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NUR 2755 Multidimensional Care IV MDC 4 Rasmussen Exam 9 2025/26 $9.99
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NUR 2755 Multidimensional Care IV MDC 4 Rasmussen Exam 9 2025/26

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NUR 2755 Multidimensional Care IV MDC 4 Rasmussen Exam 9 2025/26 NUR 2755 Multidimensional Care IV MDC 4 Rasmussen Exam 9 2025/26 NUR 2755 Multidimensional Care IV MDC 4 Rasmussen Exam 9 2025/26 NUR 2755 Multidimensional Care IV MDC 4 Rasmussen Exam 9 2025/26 NUR 2755 Multidimensional Care ...

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  • January 9, 2025
  • 28
  • 2024/2025
  • Exam (elaborations)
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  • NUR 2755 Multidimensional Care IV MDC 4
  • NUR 2755 Multidimensional Care IV MDC 4
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Exam 9 2025/26 Il! Il! Il! Il!


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Understand treatments and nursing care for IICP, Increasing Intracranial Pressure - Maintain
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airway patency.
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Monitor neurological status; assessment areas include LOC, behavior, motor/sensory functions,
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pupillary size and reaction to light, and vital signs.
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Monitor IICP monitor orventilator. Il! Il! Il! Il!



Decrease stimuli. Il! Il!




Raise pads and bed rails; seizures may occur.
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Elevate the head of bed 30 degrees unless otherwise indicated.
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Monitor arterial blood gases. Il! Il! Il! Il!




Position client as prescribed. Il! Il! Il! Il!




Prevent complications associated with immobility.
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Monitor fluid and electrolytes. Il! Il! Il! Il!



Monitor bladder distention and bowel constipation.
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Provide emotional support as needed.
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Administer medications as ordered. Il! Il! Il! Il!

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Clients with IICP may undergo various intracranial surgical techniques to treat the underlying
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cause. In addition, infarcted or necrotic tissue may be resected to reduce brain mass. A
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drainage catheter or shunt may be inserted laterally via a burr hole into a ventricle to drain
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excess CSF and reduce hydrocephalus. The removal of even a small amount of CSF may
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dramatically reduce IICP and restore cerebral perfusion pressure.
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Diuretics, particularly osmotic diuretics, are commonly used to reduce ICP and are the
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mainstays of pharmacologic treatment. Loop diuretics such as furosemide (Lasix), the drug of
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choice, and ethacrynic acid (Edecrin) may be prescribed for some clients with IICP.
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Antipyretics, such as acetaminophen, are used alone or in combination with a hypothermia
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blanket to treat hyperthermia. (Hyperthermia increases the cerebral metabolic rate and
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exacerbates an existing increase in ICP.) Anticonvulsants are often required to manage seizure
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activity associated with brain injury and IICP. Antihypertensives, in particular beta-blockers,
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may be used if the mean arterial pressure (MAP) is high. Vasopressors may be used if the
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MAP is low. Gastrointestinal prophylaxis with intravenous histamine H2 antagonists or proton
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pump
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Monroe-Kelliw hypothesis - A hypothesis that states if the volume of any of the three Il! Il! Il! Il! Il! Il! Il! Il! Il! Il! Il! Il! Il! Il!



intracranial components (the brain, cerebrospinal fluid, and blood) increases, the volume of the
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others must decrease to maintain normal pressures in the cranial cavity.
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The normal ICP is 5-15 mmHg (measured intracranially with a pressure transducer while
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the
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client is lying with the head elevated 30 degrees) or 60-180 cm H2O (measured with a
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water
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manometer while the client is lying in a lateral recumbent Il! Il! Il! Il! Il! Il! Il! Il! Il!



position).
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Understand VP shunts, why they are needed, nursing interventions and teachings, complications
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involved. - I know the book does not go over VP Shunts in great detail just mentions them as
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a treatment option for Hydrocephalus. A Ventriculoperitoneal shunt is a medical device used
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to relieve IICP. It is basically a catheter starting in the head internally implanted and draining
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into the peritoneum to relieve the excess CSF. You as the nurse will be in charge of teaching
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families and patients complications involved. Complications would be the S+S of IICP. Just
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understand what this device is for.
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Nursing interventions for Head injury and goals associated with head injury - Nurses can
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help
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clients prevent head injury by providing anticipatory guidance related to safe
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practices,
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especially wearing protective equipment such as helmets when engaging in sports or
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activities
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with a high risk for Il! Il! Il! Il!



concussion.
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Know the process of caring for MVA patients from the ED to home care - Nursing
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interventions
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and associated complications involved with
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MVA
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Maintain Airway Patency and Ventilation Il! Il! Il! Il! Il!




Assess for Disability and Expose Obscured Areas
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Promote Fluid Volume Balance Il! Il! Il! Il!



Prevent Infection Il! Il!




Promote Mobility Il! Il!




Offer Spiritual Comfort Measures
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Promote Psychosocial Well-Being Il! Il! Il!



Facilitate Community-Based Care Il! Il! Il!

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Mild head injury to brain, bruising, bleeding, and/or swelling
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Tearing or injury to the posterior cruciate ligament of the knee, whiplash, spinal cord injury
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either incomplete or complete
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For the client who has sustained injury in a motor vehicle crash, primary consideration should
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be given to the airway: Assess if the airway is patent, maintainable, or nonmaintainable.
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Assess for manifestations of airway obstruction: stridor, tachypnea, bradypnea, cough,
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cyanosis, dyspnea, decreased or absent breath sounds, changes in oxygen levels, and changes
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in level of consciousness. Assessing the airway and initiating interventions are the first steps in
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managing the client with multiple injuries. A cervical collar (or C-collar), which stabilizes and
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maintains neutral alignment of the cervical spine, should be applied to clients with potential or
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suspected cervical spine injury. Longboard spinal immobilization, which provides support and
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immobilization of the entire spine below the level of the neck, should be instituted for clients
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, with a potential or suspected spinal cord injury. Cervical and longboard spinal immobilization
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should be discontinued only by physician's order after determining that the client has not
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sustained a spinal injury. Although not always needed, this determination may require
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evaluation of the client's spine using CT scan.
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Spinal cord injuries, nursing interventions treatments and medications - Immediate care will
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include assistance with ventilation, immobilization, care of wounds, and bladder and bowel
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control. Interventions during the recovery phase will include assistance with mobility, exercise,
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and self-care activities and prevention of complications. Rehabilitation interventions will
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include assistance with ambulation, training for ADLs, and referral to rehabilitation therapy.
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Most clients will receive high-dose methylprednisone within 8 hours after injury to improve
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neurological recovery. Methylprednisone appears to decrease inflammation and reduce damage
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to surrounding nerve cells. Adverse effects are usually minor. Prophylactic anticoagulation
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therapy (e.g., heparin, Coumadin) may be given to help prevent DVT and pulmonary
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embolism. Infections, especially pneumonia, should be treated promptly with appropriate
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antibiotics; pain can be treated with opioids, NSAIDs, and other analgesics as needed.
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After a SCI, surgery may also be needed to stabilize the spine. Spine stabilization may involve
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realigning the spine and using instrumentation such as rods and screws to internally
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immobilize the spine. A bone graft from the client or bone bank is often added to promote
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fusion of the vertebrae. Surgery can also be performed to set up spinal traction using Gardner-
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Wells tongs or other traction devices or external fixation with a halo brace. A halo brace is
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often used for clients with cervical fractures without major cord damage. The client may be in
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traction or external fixation for several weeks or months.
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Nursing roles and care for spinal cord injuries, Bowel and Bladder training - Clients with a
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spinal cord injury will require extensive nursing care. Immediate nursing care involves
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maintaining an airway, assisting with ventilation, and immobilizing the client. Nursing care
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also includes preventing complications such as urinary or bowel problems, pressure sores, and
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infection. During the healing process, the nurse will also play a role in the client's
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rehabilitation and client teaching for home care.
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Bladder training, which requires that the client postpone voiding, resist or inhibit the sensation
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of urgency, and void according to a timetable rather than according to the urge to void. The
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goals are to gradually lengthen the intervals between occasions of urination to correct the
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client's frequent urination, to stabilize the bladder, and to diminish urgency. This form of
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training may be used for clients who have bladder instability and urge incontinence. Delayed
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voiding produces larger voided volumes and longer intervals between instances of voiding.
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Initially, voiding may be encouraged every 2-3 hours except during sleep, and then every 4-6
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hours. A vital component of bladder training is inhibiting the urge-to-void sensation: Every
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time the client has a premature urge to void, repeat the instruction to practice deep, slow
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breathing until the urge diminishes or disappears.
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End of life Nursing Dx -
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Fear
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Death
Anxiety
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