Nursing actions
Procedures
Trauma Troubles
Pressure Potpouri
Brain Blends
100
While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg. What is the nurse best interpretation of this value?
What is an increase ICP?
100
The nurse is caring for a client complaining of intense headaches. A MRI is ordered. In reviewing the client's information, which is of most of concern? A. client is allergic to shellfish, B. Client has a cardiac pacemaker, C, client is a diabetic D. client has no IV access
What is the client has cardiac pacemaker?
100
In assessing a patient with low back pain, which priority assessment question or statement will the nurse provide? A. “How long have you had back pain?” B.“How does your back pain affect your activities of daily living?” C.“Tell me about your pain and what interventions are helpful in managing your pain.” D.“Have you ever had magnetic resonance imaging to find a cause for your back pain?”
What is tell me about your pain and what interventions are helpful in managing your pain?
100
This is the earliest sign of increased ICP
What is decreased level of consciousness
100
"The worst headache of my life" is most often associated with this
What is subarachnoid hemorrhage
200
How do you calculate a CPP?
What is (MAP-ICP)?
200
The client presents with fever, chills, positive Kernig and Brudinski as well as nucchal rigidity. What disorder is suspected? A. Flu B. Cerebrovascular accident (CVA), c. meningitis, D. Cerebral arteritis
What is the meningitis?
200
These are initial treatments for traumatic brain injuries
Oxygenation and ventilation
200
This is the normal ICP
What is 7-15 mmHg
200
Surgical intervention is required for this type of skull fracture
What is depressed
300
A 19-year-old man who was involved in a motor vehicle accident is brought to the ED. The patient was stopped at a red light when he was hit from behind by another vehicle traveling at 15 mph. The patient was placed in a cervical immobilizer by the paramedics. He is alert and oriented, states that his neck hurts, and is in no apparent distress. He currently rates his neck pain as a “5” on a 0-to-10 scale. Which assessment will the nurse perform first? A.Airway B.Circulation C.Sensory-motor D.Level of consciousness
What is Airway?
300
These are not examined during a rapid neuro assessment
What are the cranial nerves
300
These are serious complications of subarachnoid hemorrhage
What are rebleeding and vasospasm
300
These are the components of Cushing's Triad
What are bradycardia, increased SBP, decreased RR
300
This is the maxium dose of tPA
What is 90 mg
400
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°F. 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?
What is frequent neurological assessments?
400
Eye opening, motor response, and verbal response are components of this
What is the Glasgow Coma Scale
400
Altered level of conciousness, lucidity, followed by obtundation are symptoms of this cerebral bleed
Epidural hematoma
400
This IV fluid can decrease cerebral water content
What is hypertonic (3%) saline
400
This symptom may indicate cerebral bleeding post tPA administration
What is change in level of consciousness
500
The patient is now conscious upon arrival at the emergency department with a GCS score of 15. One hour later, the nurse assess a GCS of 3. What is the priority nursing action?
What is Notify the provider immediately?
500
This cranial nerve moves the eyes laterally
What is the abducens (CN VI)
500
An injury where the brain hits both the front and back of the skull is called this
What is coup-counter coup
500
This Medication is used to treat of cerebral edema.
What is Mannitol?
500
A patient with a spinal cord injury at C5-C6 reports a sudden severe headache. The patient is flushed. Vital signs include a blood pressure of 190/100 mm Hg and heart rate of 52 beats/min. What is the priority nursing intervention? A.Notify the health care provider. B.Place the patient in a sitting position. C.Check the patient for fecal impaction. D.Check the urinary catheter for kinks or obstruction.
What is Place the patient in a sitting position?
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