response?

Answer 5

• carefully move client to a flat surface and turn them on their side

Question 6

A client has an altered LOC due to blunt force trauma to the head. The nurse should first gauge the clients LOC on the result of what diagnostic tool?

Answer 6

Glasgow Coma Scale

Question 7

What score indicates severe impairment of neurologic function on the GCS?

Answer 7

3

Question 8

Assessing a clients pupils, what reaction would confirm increasing ICP?

Answer 8

• fixed and dilated
• unequal response