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7 Cards in this Set

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The relationship of ICP to volume is affected by the brain's elastance and compliance in that:

a. as volume in the brain increases, there is decreased elastance
b. a decrease in compliance occurs as volume and pressure increase
c. with high elastance, an increase in volume does not increase ICP
d. with high compliance, a small increase in volume results in high changes in pressure
b. Compliance is the expansability of the brain, and as volume and pressure increase, compliance is lowered, and elastance increases. Elastance is the inverse of compliance and represents the brain's stiffness and ability to accommodate changes in volume. Elastance increases as volume in the brain increases. With high elastance, or stiffness, large increases in pressure occur with only small increases in volume, and with high compliance, small increases in volume are accomodated.
The earliest signs of increased ICP the nurse should assess for include:

a. Cushing triad
b. unexpected vomiting
c. decreasing LOC
d. dilated pupil with sluggish response to light
c. One of the most sensitive signs of increased ICP is a decreasing LOC.
The nurse recognizes the presence of Cushing triad in the patient with:

a. increased pulse, irregular respiration, increased BP
b. increased pulse, decreased respiration, increased pulse pressure
c. decreased pulse, irregular respiration, increased pulse pressure
d. decreased pulse, increased respiration, decreased systolic BP
c. Cushing triad consists of three VS measures that reflect ICP and its effect on the medulla, the hypothalamus, the pons, and the thalamus. Because these structures are very deep, Cushing triad is usually a late sign of ICP.
Metabolic and nutritional needs of the patient with increased ICP are best met with:

a. enteral feedings that are low in sodium
b. the simple glucose available in D5W IV solutions
c. a fluid restriction that promotes a moderate dehydration
d. balanced, essential nutrition in a form that the patient can tolerate
d. A patient with increased ICP is in a hypermetabolic and hypercatabolic state and needs adequate glucose to maintain fuel for the brain and other nutrients to meet metabolic needs. Malnutrition promotes cerebral edema, and if a patient cannot take oral nutrition, other means of providing nutrition should be used.
The three criteria for the definition of coma are that the patient is unable to . . .
1. speak

2. obey commands

3. open eyes to verbal or painful stimuli
A patient has a nursing dx of altered cerebral tissue perfusion r/t cerebral edema. An appropriate nursing intervention for the patient is:

a. avoiding positioning the patient with neck and hip flexion
b. maintaining hyperventilation to a PaCO2 of 15 to 20 mmHg
c. clustering nursing activities to provide periods of uninterrupted rest
d. routine suctioning to prevent accumulation of respiratory secretions
a. Nursing care activities that increase ICP include hip and neck flexion, suctioning, clustering care activities, and noxious stimuli and should be avoided or performed as little as possible.
An unconscious patient with increased ICP is on ventilatory support. The nurse notifies the physician when ABG results reveal a:

a. pH of 7.43
b. SaO2 of 94%
c. PaO2 of 50 mmHg
d. PaCO2 of 30 mmHg
c. A PaO2 of 50 mmHg reflects a hypoxemia that may lead to further decreased cerebral perfusion and hypoxia and must be corrected. The pH and SaO2 are within normal range, and a PaCO2 of 30 mmHg reflects an acceptable value for the patient with moderate hyperventilation.