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This activity contains 10 questions.
The nurse is planning the care for a client with a closed head injury. Which of the following would be appropriate to include in this client's plan of care?
Maintain client in the supine position.
Maintain blood pressure above normal.
Encourage anaerobic metabolism.
Encourage increase in cerebral blood flow.
Maintain HOB elevated to 30 degrees.
Maintain oxygen level below maximum.
A client admitted to the ICU for a drug overdose is demonstrating an increase in intracranial pressure. The nurse knows that this caused by:
Metabolic changes of the blood-brain barrier.
Decreased cardiac output.
Obstruction in the Circle of Willis.
A client in the ICU is demonstrating an increase in intracranial pressure. Which of the following could contribute to this assessment finding?
Tight oxygen face mask
HOB elevated to 30 degrees
Drop in blood pressure
Endotracheal tube ties tied tightly around the neck
Fluid volume deficit
A client in the ICU has a MAP of 90 mm Hg and an ICP reading of 85 mm Hg. The nurse interprets these figures to mean:
Cerebral perfusion pressure will be 175 mm Hg.
The client needs to be placed in the supine position.
The client's blood pressure is too low.
CPP is dropping.
Upon assessment of a client in the neuro ICU, the nurse finds that one pupil is greatly dilated while the other restricts to light. This finding could be an indication of:
The nurse is caring for a client with a brain tumor that is obstructing the flow of CSF. Nursing care will most likely be focused on:
Prepare for intubation because respiratory depression is pending.
Keep the client as comfortable as possible, as death is imminent.
Hyperoxygenate prior to suctioning.
Expect this client to have surgery or radiation to reduce the size of the brain tumor.
Explain to the client that the doctor might want to have a shunt placed to help reduce the amount of fluid building up in the brain.
Implement measures to maintain an above average blood pressure.
The nurse is preparing to assess a client's level of consciousness, particularly arousal. Which of the following assessment tools would be the most appropriate for the nurse to use?
Glasgow Coma Scale
A client is demonstrating signs of deteriorating brain function. Which of the following signs is the nurse likely to find upon assessment of this client?
Eyes open spontaneously without stimulation
Respiratory rate within normal limits
Eyes move as head turns
Eyes fixed in mid-position
Response to commands
A client with an intracranial pressure monitoring device is demonstrating a variety of wave patterns. The nurse reviews this tracing and determines that everything is within normal limits. Which type of wave pattern is this client most likely demonstrating?
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The nurse caring for clients with cranial disorders knows that nursing care needs to take into consideration the Monro-Kellie hypothesis. What are the percentages for each element of this hypothesis?
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