Clients with brain attacks and brain injury may have a nursing diagnosis of Adaptive Capacity: Intracranial, Decreased
Which of the following defining characteristics or related factors alert the nurse to the possibility of a client problem, verifying this nursing diagnosis? (Select all that apply.) A. Baseline ICP less than 11 mm Hg
B. Increase of ICP above 20 mm Hg that is sustained for more than 5 minutes following a sin-gle environmental or nursing maneuver stimulus
C. Decreased perfusion pressure less than 50 mm Hg
D. Systemic hypertension with intracranial hypertension
E. Decrease in Glasgow Coma Scale of 2 or more points
F. New unilateral pupil dilation
B, C, E, F
Rationale: Normal ICP is defined as less than 10 mm Hg. Cerebral perfusion pressure of 50 to 60 mm Hg can lead to impaired brain tissue perfusion, secondary damage, and decreased function. One way to improve brain tissue perfusion is to promote a controlled systemic hypertension in the presence of refractory increased intracranial pressure. A decrease in the GCS score of 2 or more points or new unilateral pupil dilation is considered a neurosurgical emergency and requires communication with the physician and probably a CT scan to determine the unexpected change in neurologic status.
You might also like to view...
Which one of the following assessments would not be pertinent when determining teaching strategies for a home care client with a new colostomy?
A. Degree of mental alertness. B. Whether the client is right- or left-handed. C. Bowel habits prior to surgery. D. Degree of abdominal distention.
While caring for a postpartum patient who had a vaginal delivery yesterday, the nurse assesses a firm uterine fundus and a trickle of bright blood. How does the nurse most likely feel and react to this finding?
a. Concerned and reports a probable cervical laceration b. Attentive and massages the uterus to expel retained clots c. Distressed and reports a possible clotting disorder d. Satisfied with the normal early postpartum finding
Which of these phrases BEST describes an emergency within the context of health care?
a. a sudden disruption in normal functioning with serious consequences b. a disturbance in homeostasis that prevents normal body activity c. a medical condition requiring immediate intervention d. a health care crisis occurring when normal care procedures cannot be carried out
Nurses who work with patients who have cognitive disorders know that the current trend in treatment is to:
A) Maintain the patients in their community as long as possible B) Medicate the patients with high doses of antianxiety medications C) Provide the patients with intensive occupational therapy D) Make the patients responsible for their own actions and decisions