Pearson - Increased Intracranial Pressure – Module Verified Solutions

Pearson - Increased Intracranial Pressure – Module Verified Solutions 15 The patient's level of consciousness is assessed by using the Glasgow Coma Scale. Any score lower than 15 indicates a decrease in the patient's level of consciousness. previous ️A child is brought to the emergency department after hitting his head following a fall from a skateboard. Which score on the Glasgow Coma Scale represents no deficit? 5 8 10 15 Medications Older adults may take medications that increase their risk for falls and trauma. Sensory losses such as decreased visual acuity and instabilities due to decreased muscle mass can increase the risk for falls. Not all medical conditions put the patient at risk. Undiagnosed or poorly controlled arrhythmias may cause a decrease in cerebral blood flow, which can lead to vertigo and falls. ️The nurse is discussing risk factors that put older adults at risk for falls that can result in increased intracranial pressure. Which risk factors should the nurse include? Increased muscle mass Medications Other medical conditions Increased visual acuity "Your husband's intracranial pressure is 14 mmHg and within normal limits." The normal range for intracranial pressure (ICP) is typically 1.5-15 mmHg, but it can vary based on measurement techniques and age. Normal ranges across the lifespan are as follows: 1.5-6 mmHg in infants, 3-7 mmHg in children, and 5-15 mmHg in adults. ️An adult patient's spouse reports to the nurse that their husband appears more alert than before. The spouse asks, "Is he getting better?" Which response by the nurse is accurate? "Your husband's intracranial pressure is 25 mmHg and within normal limits." "Your husband's intracranial pressure is 40 mmHg and within normal limits." "Your husband's intracranial pressure is 14 mmHg and within normal limits." "Your husband's intracranial pressure is 60 mmHg and within normal limits." Implementing seizure precautions By closely monitoring patients who may be at risk of increased intracranial pressure (IICP), the nurse can detect any changes promptly and therefore improve patient outcomes with early treatment interventions. If the patient is suspected of having IICP, methods for keeping the pressure from increasing further include elevating the patient's head to 30 degrees, keeping their neck in a neutral position, decreasing stimuli, avoiding overhydration, maintaining a normal body temperature, and maintaining a normal oxygen level. It is recommended to raise pads and bedrails, as seizures may occur due to increased pressure. The Trendelenburg position places the head below the shoulders and is contraindicated when a patient has increased intracranial pressure. Creatinine level monitoring is used to determine kidney health and is unrelated to intracranial pressure. ️The nurse is planning care for a patient with a diagnosis of increased intracranial pressure (IICP). Which intervention should the nurse include? Increasing stimuli Monitoring creatinine level Placing the patient in the Trendelenburg position Implementing seizure precautions "If my mother is hard to wake up, I should call 911." Any change in the level of consciousness, such as difficulty to awaken or increased confusion, can mean that the pressure is increasing and indicate a medical emergency. If the patient complains of a stiff neck, severe headache, or nausea and vomiting, take the patient to the emergency department. Changes in vision or motor control should be reported immediately. ️An older woman who was hospitalized for increased intracranial pressure is being discharged into the care of her daughter. Which statement by the patient's daughter reflects an understanding of the care for her mother? "I should expect my mother to have some nausea and vomiting." "My mother will probably have severe headaches." "If my mother is hard to wake up, I should call 911." "I should expect her to complain of visual changes." "As pressure in the brain increases, the fluid surrounding the brain decreases and blood flow is decreased, resulting in less oxygen to the brain." Three components make up the pressure-volume equilibrium—the brain, the blood, and the cerebrospinal fluid. Any of these components can change and affect the other two and cause an imbalance and resulting increase in pressure. Low blood pressure and increased blood flow to the brain would not affect the pressure in the brain and cause it to increase. Tumors may be involved, but there is no information to confirm this. ️The nurse is talking to the spouse of a patient who has increased intracranial pressure. Which statement confirms that the spouse understands what is happening with the patient? "There is a tumor in the brain causing pressure on the blood vessels." "As pressure in the brain increases, the fluid surrounding the brain decreases and blood flow is decreased, resulting in less oxygen to the brain." "Low blood pressure is causing the brain to have too much fluid in it, causing a decrease in blood flow and the amount of oxygen reaching the brain." "The blood flow to the brain has increased and is causing an increased pressure." Tissue ischemia The pressure exerted by cerebral edema, the increase in fluid that is retained in brain tissue, is the