How do you measure MAP Answer - (SBP + 2DBP)/3
(easy as 1, 2, 3)
The patient in critical care has a blood pressure of 130/70, ICP of 30. Calculate
the patient's CPP. Answer - (130 + 2(70) / 3 = 90
90 - 30 = 60
Which of the following responses to painful stimulus indicates the grimmest
prognosis while performing your neurological check on a brain-injured patient
using the glasgow coma scale (GCS)? Answer - Decerebrate posturing
(abnormal extension)
What is the earliest indicator of changes in ICP? Answer - Change in level of
consciousness
Calculate the CPP of a patient who has the following vital signs: temp 99.1 ,HR
90, BP 100/60, O2 sat 97% on 2L NC, respirations 16, and ICP of 10. (ROUND TO
THE NEAREST WHOLE NUMBER, only type the correct number) Answer - 63
, A patient with intracranial pressure monitoring has a pressure reading of 12
mm Hg. The nurse understand that this pressure reflects: Answer - A normal
balance among brain tissue, blood, and cerebrospinal fluid.
A nurse is caring for a client who has increased ICP and a new prescription for
mannitol. For which of the following adverse effects should the nurse monitor?
Answer - Hyponatremia
A nurse plans care for the patient with increased intracranial pressure with the
knowledge that the best way to position the patient is to: Answer - Elevate the
head of the bed to 30 degrees
Information provided by the patient that would help distinguish a hemorrhagic
stroke from a thrombotic stroke includes: Answer - Sudden onset of severe
headache
A nurse is caring for a client 4 hr following evacuation of a subdural hematoma.
Which of the following assessments is the nurse's priority Answer - Respiratory
status
The nurse is alert to a possible acute subdural hematoma in the patient who
Answer - Complains of a thunderclap headache
A patient with a T4 spinal cord injury has neurogenic shock due to sympathetic
nervous system dysfunction. What would the nurse recognize as characteristic
of this condition? Answer - Hypotension
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