The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment?
a. CNs, motor function, and sensory function
b. Deep tendon reflexes, vital signs, and coordinated movements
c. Level of consciousness, motor function, pupillary response, and vital signs
d. Mental status, deep tendon reflexes, sensory function, and pupillary response
ANS: C
Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process. These people must be closely monitored for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure. The nurse should use an abbreviation of the neurologic examination in the following sequence: level of consciousness, motor function, pupillary response, and vital signs.
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A) the patient is complaining of a headache. B) the patient's level of consciousness is decreasing. C) the patient has spiked a fever. D) the patient is agitated.
Direct questioning about domestic violence in the home should be:
a. a routine component of history taking with female patients. b. avoided for fear of offending the woman's partner. c. conducted only in cases in which there is a history of abuse. d. used only when the patient is obviously being victimized.
The mother of a 16-week-old infant calls the clinic, concerned because she cannot feel the posterior fontanelle on her infant. Which response by the nurse would be most appropriate?
1. "It is normal for the posterior fontanelle to close by 8–12 weeks after birth." 2. "Bring your infant to the clinic immediately." 3. "This is due to overriding of the cranial bones during labor." 4. "Your baby must be dehydrated."
The term metacommunication is best defined as:
A) congruent relationships in the spoken topics. B) documenting a conversation between the client and nurse. C) contextual factors that impede communication patterns. D) interpersonal bridge between verbal and nonverbal communication.