ICP Already Graded A+

ICP Already Graded A+ A newly admitted client with increased intracranial pressure caused from a head injury has a Glasgow Coma Scale (GCS) score of 6. Which interventions should the nurse prepare to implement? A) Assess airway, breathing, and circulation. B) Assess patency of the Foley catheter. C) Treat the client's pain. D) Get a complete history from the client. ️Answer: A Explanation: A) The GCS (Glasgow Coma Scale) is a standardized system for assessment of consciousness. A score of 15 indicates full alertness and a score of 8 or less is usually indicative of coma; the lowest possible score is 3. The client's score is low so the nurse should follow the ABCs (airway, breathing, and circulation) of care in this case. Treating the client's pain, taking a history, and assessing the patency of the Foley catheter are done only after the airway is clear and the client is breathing. The nurse is reviewing results of diagnostic testing performed on a client with increased intracranial pressure (ICP) in preparation for an evaluation to be done by the neurosurgeon during morning rounds. Which diagnostic test results should be on the medication record for the physician's review? Select all that apply. A) Bronchoscopy results B) MRI result C) Head CT scan with and without contrast D) Electroencephalogram E) Complete blood count of the cerebrospinal fluid ️Answer: B, C, D, E B) Diagnosis of increased ICP is made on the basis of observation and neurologic assessment; even subtle changes can be clinically significant. Testing can include CT scan with and without contrast, MRI, electroencephalogram, and cerebrospinal fluid evaluation. Bronchoscopy is not performed routinely for a client with increased intracranial pressure. The nurse is determining ways to decrease environmental stimuli for a client with increased intracranial pressure. What actions should the nurse take to support this client's care need? Select all that apply. A) Limit the client's visitors. B) Teach family to speak softly and minimize touching. C) Elevate the head of the bed. D) Provide all care quickly at one time to provide periods of rest. E) Keep the room dark and quiet. ️Answer: A, B, E Explanation: A) A dark, quiet room is important to reduce stimuli. Family members should be encouraged to talk to the client in a soft voice with minimal touching. Visitors should be limited. Care should be provided throughout the day for short periods of time to limit extended stress and stimulation. Elevating the head of the bed is important to reducing intracranial pressure but has no effect on stimulation. The nurse is planning care for an older client with a head injury sustained from a motor vehicle crash. Which information should the nurse keep in mind when planning this client's care? Select all that apply. A) Anxiety, illness, and pain can alter the ability to learn. B) Reflexes are less intense in an older client. C) Impulse transmission and reactions to stimuli are slower. D) The plantar and Achilles reflexes are hyperactive in this age group. E) Impairment in vision and hearing should be taken into consideration. ️Answer: A, C, E Explanation: A) In the older client, anxiety, illness, and pain can alter the ability to learn. Reflexes are less intense in an older client. Responses to stimuli are slower because of reduced impulse transmission. Many older adults have some impairment of hearing and visions, which should be taken into consideration when planning care. Reflex responses may slightly increase or decrease. Many older clients show a loss of the Achilles reflex, and the planar reflex may be difficult to elicit. A client with a head injury is demonstrating signs of increased intracranial pressure (IICP). Which classifications of medications should the nurse prepare to administer to this client? Select all that apply. A) Loop diuretics B) Antibiotics C) Anticonvulsants D) Histamine H2 antagonists E) Antipyretics ️Answer: A, C, D, E Explanation: A) Medications play an important role in the management of IICP. Loop diuretics are commonly used to reduce ICP. Antipyretics such as acetaminophen are used alone or in combination with a hypothermia blanket to treat hyperthermia. Anticonvulsants are often required to manage seizure activity associated with brain injury and IICP. Gastrointestinal prophylaxis with intravenous histamine H2 antagonists are often used because clients with IICP are at increased risk for developing stress gastritis and ulcers. Antibiotics are not routinely prescribed as treatment for IICP. A 10-year-old loses consciousness after being hit in the head with a bat at baseball practice. The child was not wearing a helmet. The last set of vital signs showed heart rate 48, blood pressure 148/74, and respiratory rate 28 and irregular. What does this vital signs assessment indicate to the nurse? A) Typical for a sleeping child at this age B) A sign of increased intracranial pressure C) Normal for this child D) A sign that this child has a spinal cord injury ️Answer: B B) These vital signs show increased blood pressure with a wide pulse pressure, slow heart rate, and respirations that are irregular, all indicating possible significant increased intracranial pressure. Normal heart rate for an awake child at this age is 70-110. Normal blood pressure is 92-126/55-86. Normal respirations are 20 and regular. These vital signs are a sign of increased intracranial pressure. If it were a spinal cord injury, and neurogenic shock were suspected, the child would be hypotensive. Normal sleeping pulse at this age is 60-90. The nurse is caring for a client in the neurological ICU with head trauma. The client is being monitored for increased intracranial pressure (IICP). Using the Monroe-Kellie hypothesis as a basis for explanation, which comment by the nurse to the client's family would be most appropriate? A) "There is nothing that can be done." B) "Increasing brain pressure decreases the amount of blood flow to the brain it