Exam 59: Nursing Management Acute Intracranial Problems

The nurse is caring for a client who has just been admitted with meningococcal meningitis. Which of the following observations requires the nurse to act?

Family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring for a client. Which of the following responses by the nurse is best?

Which of the following assessment information should the nurse collect to determine whether a client is developing post-concussion syndrome?

Which of the following assessment findings should the nurse report immediately to the health care provider when caring for a client with increased intracranial pressure?

The nurse is caring for a client who is unconscious with a traumatic head injury and has a blood pressure of 126/72 mm Hg, and an intracranial pressure of 18 mm Hg. What is the client's cerebral perfusion pressure?

Which of the following assessment findings in a client who was admitted the previous day with a basilar skull fracture is most important to report to the health care provider?

The nurse is caring for a client with increased intracranial pressure (IICP). Which of the following are late signs of IICP? (Select all that apply.)

After the emergency department nurse has received a status report on the following clients who have been admitted with head injuries, which client should the nurse assess first?

The nurse is assessing a client with bacterial meningitis and obtains the following data. Which of the following findings should be reported immediately to the health care provider?

After receiving change of shift report, which of the following clients should the nurse assess first?

The nurse is suctioning a client with a traumatic head injury and notes that the intracranial pressure has increased from 14 to 16 mm Hg. Which of the following actions should the nurse take first?

A client is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the partner. Which of the following actions should the nurse take first?

The nurse is caring for a client who has had a head injury. Which of the following assessment information requires the most rapid action by the nurse?

The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which of the following nursing actions is most important?

The nurse is caring for a client who has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which of the following actions should the nurse take first?

The nurse is caring for a client who has increased intracranial pressure and is disoriented and anxious. Which of the following nursing actions should be included in the plan of care?