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NUR 265 exam 3|29 Answered Questions
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NUR 265 exam 3|29 Answered QuestionsComplications of TBI include? - -Secondary injury, hypotension decreased
cerebral percussion.
-NSG for tbi? - -Maintain O2, monitor for S/S of ICP, Check drainage for
glucose/halo sign, hyperventilate pt to blow off CO2. Midline positioning, stay
on backboard & do not remove C-collar. ABC's!!! No hip flexing, log roll,
elevate HOB.
-S/S of increased ICP - -Early: Change in LOC, agitation, headache, and
vomiting.
Late: Pupillary dilation, compression and loss of reflexes.
-Medication that can lower ICP? - -Mannitol
-High spinal chord injuries have a huge risk of causing? - -Respiratory
compromise
-What is Cushing's triad? - -Widened Pulse pressure
bradycardia
irregular respirations
-What is decorticate posturing? - -Extremities are pointing towards the
"core" meaning severe brain damage
-What is decerebrate posturing? - -Extremities are pointing away from the
core.
-ICP NSG? - -Avoid coughing, straining, gagging.
Neuro & VS checks Q1-2H
Monitor for fever & give cooling blanket to treat
HOB lower than 25
Neck midline, no hip flexion
No cluster care
Decrease stimuli
Monitor pupils & IO's
-NSG for encephalitis? - -Seizure precautions, suction at bedside, decrease
stimuli, give mannitol as ordered, monitor for signs of increased ICP.
-NSG for meningitis? - -Monitor for kerning's & budinski's signs
Get lumbar pucture
Droplet precautions
Neuro assessment frequently
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