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concept in nursing 2
increased intracranial pressure
| Question | Answer |
|---|---|
| Identify the physiologic events which can lead to increased intracranial pressure and accumulation of CO2. | -Brain abscess -Occipital tumor -Subdural hematoma -Bacterial meningitis -Blunt force trauma to the head |
| The nurse is caring for a patient with a brain tumor and increased intracranial pressure. The initial vital signs were BP 128/88, HR 106, RR 22, Oxygen saturation 98%. Which follow-up vital signs would indicate worsening ICP? | BP 172/98, HR 64, RR 24, oxygen saturation 99% |
| A nurse is caring for a patient with increased ICP due to a subdural hematoma. Upon assessment, the nurse notes one pupil is 3mm and the other is 7mm. Which action should the nurse take next? | Assess the cranial nerves for abnormalities. |
| The nurse is administering IV dexamethasone to a patient with a frontal lobe tumor who reports left upper quadrant pain, nausea and vomiting. Upon assessment, the nurse notes coffee ground emesis and tenderness on palpation. | -- |
| Which provider order would the nurse anticipate? | Insert NG tube |
| The nurse is caring for a patient who sustained major head trauma after a motor vehicle collision. The patient’s lab values reveal a BUN of 47, creatinine of 3.1, hemoglobin of 6.8 and potassium level of 6.1. Which provider order would the nurse question? | Give Mannitol IV |
| During the assessment of a patient with a head injury from a fall, the patient reports a sudden severe headache, nausea and vomiting. The nurse notes right sided weakness, slurred speech and a right facial droop. | -- |
| For which collaborative care procedure would the nurse expect to prepare the patient? | Burr holes |
| A nurse is monitoring a patient with increased intracranial pressure using a ventriculostomy. The patient’s ICP monitor indicates that the P2 wave is higher than the other waves. Which provider order would the nurse anticipate? | Prepare for surgery. |
| A nurse is caring for a patient after resection of a temporal lobe tumor. The patient begins to complain of headache and nausea. Which action should the nurse take? | Elevate head of patient’s bed |
| A nurse is assisting the provider during a neurological assessment on an unconscious adult patient with increased intracranial pressure. When holding the eyelids open and moving the patient’s head to the right side, the eyes move to the right side. | -- |
| How would the nurse report this finding? | abnormal oculocephalic reflex |
Created by:
Lightnning54
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