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Exam 7: Intracranial Regulation

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Question 1

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The nurse is caring for a client with a diagnosed closed head injury that requires intracranial pressure monitoring.Which signs/symptoms indicate that the client's intracranial pressure is rising? Select all that apply.

A) The nurse notes "Doll's eyes" when assessing the client's pupils.
B) The nurse documents eupnea in respect to respiratory effort.
C) The nurse finds that all extremities are flaccid.
D) The nurse notes that blood pressure is stable.
E) The nurse documents that the client is in a comatose state.

F) B) and E)
G) A) and C)

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Question 2

Multiple Choice

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The nurse is instructing a UAP in the technique of assisting a client to stay in the proper position for a lumbar puncture.The nurse will know that the UAP is doing it correctly if the UAP holds which parts of the client's body immediately before the procedure begins?

A) Behind the client's neck and knees
B) Behind the client's neck and feet
C) Under the client's arms and knees
D) Around the client's neck and behind the knees

E) A) and B)
F) None of the above

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Question 3

Multiple Choice

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While holding a 2-year-old child in a flexed position for a lumbar puncture,the nurse monitors which vital sign to detect any abnormality caused by the child's position?

The nurse notes that an elderly resident of a long-term care facility has fallen and the client is unable to say whether or not he hit his head.Which are the first signs that the nurse will note if this client has sustained a closed head injury? Select all that apply.

Prior to beginning to assist a healthcare provider with a lumbar puncture on an adult client,the nurse asks another nurse to also assist in the procedure for what reason?

The nurse is caring for an older adult client who has been diagnosed with a closed head injury.The healthcare provider decides to monitor the client's intracranial pressure (ICP) using an ICP transducer system.The nurse will place the client in which position to prevent compromise of the client's condition?

The nurse is caring for a client with a diagnosed head injury who has an ICP transducer system to monitor the client's intracranial pressure.Which sign on the ICP monitor indicates that the client's condition is worsening?

The nurse is completing a Glasgow Coma Scale reassessment of a client who fell down a flight of stairs 8 hours ago.On admission,the client displayed spontaneous eye opening.The nurse does not see this response at this time and knows to do which to know if the client responds at the next level of eye opening?

The charge nurse in a long-term care facility is called to assess an older adult client diagnosed with Alzheimer disease who has fallen and has a head laceration.The nurse is aware that the Glasgow Coma Scale is not an accurate tool to assess this client's level of consciousness because of which reason?

The intensive care unit nurse is preparing to assess the level of consciousness of a client who is intubated and has both hands restrained to prevent the client from pulling out the endotracheal tube.The client's injury occurred due to a stabbing incident that ultimately caused the client to fall and hit his head.Which item related to the client will cause the nurse to report an incomplete Glasgow Coma Score (GCS) ?

The charge nurse is preparing to assign a staff member to assist the healthcare provider planning to perform a lumbar puncture on a 9-month-old infant who is irritable and has an elevated temperature.Which staff member would be the best one to assist in this procedure?

The nurse is caring for an older adult client who sustained a closed head injury approximately 4 hours ago.At the time of the injury,the client denied any pain or other symptoms.Which statement by the client would cause the MOST concern to the nurse?

The nurse is caring for an older adult client who is being observed after sustaining a minor head injury.The client's only complaints related to the head injury are headache and dizziness.Which interventions would be most helpful to this client in preventing a possible increase in intracranial pressure?

The nurse instructs the UAP to hold the infant in a side-lying position in preparation for a lumbar puncture.The nurse shows the UAP how to flex the infant so that the spine is exposed and curved.Which explanation is the BEST to help the UAP understand why this position must be maintained?

The nurse is assisting with a lumbar puncture of an infant who is irritable and feverish.The manometer indicates increased intracranial pressure and the cerebral spinal fluid appears cloudy.The nurse will institute which interventions as a result of these findings?

The healthcare provider is preparing to perform a lumbar puncture on a 5-year-old child and requests that the child be placed in a sitting position.How will the nurse assist the child to maintain this position?

The nurse working in the emergency department is preparing to determine the level of consciousness on a client who was involved in a motor vehicle accident with a possible head injury.Which client precondition would prevent the nurse from using the Glasgow Coma Score?

The nurse enters a client's room with a suspected head injury in preparation for completing a neurological assessment that includes a Glasgow Coma Score (GCS) .Upon entering the room and turning on a light,the nurse notes that the client doesn't open his eyes immediately.Which is the nurse's next action?

The nurse is talking to parents of a 6-month-old infant who will have a lumbar puncture to rule out meningitis.The mother tells the nurse that she refuses to leave the baby and that no one will touch her child unless she is there.Which is the nurse's BEST response to this mother?

The nurse is caring for a client diagnosed with diabetic ketoacidosis and notes that the client's level of consciousness appears to be deteriorating.The nurse is aware that which assessments are a component of both the Glasgow Coma Score and the Full Outline of Un-Responsiveness (FOUR Score) Coma Scale? Select all that apply.