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Advanced Med Surg Exam 1
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,1.
What is the earliest sign of increased ICP? Decreased LOC
2.
Behavior changes in the pt w/ increased ICP include Confusion
restlessness, irritability and .
3.
A key feature of increased ICP is vomit- Projectile
ing.
4.
A key feature of increased ICP is , which Aphasia
means that the pt will have problems w/ language
and/or speech.
5.
A key feature of increased ICP is , which Dysarthria
means the pt will have changes in speech pattern
including slurred speech.
6.
A key feature of increased ICP is pupillary changes Blown
of dilated and nonreactive pupils ( pupils) or
constricted and nonreactive pupils (very late sign).
7.
A key feature of increased ICP is nerve dys- Cranial
function.
8.
A key feature of increased ICP is , which Ataxia
means that the pt will lack muscle control and coor-
dination that affects gait and balance.
9.
A key feature of increased ICP is , usually Seizures
w/in the first 24h after a stroke.
10.
A key feature of increased ICP is cushing triad. What Severe HTN, widened
are the components of cushing triad? pulse pressure, bradycar-
dia
, 11. A key feature of increased ICP is postur- Decerebrate
ing, shown in the picture.
12. A key feature of increased ICP is postur- Decorticate
ing, shown in the picture.
13. When caring for the pt w/ increased ICP, the RN should Elevate
the head of the bed to improve perfusion
pressure.
14. When caring for the pt w/ increased ICP, the RN should O2
provide to prevent hypoxia for a sat of less
than 95% or per protocol/prescription.
15. When caring for the pt w/ increased ICP, the RN should Midline
maintain the pt's head in a , neutral position
to promote venous drainage from the brain.
16. When caring for the pt w/ increased ICP, the RN should Flexion
avoid sudden and acute hip or neck during
positioning.
17. When caring for the pt w/ increased ICP, the RN should Clustering
avoid nursing procedures.
18. When caring for the pt w/ increased ICP, the RN should Hyperoxygenate
the pt before and after suctioning to
avoid transient hypoxemia and resultant ICP elevation
from dilation of cerebral arteries.