NR 325 Exam #2 Questions with Complete Solutions

Cerebral Edema - Answer-watch for brainstem herniation Increases CSF and CPP - Answer-Increased CSF causes there to be less blood in the brain, so CPP goes down. Normal ICP level - Answer-5-15 CPP - Answer-MAP-ICP Glasgow Coma Scale - Answer-eyes, verbal, motor 456 Max- 15 pts, below 8= coma Patient has hit their head, GCS is 15, CT results are unremarkable, what are DC instructions? - Answer--check on him every hour -monitor for HA Decorticate posturing - Answer-characterized by upper extremities flexed at the elbows and held closely to the body and lower extremities that are externally rotated and extended. occurs when the brainstem is not inhibited by the motor function of the cerebral cortex. Decerebrate - Answer-extension away from body, pronation of arms/legs, more severe What increases ICP - Answer-suctioning a patient, valsalva maneuver, pain NI for increased ICP - Answer--keep head midline with no flexion -elevate HOB to 30 degrees -do not give a hypo solution, will make ICP worse -give mannitol -give hypertonic saline -phenytoin since at risk for seizures -stool softeners to avoid valsalva maneuver -manage pain -decrease stimuli (lights, people) -will be put on both seizure and safety precautions SA of phenytoin - Answer-gingival hyperplasia, gingivitis, so go to a dentist and have good oral care Early sx of increased ICP - Answer--Altered LOC -Vomiting