Chapter 13: Nervous System Alterations Test Bank

1. The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5°. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patient’s plan of care? a. Frequent neurological assessments b. Side to side position changes c. Range of motion to extremities d. Frequent oropharyngeal suctioning ANS: A Nurses complete neurological assessments based on ordered frequency and the severity of the patient’s condition. The newly admitted patient has an altered neurological status so frequent neurological assessments are most important to include in the patient’s plan of care. Side to side position changes, range of motion exercises, and frequent oral suctioning are nursing actions that may need to be a part of the patient’s plan of care but in the setting of increased intracranial pressure should not be regularly performed unless indicated. DIF: Cognitive Level: Application REF: p. 365 | Nursing Care Plan OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 2. A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. Her blood pressure is 144/90 mm Hg, and her mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)?