Exam 2 Review

You are a nurse working in the neurological unit of a hospital. A patient has just been admitted with a severe head injury. The patient's condition is deteriorating rapidly, and you suspect the development of Cushing's Triad. You quickly assess the patient's vital signs and note the following changes:

Blood pressure: 180/110 mmHg Heart rate: 50 beats per minute Respiratory rate: 8 breaths per minute

Which of the following interventions should the nurse prioritize?

• Administer a vasodilator medication

• B) Initiate cardiopulmonary resuscitation (CPR)

• Maintain a patent airway and administer oxygen

• Prepare for immediate surgery to relieve intracranial pressure

Answer explanation

Explanation: Cushing's Triad is a clinical syndrome characterized by three classic signs: hypertension (elevated blood pressure), bradycardia (slow heart rate), and irregular or abnormal respirations. These signs indicate increased intracranial pressure, which can lead to life-threatening complications. In this scenario, the patient's blood pressure is elevated, heart rate is slow, and respiratory rate is low. The priority nursing intervention is to ensure a patent airway and administer oxygen to support oxygenation and perfusion to the brain. This intervention helps to address the underlying cause of the changes in vital signs and provides immediate support to the patient's compromised neurological status. Administering a vasodilator medication (option A) might lower blood pressure but does not address the other manifestations of Cushing's Triad. Initiating CPR (option B) is not warranted at this point as the patient still has a pulse. Immediate surgery to relieve intracranial pressure (option D) may be necessary in some cases, but it is not the initial priority in this scenario.

Meningitis can cause hearing loss that progresses over time

• True

• False

what is not a symptoms of increased ICP?

• severe headache

• hypotension

• cushings triad

• papilledema

cushings triad is a decrease in BP, increase in pulse and increase in respirations

• true

• false

what is not a descriptor of pain?

• aching

• cramping

• color

• constant

This disease is also called Lou Gehrig's Disease and is a progressive degeneration of nerve cells that control motor movement.

• Atriovenous Malformations (AVM)

• Multiple Sclerosis (MS)

• Amyotrophic Lateral Sclerosis (ALS)

A chronic nervous system disease characterized

by a slowly spreading tremor, muscular

weakness, and rigidity

• epilepsy

• muscular dystophy

• Parkinson's disease

• meningitis

You are a nurse caring for a patient with increased intracranial pressure (ICP) in the neurological intensive care unit. The patient's ICP is being closely monitored, and you are responsible for implementing appropriate interventions to manage the condition.

• Encouraging straining during bowel movements

• Administering intravenous fluids at a rapid rate

• Administering prescribed diuretic medications

• Keeping the head and neck midline to maintain a patent airway

Answer explanation

When caring for a patient with increased ICP, one of the primary interventions is to keep the head and neck midline to maintain a patent airway and maximize oxygenation. The HOB should be raised to at least 30-45 degrees in order to utilize gravity to help drain the CSF fluid away from the brain. Option A), encouraging straining during bowel movements, is contraindicated as it can lead to increased intra-abdominal pressure and subsequent increased ICP. Option B, administering intravenous fluids at a rapid rate, should be avoided as excess fluid volume can contribute to increased cerebral edema and worsen ICP. Option c), administering prescribed diuretic medications, may be appropriate in some cases, but it should be done under the guidance of the healthcare provider, as diuretics need to be carefully titrated to prevent dehydration and electrolyte imbalances.

The nurse is giving bedside shift report for a Pt with a TBI. The offgoing and oncoming nurse notices which of the following that could indicate subtle changes in LOC?

• The Pt awakens from a nap and takes a moment to realize where they were

• The Pt begins nervously pulling at their wristband

• The Pt had a restless night and appeared very sleepy at 0700

• The Pt's has slurred speech that wasn't previously noted

• The Pt has decreased hand grasp strength unilaterally

It is determined that the patient with a Glasgow coma of 5 will not survive the injuries sustained by a TBI. What must occur before the patient is extubated?

• Call a clergy member of the patient's faith to bedside

• Call a code to attempt life-saving measures one last time

• Call organ procurement and ask family about organ donation

• Call the legal team to ensure advance directives are followed