A nurse is caring for a child with a closed head injury. Which of the following interventions should the nurse institute to decrease intracranial pressure? Select all that apply. Select one or more: a. Instruct to avoid coughing and blowing nose. b. Keep the head of the bed flat. c. Provide a calm, restful environment. d a nurse is admitting an infant who has severe dehydration from acute gastroenteritis, what finding should the nurse expect. 3% weight loss. a nurse is caring for a child with closed head injury, what interventions should the nurse institute to decrease ICP. avoid extension of the the head. keep the body in alignment Position the child with the head elevated at 30 degrees for 1 hour after meals to prevent reflux, heartburn, abdominal pain, and chest pain. A nurse is caring for a child with a closed head injury. What clinical manifestations would suggest deterioration in this client's condition? ANSWER 4-changes in vital signs-altered mental statu
1. An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? Reposition the client to avoid neck flexion Administer 1 g Mannitol IV as ordered Increase the ventilator's respiratory rate to 20 breaths/minute Administer 100 mg of pentobarbital IV as ordered 51.A nurse is caring for a group of client s. which of the following findings should the nurse report to the provider ? An 18 -month -old toddler who has a heart rate of 68/min. A school-age child who has a rectal body temperature of 37.3C ( 99.1F)
Minor closed head injury is one of the most frequent reasons for visits to a physician. 1 Although >95 000 children experience a traumatic brain injury each year in the United States, 2 consensus is lacking about the acute care of children with minor closed head injury. The evaluation and management of injured children may be influenced by local practice customs, settings where children are. The emergency room nurse is caring for an unconscious 6-year-old girl who has had a severe closed-head injury and notes the following changes in her vital signs. Her heart rate has dropped from 120 to 55, her blood pressure has increased from 110/44 to 195/62, and her respirations are becoming more irregular. After calling the physician A 24 year-old man was admitted to the hospital after receiving a closed head injury in a motor vehicle accident. He had a Glasgow Coma Score of 6 on admission and was being mechanically ventilated. The nurse is caring for a 4 year-old patient with a diagnosis of cystic fibrosis and pneumonia. The child is feeling better on the 3rd day of. When used to treat status epilepticus, diazepam may be given every 10 to 15 minutes, as needed, to a maximum dose of 30 mg. The nurse can repeat the regimen in 2 to 4 hours, if necessary, but the total dose shouldn't exceed 100 mg in 24 hours. The nurse must not administer I.V. diazepam faster than 5 mg/minute
Increased intracranial pressure (ICP) can occur as a sign of a brain tumour, as a consequence of infection or maybe even as a subarachnoid haemorrhage from a fall. When the components in the skull stop being regulated, pressure builds inside of the skull, resulting in increased ICP The critical care nurse is caring for a client with a head injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimuli and assumes decorticate posturing. THe home health nurse is caring for a 22 year old female client who sustained an L-5 spinal cord injry 2 months ago. The ICU is very busy and Mr. A client has a closed head injury. Vital signs are T 103°F rectally; pulse 100; respirations 24; B.P. 110/84. Hourly urine output is 200 ml/hr. The nurse is caring for a 73-year-old patient with chronic pain being treated with opioids. One complication to be monitored for is: constipation. diarrhea. anorexia
1) Emesis of 100 mL. 2) Oral temperature of 37.5° C (99.5° F) 3) Thick, red-colored urine. 4) P ain level of 4 on a 0 to 10 rating scale. 5. A nurse is caring for a client who has a temperatur e of 39.7° C (103.5° F) and has a pr escription. for a hypotherm ia blank et Q. 13 A Nurse is caring for client who has been taking diuretics on long term basis. A fluid volume deficit is suspected. Q. 59 A 10 month old is brought to the emergency room for a head injury after falling down the stairs. An immediate CT Scan is ordered. Q. 67 A 4 year old newly diagnosed with leukemia is placed on bed rest. While. Eight hours until at least 72 hours have elapsed and resident is stable. Neurological assessments include (at a minimum) pulse, respiration, and blood pressure measurements; assessment of pupil size and reactivity; and equality of hand grip strength. Completing the Glasgow Coma Scale immediately, then once each shift following a head injury. A 4-year-old child is diagnosed with otitis media. The mother asks the nurse about the causes of this illness. The nurse responds, knowing that which conditions are risk factors related to otitis media? Select all that apply. 1. Bottle-feeding 2. Household smoking 3. Exposure to illness in other children 4. A history of urinary tract infections 5 A nurse is caring for a 35-year-old client who has been diagnosed with hypovolemic shock as a result of severe hemorrhage. In which position should the nurse place this client to promote optimal circulation? Left side-lying with the head flat ; Supine with the legs elevate
1) An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? Reposition the client to avoid neck flexion Administer 1 g Mannitol IV as ordered Increase the ventilator's respiratory rate to 20 breaths/minute Administer 100mg o The nurse is caring for a 27-year-old patient with a diagnosis of head trauma. The nurse notes that the patient's urine output has increased tremendously over the past 18 hours. The nurse suspects that the patient may be developing: a. diabetes insipidus. b. diabetic ketoacidosis. c. hyperosmolar hyperglycemic syndrome ptg6843614 Contents at a Glance Introduction 1 CHAPTER 1 Practice Exam 1 and Rationales 5 CHAPTER 2 Practice Exam 2 and Rationales 73 CHAPTER 3 Practice Exam 3 and Rationales 145 CHAPTER 4 Practice Exam 4 and Rationales 209 CHAPTER 5 Practice Exam 5 and Rationales 275 APPENDIX A Things You Forgot 341 APPENDIX B Need to Know More? 349 APPENDIX C Alphabetical Listing of Nursing Boards in the 35 Closed chest drainage The nurse is caring for a 12-year-old client with appendicitis. The client's mother is a Jehovah's Witness and refuses to sign the blood permit. What nursing action is most appropriate? and a client with a frontal head injury The client who arrives with a large puncture wound to the abdomen and the client with.
Description. Increased intracranial pressure is a rise in the pressure inside the skull that can result from or cause brain injury. is the pressure in the skull that results from the volume of three essential components: cerebrospinal fluid (CSF), intracranial blood volume and central nervous system tissue. The normal intracranial pressure is between 5-15 mmHg Raise the head of the bed, lower the legs, and remove constrictive clothing. Apply hemodynamic monitoring. Question 2 of 10. A 22-year-old client has suffered a spinal cord injury in which he is experiencing spinal shock and cannot feel his legs. Twenty-four hours after the injury, the client tells the nurse, This will be good for me This nursing test bank set includes 150 NCLEX-style practice questions divided into three parts. Question content of these nursing test banks includes nursing care management of patients with neurological disorders such as stroke, multiple sclerosis, seizures, traumatic brain injury, spinal cord injuries, and more Below are recent practice questions under UNIT 1 -Medical-Surgical Nursing for Respiratory Disorders. You can view your scores and the answers to all the questions by clicking on the SHOW RESULT red button at the end of the questions. 1. A home health nurse is visiting a client with severe chronic obstructive pulmonary disease 10. A 68 year old client is diagnosed with a right-sided brain attack and is admitted to the hospital. In caring for this client, the nurse should plan to: Application of elastic stockings to prevent flaccid by muscle; Use hand roll and extend the left upper extremity on a pillow to prevent contractions; Use a bed cradle to prevent dorsiflexion.
Course: Medical-Surgical Nursing (NUR1211) 90 questions. A nurse is car ing for a client who is having a seizur e. Whic h of the follo wing. interventions in the nurse 's priority? T urn the client to the side. A nurse is car ing for a group of c lients. The nurse sh ould plan to mak e a ref erral to The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply Any injury you receive to your head, that does not go through the skull, is a closed head injury. Closed head injuries can range from minor injuries to devastating, life-threatening major injuries. Count on our experts to help you when you need it the most. Closed head injury can cause broken bones to the skull or face, as well as significant. List the order in which he will assess these clients from first to last.(1. A 50-year-old female with moderate abdominal pain and occasional vomiting.2. A 35-year-old jogger with a twisted ankle. having a pedal pulse and no deformity.3. An ambulatory dazed 25-year-old male with a bandaged head wound.4 13. When planning care for a 8-year-old boy with Down syndrome, the nurse should: Plan interventions according to the developmental level of a 7-year-old child because that's the child's age; Plan interventions according to the developmental levels of a 5-year-old because the child will have developmental delay
A. According to the National Pressure Ulcer Advisory Panel, if a pressureulcer reopens in the same site, the ulcer should be listed at the previous staging. diagnosis (for example, if it was a Stage IV before it closed, it would be a Stage IV when it reopened). 1. Remember that pressure ulcers heal to a progressively more shallow depth Emergency nursing is a nursing specialty that focuses on the care of patients who require prompt medical attention to avoid long-term disability or death. It involves the assessment, diagnosis, and treatment of perceived, actual or potential, sudden or urgent, physical or psychosocial problems that are primarily episodic or acute
. However, you should know the signs to look for in case a problem begins. Your doctor can help you determine this. Severe injuries often require medical attention and a hospital stay. You may need surgery to treat the condition. Call 911 if you are with someone who has a severe head injury 2. Identify age-specific differences in the nurse's response to a patient's rights and basic needs. 3. Identify nursing actions that differ among age groups based upon physical and motor/sensory differences. 4. Identify nursing actions that differ among age groups based upon cognitive differences. 5 A. A 19 year old female who is a quadriplegic. B. A 35 year old male with a BMI of 13.6 that is incontinent of stool and has a right leg splint. C. A 55 year old female who has controlled diabetes and is ambulating three times a day. D. A 76 year old male with an elevated ammonia level and is excessively sweaty. E
. The Glasgow Coma Scale (GCS), designed in 1974, is a tool that has the ability to communicate the level of consciousness of patients with acute or traumatic brain injury. Developed by Graham Teasdale and Bryan J. Jennett, professors of neurosurgery at the University of Glasgow's Institute of Neurological. Nursing Care Plans. Nursing care planning of a patient with a fracture, whether in a cast or in traction, is based upon prevention of complications during healing. By performing an accurate nursing assessment on a regular basis, the nursing staff can manage the patient's pain and prevent complications Injuries to the extremities, spinal cord, head, blood vessels, or nerves can cause sensorimotor deficits. Michael's GCS score stays at 15. He didn't lose consciousness during or after the fall and he can recall the event vividly. His pupils are equal (4 mm/4 mm) and round, and react to light normally A. Acute Care Gladys Howe, a 67-year-old female in congestive heart failure, was admitted to the hospital ICU. a 44-year-old male, is admitted to the Core curriculum for nephrology nursing: Module 4. Acute kidney injury (6th ed., p. 31). Pitman, NJ: American Nephrology Nurses Association. 4. D. Perform all of the above. A to C are al Ask relevant questions related to past or recent history of head injury, neurological illness, or symptoms, confusion, headache, vertigo, seizures, recent injury or fall, weakness, numbness, tingling, difficulty swallowing (dysphagia) or speaking (dysphasia), and lack of coordination of body movements. Focused interview: 2. Assess mental health.
instructions for more specialized wound care will be provided by the nurse or doctor. SITUATION A 36 year old man working in a factory was found after the fire had erupted in the building. He sustained a deep-partial burn on his face, neck, chest and right leg. He was brought subsequently to the nearest hospital Running head: THE IMPORTANCE OF FAMILY-CENTERED CARE 4 nurse can provide support and confidence for a family to learn new skills and make critical decisions. The Benefits of Family-Centered Care There are many benefits associated with the practice of family-centered care. Nurses should not only establish rapport with the patient but also with th Level and zero your EVD. Perform interventions like keeping the head of the bed at between 30 and 45 degrees, and decreasing stimuli to prevent increases in ICP. Finally prepare the patient for a craniectomy or EVD placement if necessary. We love you guys. That is it for this lesson on the care plan for increased ICP While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18/min, and a temperature of 102° F
The nurse is caring for a dehydrated client who is terminally ill. When caring for this client the nurse should take which action? 1. Force the client to eat. 2. Force the client to drink. 3. Use moist cloths and swabs for mouth comfort. 4. Provide the unconscious client with ice chips A client is admitted to the unit 2 hours after an injury with second-degree burns to the face, trunk, and head. The nurse would be most concerned with the client developing what? C. A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury The nurse is caring for a 6-year-old client admitted. Client will be able to report and show manifestations that fever is relieved or controlled through verbatim, temperature of 36.8ᴼC per axilla, respiratory rate of 12- 18 breaths per minute, pulse rate of 60- 75 beats per minute, stable blood pressure, absence of muscular rigidity/ chills and profuse diaphoresis after 4 hours of nursing care .1 mo), Barlow and Minns reported that lowest CPP during intensive care was associated with poorer outcomes in a 6-point scale 3-122 months (mean, 33 mo) after injury (p = 0.0047)
. Children who are 3 years old might have difficulty remembering what each marker represents. c. FACES pain rating scale. The FACES pain rating scale presents client with various faces that represent various levels of pain. A 3-year-old child is able to identify faces that represent different pain. A client with head injury is confused, drowsy and has unequal pupils. 98. A 70-year-old female comes to the clinic for a routine checkup. She is 5 feet 4 inches tall and weighs 180 pounds. 90. A client diagnosed with cerebral thrombosis is scheduled for cerebral angiography. Nursing care of the client includes the following EXCEPT A. a. 1,2 & 4 b. 2, 3 & 4 c. 1, 3 & 4 d. 1,2 & 3 49. Which of the following should be given the HIGHEST PRIORITY before physical examination is done to a patient
The nurse is caring for a 35-year-old client who reports a history of syphilis infection discovered at age 25. The nurse knows that which of the following is true regarding syphilis at this stage? The client will have chancre-like sores in the genital are Closed-head injury is a type of traumatic brain injury in which the skull and dura mater remain intact. Closed-head injuries are the leading cause of death in children under 4 years old and the most common cause of physical disability and cognitive impairment in young people
The 12-‐year-‐old female with flu c. The 12-‐year-‐old boy with flu d. The 12-‐year-‐old boy with leukemia The primary cause of pain is at the site of inflammation is: a. Release of bradykinin. b. Injury to nerve endings. c The nurse is caring for a comatose client who has suffered a closed head injury. What intervention should the nurse implement to prevent an increase in intracranial pressure (ICP)? The nurse is caring for a 74-year-old client with chronic open-angle glaucoma. After the nurse administers pilocarpine (Pilocar), the client reports blurred vision Caring for Someone with a TBI. How to care for a TBI will vary case-by-case. How long and how arduous the road to recovery is will directly affect the type of care needed. Some general tips on how to care for a TBI include: Rest, rest, rest, and rest some more! This goes for both the caregiver and the sufferer of a TBI 3. Discuss the nursing care of pa - tients receiving enteral feeding. The authors and planners of this CNE activity have isc l oed nrv a tf hp w any commercial companies pertaining to this activity. See the last page of the article to learn h ow tea rnCNEc di. Expiration: 1/1/20 CNE 1.4 contact hour
The nurse is caring for a 15-year-old primigravida who visits the clinic for the first time at 20 weeks' gestation. A priority goal for this client is that she'll be able to: A. maintain a steady weight gain until term. B. record the number of fetal movements four times daily. C. attend prenatal care appointments on a regular basis 124. The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition: a. The client has complete bilateral paralysis of the arms and legs. b. The client has weakness on the right side of the body, including the face and tongue. c The nurse is assessing a 3-month-old infant with a head injury for increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel has not closed and is soft and flat. The nurse should first: a) Document the finding. b) Notify the physician. c) Increase oral fluids. d) Elevate the head of the bed. Read.
Increased interest in play13. When planning care for a 8-year-old boy with Down syndrome, the nurse should:a. Plan interventions according to the developmental level of a 7-year-old child because that'sthe child's ageb. Plan interventions according to the developmental levels of a 5-year-old because the childwill have developmental delaysc The majority of head injury in young children is the result of accidental injury, however in children less than 2 years old, 80% or more of deaths from head injury are due to non-accidental trauma.  There is a second peak in head injuries during adolescence Each year, head injuries result in more than 2 million emergency department visits in the United States, with more than 72,000 deaths. An additional 80,000 to 210,000 people with moderate or severe head injuries become disabled or require extended hospital care The nurse is preparing a plan of care for a child with a head injury. On review of the records, the nurse notes that the health care provider has documented decorticate posturing. The nurse plans care knowing that this type of posturing indicates which finding? 1. Damage to the pons 2. Damage to the midbrain 3. Damage to the diencephalon 4 A. A private room down the hall from the nurses' station. B. An isolation room three doors from the nurses' station. C. A semiprivate room with a 32-year-old client who has viral meningitis. D. A two-bed room with a client who previously had bacterial meningitis. 4
A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury. The client who arrives with a large puncture wound to the abdomen and the client with chest pain. The nurse is caring for a 6-year-old client admitted with a diagnosis of conjunctivitis Geriatric Nursing Protocols and Symptoms. These Geriatric Nursing Protocols, published in Evidence-Based Geriatric Nursing Protocols for Best Practice, are included on our site with permission from the authors. You can explore the protocols or common geriatric symptoms to complement these protocols. Use the drop-downs menus below to select. A 19-year-old with a fever of 103.8°F (39.8°C)who is able to identify a sibling but not the place and time.3. A 49-year-old with a compound fracture of the right leg reportingsevere pain.4. A 65-year-old with a flushed face, dry mucous membranes, anda blood sugar of 470 mg/dL A. A 42 year old male with partial-thickness burns on the front of the right and left arms and legs. B. A 25 year old female with partial-thickness burns on the front of the head and neck and front and back of the torso. C. A 36 year old male with full-thickness burns on the front of the left arm. D. A 10 year old with superficial burns on the.