Nurs 2420 Unit 3 Neuro/Sensory (with Complete Solutions)

Clinical Manifestations of Increased ICP correct answers Infants: bulging fontanels, separate cranial sutures, high-pitched cry, poor feeding, setting sun sign Children: HA, N/V, seizures, drowsiness Nursing Interventions for increased ICP correct answers Assess LOC, Neuro exams, Glascow coma scale, vitals, odor of breath, examine skin for signs of injury Dolls head maneuver correct answers Test done for ICP, both eyes should move in OPPOSITE direction of head rotation Caloric Test correct answers 10 ml ice wat in auditory canal for 20 seconds, eyes should move together to the side being stimulated should not be performed on child who is awake or has ruptured tympanic membrane Decorticate posturing correct answers arms flexed inward and bent in toward the body and the legs are extended Decerebrate posturing correct answers posturing in which the neck is extended with jaw clenched; arms are pronated, extended, and close to the sides; legs are extended straight out; more ominous sign of brain stem damage. Most Severe. Nursing Care of the Unconscious Child correct answers Maintain ABC, Stabilize spine, treat shock, reduce ICP, neuro assessments, pain management(morphine not recommended) Meds for Unconscious Child correct answers fentanyl, midazolam- monitor bowel function for constipation Nursing Interventions for Unconscious Child correct answers Low stimuli environment, limit visitors, prevent any sudden movements, proper positioning(side lying) & prevent straining Clinical Manifestation of Bacterial Meningitis correct answers abrupt onset, fever, chills, HA, N/V, lethargy, irritability, seizures, photophobia, confusion, drowsiness, coma, nuchal rigidity, + Kernig/Brudzinski signs, poor feeding, weak cry, irregular temp Nursing Interventions of Bacterial Meningitis correct answers Isolation precautions, antimicrobial therapy, maintenance of hydration/ventilation, increased ICP, manage systemic shock, control seizures/temp, treat complications. Care Management of Bacterial Meningitis correct answers Admin abx as soon as they're ordered, place pt. on resp. isolation for 24 hrs., decrease stimuli, side lying or flat position, keep pt. hydrated/comfortable support pt. and family