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The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of ineffective cerebral tissue perfusion. What would be an expected outcome that the nurse would document for this diagnosis?
- A. Copes with sensory deprivation.
- B. Registers normal body temperature.
- C. Pays attention to grooming.
- D. Obeys commands with appropriate motor responses.
Correct Answer: D
Rationale: Obeying commands with appropriate motor responses indicates improved cerebral perfusion. Other outcomes relate to sensory perception, thermoregulation, or body image, not perfusion.
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The nurse has created a plan of care for a patient who is at risk for increased ICP. The patients care plan should specify monitoring for what early sign of increased ICP?
- A. Disorientation and restlessness
- B. Decreased pulse and respirations
- C. Projectile vomiting
- D. Loss of corneal reflex
Correct Answer: A
Rationale: Disorientation and restlessness are early signs of increased ICP. Decreased pulse, vomiting, and loss of reflexes are later manifestations.
The nurse is caring for a patient with a brain tumor. What drug would the nurse expect to be ordered to reduce the edema surrounding the tumor?
- A. Solumedrol
- B. Dextromethorphan
- C. Dexamethasone
- D. Furosemide
Correct Answer: C
Rationale: Dexamethasone reduces edema around brain tumors. Solumedrol is less specific, furosemide is not ideal, and dextromethorphan is for cough suppression.
A school nurse is called to the playground where a 6-year-old girl has been found unresponsive and staring into space, according to the playground supervisor. How would the nurse document the girls activity in her chart at school?
- A. Generalized seizure
- B. Absence seizure
- C. Focal seizure
- D. Unclassified seizure
Correct Answer: B
Rationale: Staring and unresponsiveness characterize an absence seizure, common in children. Generalized and focal seizures involve motor activity, and unclassified seizures lack clear patterns.
A patient with increased ICP has a ventriculostomy for monitoring ICP. The nurses most recent assessment reveals that the patient is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication?
- A. Encephalitis
- B. CSF leak
- C. Meningitis
- D. Catheter occlusion
Correct Answer: C
Rationale: Nuchal rigidity and photophobia are signs of meningitis, a potential ventriculostomy complication. Encephalitis, CSF leak, and catheter occlusion present differently.
The nurse is caring for a patient who sustained a moderate head injury following a bicycle accident. The nurses most recent assessment reveals that the patients respiratory effort has increased. What is the nurses most appropriate response?
- A. Inform the care team and assess for further signs of possible increased ICP.
- B. Administer bronchodilators as ordered and monitor the patients LOC.
- C. Increase the patients bed height and reassess in 30 minutes.
- D. Administer a bolus of normal saline as ordered.
Correct Answer: A
Rationale: Increased respiratory effort may indicate rising ICP, requiring immediate team notification and further assessment. Bronchodilators, bed elevation, or saline are inappropriate initial actions.