NURS 370 (ICP, Stroke, Cardiac, GI, Shock) –
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Terms in this set (318)
What assessment tool do we use to Glascow Coma Scale
assess consciousness?
What are common causes of impaired AEIOU:
LOC? •A- Alcohol
•E- Epilepsy
•I- Insulin
•O- Opiates
•U- Urates
TIPPS:
T- Trauma
I- Infection
P- Psychological
P- Poisons
S- Shock
What other medications can impair Insulin
consciousness? Antipsychotics
Sedatives: benzodiazepines (...pam(s)), barbiturates
(phenobarbital), medical marijuana (unintentionally)
CNS depressants
Levodopa
Anesthetics (procedural (conscious) sedation)
,When admitting a patient with a A. The patient takes warfarin (Coumadin) daily.
possible head injury after a car
accident, the nurse obtains the
following information. Which finding is
most important to report to the health
care provider?
A. The patient takes warfarin
(Coumadin) daily.
B. The patient's BP is 162/94 mm Hg.
C. The patient is unable to remember
the
accident.
D. The patient complains of a severe
dull
headache.
The physician orders intracranial C. Assess the patient's level of consciousness.
pressure (ICP) readings every hour for
a patient who had cranial surgery. The ASSESSMENT BEFORE INTERVENTION
patient's ICP reading is 24 mm Hg. It is
most important for the nurse to take
which action?
A. Determine if the patient has a
headache.
B. Document the ICP reading in the
chart.
C. Assess the patient's level of
consciousness.
D. Position the patient with the head
of
the bed at 30 degrees.
,When caring for a patient who has A. The patient is more difficult to rouse.
had a head injury, which assessment
information requires the most rapid
action by the nurse?
A. The patient is more difficult to
rouse.
B. The patient's pulse is slightly
irregular.
C. The patient's BP increases from
120/54 to 136/62 mm Hg.
D. The patient complains of a
headache at pain level 5 of a 10-point
scale.
A patient is brought to the emergency A. Obtain oxygen saturation.
department (ED) by ambulance after
being found unconscious on the There is no confirmed head injury in this question
bathroom floor by the spouse. Which stem.
action will the nurse take first?
A. Obtain oxygen saturation.
B. Check pupil reaction to light.
C. Palpate the head for hematoma.
D. Assess Glasgow Coma Scale (GCS).
A patient is hospitalized for a head A. Apply a loose gauze pad under the patients nose.
injury and frontal skull fracture. The
nurse notes that clear fluid is draining Perform a Halo test.
from the nose. What action by the
nurse is most appropriate?
A. Apply a loose gauze pad under the
patients nose.
B. Place the patient in a modified
Trendelenburg position
C. Ask the patient to gently blow the
nose to obtain a sample
D. Pinch the nostrils for 10 minutes to
stop the nasal drainage.
, A patient with a head injury has B. BP 156/60, HR 55, RR 12
admission vital signs of BP 128/68, HR
110, and RR 26. Which of these vital Cushing's triad = widening pulse pressure (SBP
signs, if taken 1 hour after admission, increases), bradycardia, bradypnea
will be of most concern to the nurse?
A. BP 130/72, HR 90, RR 32
B. BP 156/60, HR 55, RR 12
C. BP 148/78, HR 112, RR 28
D. BP 110/70, HR 120, RR 30
When a patient's intracranial pressure A. Oral temperature 39.3°C
(ICP) is being monitored with an
intraventricular catheter, which
information obtained by the nurse is
most important to communicate to the
health care provider?
A. Oral temperature 39.3°C
B. Apical pulse 102 beats/min
C. Intracranial pressure 15 mmHg
D. Systolic blood pressure 140 mmHg
What is intracranial pressure (ICP)? ICP is created by the cerebrospinal fluid, brain tissue,
What is normal ICP range? and blood within the brain tissue and skull.
5-15 mmHg
What are specific signs and symptoms Drowsiness, lethargy, bulging of the soft spot
of increased ICP in infants? (anterior fontanelle) on top of the head, distended
scalp veins, a high pitch cry, vomiting.
What are specific signs and symptoms Behaviour changes, decreased LOC, headache,
of increased ICP in children? lethargy, neurological symptoms
(weakness/numbness/tingling), decreased GCS,
seizures, vomiting, papilledema.
What factors influence ICP? List them. Temperature, oxygenation status, body position,
arterial and venous pressure, anything that increases
intrabdominal or thoracic pressure, tumours,
encephalitis, hematoma, hemorrhage, head injury,
hydrocephalus, swelling/edema
Questions With Proven Solutions
Save
Terms in this set (318)
What assessment tool do we use to Glascow Coma Scale
assess consciousness?
What are common causes of impaired AEIOU:
LOC? •A- Alcohol
•E- Epilepsy
•I- Insulin
•O- Opiates
•U- Urates
TIPPS:
T- Trauma
I- Infection
P- Psychological
P- Poisons
S- Shock
What other medications can impair Insulin
consciousness? Antipsychotics
Sedatives: benzodiazepines (...pam(s)), barbiturates
(phenobarbital), medical marijuana (unintentionally)
CNS depressants
Levodopa
Anesthetics (procedural (conscious) sedation)
,When admitting a patient with a A. The patient takes warfarin (Coumadin) daily.
possible head injury after a car
accident, the nurse obtains the
following information. Which finding is
most important to report to the health
care provider?
A. The patient takes warfarin
(Coumadin) daily.
B. The patient's BP is 162/94 mm Hg.
C. The patient is unable to remember
the
accident.
D. The patient complains of a severe
dull
headache.
The physician orders intracranial C. Assess the patient's level of consciousness.
pressure (ICP) readings every hour for
a patient who had cranial surgery. The ASSESSMENT BEFORE INTERVENTION
patient's ICP reading is 24 mm Hg. It is
most important for the nurse to take
which action?
A. Determine if the patient has a
headache.
B. Document the ICP reading in the
chart.
C. Assess the patient's level of
consciousness.
D. Position the patient with the head
of
the bed at 30 degrees.
,When caring for a patient who has A. The patient is more difficult to rouse.
had a head injury, which assessment
information requires the most rapid
action by the nurse?
A. The patient is more difficult to
rouse.
B. The patient's pulse is slightly
irregular.
C. The patient's BP increases from
120/54 to 136/62 mm Hg.
D. The patient complains of a
headache at pain level 5 of a 10-point
scale.
A patient is brought to the emergency A. Obtain oxygen saturation.
department (ED) by ambulance after
being found unconscious on the There is no confirmed head injury in this question
bathroom floor by the spouse. Which stem.
action will the nurse take first?
A. Obtain oxygen saturation.
B. Check pupil reaction to light.
C. Palpate the head for hematoma.
D. Assess Glasgow Coma Scale (GCS).
A patient is hospitalized for a head A. Apply a loose gauze pad under the patients nose.
injury and frontal skull fracture. The
nurse notes that clear fluid is draining Perform a Halo test.
from the nose. What action by the
nurse is most appropriate?
A. Apply a loose gauze pad under the
patients nose.
B. Place the patient in a modified
Trendelenburg position
C. Ask the patient to gently blow the
nose to obtain a sample
D. Pinch the nostrils for 10 minutes to
stop the nasal drainage.
, A patient with a head injury has B. BP 156/60, HR 55, RR 12
admission vital signs of BP 128/68, HR
110, and RR 26. Which of these vital Cushing's triad = widening pulse pressure (SBP
signs, if taken 1 hour after admission, increases), bradycardia, bradypnea
will be of most concern to the nurse?
A. BP 130/72, HR 90, RR 32
B. BP 156/60, HR 55, RR 12
C. BP 148/78, HR 112, RR 28
D. BP 110/70, HR 120, RR 30
When a patient's intracranial pressure A. Oral temperature 39.3°C
(ICP) is being monitored with an
intraventricular catheter, which
information obtained by the nurse is
most important to communicate to the
health care provider?
A. Oral temperature 39.3°C
B. Apical pulse 102 beats/min
C. Intracranial pressure 15 mmHg
D. Systolic blood pressure 140 mmHg
What is intracranial pressure (ICP)? ICP is created by the cerebrospinal fluid, brain tissue,
What is normal ICP range? and blood within the brain tissue and skull.
5-15 mmHg
What are specific signs and symptoms Drowsiness, lethargy, bulging of the soft spot
of increased ICP in infants? (anterior fontanelle) on top of the head, distended
scalp veins, a high pitch cry, vomiting.
What are specific signs and symptoms Behaviour changes, decreased LOC, headache,
of increased ICP in children? lethargy, neurological symptoms
(weakness/numbness/tingling), decreased GCS,
seizures, vomiting, papilledema.
What factors influence ICP? List them. Temperature, oxygenation status, body position,
arterial and venous pressure, anything that increases
intrabdominal or thoracic pressure, tumours,
encephalitis, hematoma, hemorrhage, head injury,
hydrocephalus, swelling/edema
