Intracranial Pressure and Consciousness Assessment

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Questions and Answers

A client with a spinal cord injury at T4 is experiencing a headache and a rising blood pressure. Which of the following actions should the nurse prioritize?

Check the client's urinary catheter for blockage. (correct)

Assess the client's bowel sounds for constipation.

Elevate the client's head of bed to 30 degrees.

Administer pain medication as prescribed.

A nurse is caring for a client with a C5 spinal cord injury. Which of the following nursing diagnoses should be prioritized?

Ineffective airway clearance related to high cervical spinal cord injury. (correct)

Impaired urinary elimination related to bladder dysfunction.

Disturbed sleep pattern related to pain and discomfort.

Risk for impaired skin integrity related to decreased mobility.

A nurse is assessing a client with a spinal cord injury at T6 who is restless, flushed, and has a blood pressure of 140/98 and a heart rate of 52. What action should the nurse take first?

Assess the client's level of consciousness and pupillary response.

Administer antihypertensive medication as ordered.

Notify the physician immediately regarding the client's vital signs.

Position the client in an upright position with legs lowered. (correct)

Which of the following symptoms is most suggestive of autonomic dysreflexia in a client with a spinal cord injury?

Hypertension and headache. (A) Signup and view all the answers

A nurse is providing education to a new graduate nurse about autonomic dysreflexia. Which of the following common causes should be included in the teaching?

Constipation, distended bladder, and pressure injury on the scrotum. (D) Signup and view all the answers

A client with a spinal cord injury at T3 is experiencing a throbbing headache. What action should the nurse take first?

Assess the client's vital signs, especially blood pressure. (A) Signup and view all the answers

Which of the following interventions is most appropriate for a client experiencing autonomic dysreflexia?

Performing urinary catheterization. (A) Signup and view all the answers

Which of the following is a priority nursing assessment after a client with a spinal cord injury has experienced autonomic dysreflexia?

Bladder distention. (C) Signup and view all the answers

A nurse is educating a patient with a complete spinal cord injury at T4 about autonomic dysreflexia. Which of the following statements by the nurse is most appropriate?

Autonomic dysreflexia is a life-threatening medical emergency that can lead to stroke or heart attack if left untreated. (E) Signup and view all the answers

Which of the following is NOT a typical sign of increased intracranial pressure?

Increased respiratory rate (A) Signup and view all the answers

What is Cushing’s Triad?

Increased blood pressure, decreased heart rate, decreased respirations (C) Signup and view all the answers

What type of stroke is most associated with impulsive decisions and difficulty staying in bed?

Right hemisphere stroke (A) Signup and view all the answers

What is a priority nursing instruction for a client with a T1 spinal cord injury?

Inform the client that full function of their arms will be restricted (C) Signup and view all the answers

Which group should a nurse target in a community education session on preventing spinal cord injuries?

Adolescents and young men (A) Signup and view all the answers

Which intervention is most effective in improving communication with a client suffering from expressive aphasia?

Using 'yes' or 'no' questions (C) Signup and view all the answers

What is a common finding on a CT scan for a patient who has experienced damage to the cerebellum after a stroke?

Balance impairment (D) Signup and view all the answers

What is the main reason an initially incomplete spinal cord injury can progress to complete cord damage?

Secondary injury from edema, hemorrhage, and metabolites (B) Signup and view all the answers

What does the administration of dopaminergic agents help to confirm in a patient being evaluated for Parkinson's disease?

Relief of symptoms (A) Signup and view all the answers

Why might it be difficult to predict the extent of impairment for a patient with a spinal cord injury in the immediate aftermath?

The secondary injury to the cord may continue for up to a week (A) Signup and view all the answers

What is the primary pathophysiological mechanism involved in secondary spinal cord injury?

Necrotic destruction of the cord due to hemorrhage and edema (C) Signup and view all the answers

What initial intervention should a nurse consider for a patient with Parkinson's disease who has trouble initiating movement?

Using an elevated toilet seat (C) Signup and view all the answers

What does the response of moving a hand to the face upon supraorbital notch pressure indicate?

Localizing response (B) Signup and view all the answers

Which procedure is contraindicated in a patient with increased intracranial pressure?

Lumbar puncture (D) Signup and view all the answers

Which vital sign assessment best indicates a patient experiencing Cushing triad?

BP: 200/60, HR: 50, RR: 8 (C) Signup and view all the answers

What is the first assessment that should be performed for a patient admitted with a C4 spinal cord injury?

Auscultation of lung sounds (B) Signup and view all the answers

What is a key indication for early surgical intervention in a patient with spinal cord injury?

Evidence of continued compression of the cord (C) Signup and view all the answers

Which clinical sign indicates the presence of neurogenic shock in a patient with acute spinal cord injury?

Bradycardia (C) Signup and view all the answers

What action can help prevent autonomic dysreflexia in a patient with paraplegia?

Teach about bowel program (C) Signup and view all the answers

How do generalized seizures differ from focal seizures?

Generalized seizures have bilateral synchronous discharges (A) Signup and view all the answers

Which characteristic is associated with complex focal seizures?

Automatisms such as lip-smacking (C) Signup and view all the answers

Which type of seizure poses the highest risk of mortality?

Tonic-clonic status epilepticus (B) Signup and view all the answers

What is the term used for the slight jerking of a patient's arm when assessing for Parkinson's disease?

Cogwheel rigidity (C) Signup and view all the answers

Which type of seizure is considered a medical emergency requiring immediate treatment?

Status epilepticus (A) Signup and view all the answers

Seizures are classified primarily into which categories?

Focal and generalized seizures (C) Signup and view all the answers

What should a patient be advised regarding the use of oral contraceptives while taking phenytoin?

An alternative form of birth control should be used (C) Signup and view all the answers

After a patient experiences tinnitus, diplopia, and dysarthria with no residual effects, what might the nurse anticipate teaching about?

Oral low dose aspirin therapy (D) Signup and view all the answers

When assessing a 70-year-old patient for stroke risk, what information should prompt the nurse to consult with the healthcare provider before administering aspirin?

A report of severe headache as the onset of symptoms (A) Signup and view all the answers

What should a nurse instruct a patient with cerebral atherosclerosis regarding clopidogrel?

To call the healthcare provider if stools are black or tarry (D) Signup and view all the answers

In a patient experiencing facial drooping and paralysis, which clinical manifestation should the nurse expect to find?

Difficulty understanding instructions (C) Signup and view all the answers

What is a correct description of carotid endarterectomy?

It removes obstructing plaque from the artery in the neck (A) Signup and view all the answers

What is the expected action for a patient presenting with hemiparesis and dysarthria who has a history of transient ischemic attacks?

Tissue plasminogen activator (tPA) infusion (D) Signup and view all the answers

Study Notes

Glasgow Coma Scale Use

Used to quickly assess level of consciousness.

Intracranial Pressure (ICP)

A client with ICP of 12mmHg has an imbalance between brain tissue, blood, and Cerebrospinal Fluid (CSF).
The best position for a client with increased ICP is with the head of the bed elevated 30 degrees.

Nasal Drainage

If a client has clear nasal drainage after a head injury, check for glucose.

Altered Level of Consciousness (LOC)

A rapidly changing LOC is a priority assessment.

Intracranial Pressure Contributing Factors

Brain tissue, cerebral fluid, and blood.

Increased ICP Risk Factors

Traumatic brain injury.
Cerebral hemorrhage.

Early Indicators of Increased ICP

Restlessness.

Cerebral Perfusion Pressure (CPP) Calculation

CPP = Mean Arterial Pressure (MAP) - Intracranial Pressure (ICP).
Normal CPP is 70-100mmHg.

Posturing

Decerebrate posturing (arms and legs extended) indicates increased ICP.

Positioning with Increased ICP

Avoid flexion of the neck and hips.

Normal Intracranial Pressure

15mmHg.

Interventions to Avoid with Increased ICP

Frequent suctioning to maintain a clear airway.

Cushing's Triad

Increased blood pressure, decreased heart rate, and decreased respirations.

Spinal Cord Injury Teaching

Include information about full function limitations for clients and families with T1 spinal cord injuries.
Target adolescent and young men in spinal cord injury prevention education.

Complete Cord Damage

Initially incomplete spinal cord injuries may lead to complete damage due to edema, hemorrhage, and metabolite infraction and necrosis of the cord.

Secondary SCI Pathophysiology

Necrotic destruction of the cord due to hemorrhage and edema.

Spinal Cord Injury Immobilization

Skeletal traction with skull tongs.

Urinary Function Maintenance in Acute Spinal Cord Injury

Indwelling catheter.

Neurogenic Shock

Bradycardia is a clinical modification of neurogenic shock in clients with acute spinal cord injuries.

Autonomic Dysreflexia

Signs of autonomic dysreflexia includes throbbing headache and increasing blood pressure.
Assess bladder distension in a client with suspected autonomic dysreflexia.

Risk Factors for Autonomic Dysreflexia

Spinal cord injury at C7.

Initial Interventions for Autonomic Dysreflexia

Assessing the patient's blood pressure.

Causes of Autonomic Dysreflexia

Bladder distension; pressure injury on the scrotum, fecal impaction, urinary tract infection.

Imaging for Spinal Cord Injury

MRI; gold standard for imaging ligament injury to the spinal cord vertebrae.

Neurogenic Shock Hypotension

The loss of ability to regulate blood vessel diameter, causing vasodilation.

Spinal Cord Injury Safety Priority

Maintaining spinal immobilization.

Venus Pooling and DVT Prevention

Place a pillow under the knees.

Eye Component Assessment

Spontaneous eye opening, to verbal stimuli, pain, non-testable

Scoring in GCS

Score and rate and check observable response, for eye movement, verbal response and motor response.
Record result as a score ranging from 3 (most severe, comatose) to 15 (fully alert and responsive).

Recording with GCS

For example, eyes not testable (NT)

Supratrochlear Pinch Stimuli

Use to assess motor response, if bending to touch the stimuli or to move hand towards face.

Parkinson's Disease

Symptoms, tremor, rigidity, and bradykinesia
Dopaminergic agents
Levodopa (precursor of dopamine), that helps to reduce nausea.
Carbidopa, an agent with levodopa to prevent peripheral tissue metabolism before reaching brain.
Cautious lifting of toes and wide stance for gait balance in individuals with Parkinson's Disease.

Parkinson's Disease Intervention for Initiating Movement

Use of canes and walkers, which are prone to injury.

Stroke-like Symptom Assessment

The "FAST" assessment (facial drooping, arm weakness, speech difficulties, and time) is crucial.
Impulsive decision-making (inability to make correct decisions) for stroke patients.

Cerebellum Damage After Stroke

Balance impairment and muscle soreness and pain.

Parkinson's Disease Diagnostic Confirmation

Medications such as dopaminergic agents.

Falls Prevention in Parkinson's

Maintaining a wide stance, Cautiously lift the toes when stepping.

Stroke Treatment

tPA (tissue plasminogen activator) administered within 3-4.5 hours following symptom onset.

Hemorrhagic Stroke

Contraindicated to administer tPA.

Open-angle Glaucoma

Aqueous humor cannot drain.
Peripheral vision loss is typical.

Vertigo vs. Ménière's Disease

The main difference is their pathology: vertigo is characterized by episodic vertigo, whereas Ménière's disease is characterized by episodic vertigo, hearing loss, tinnitus, and a sense of fullness in the ear.

Otosclerosis Symptoms

Progressive hearing loss that is typically conductive in nature.

Acute Otitis Media Symptoms

High-pitched crying, ear pulling.

Otitis Media with Effusion (OME)

Fluid behind the eardrum without signs of infection is present

Communicating vs. Noncommunicating Hydrocephalus

Communicating: Impaired CSF absorption.
Noncommunicating: Blockage in ventricular system.

Intracranial Aneurysm Symptoms

A sudden, severe headache described as the worst headache of a patient's life.

Intracranial Aneurysm Nursing Intervention

Maintain calm and quiet environment to reduce blood pressure and stress.

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Description

This quiz assesses your knowledge of intracranial pressure (ICP), Glasgow Coma Scale usage, and altered levels of consciousness. It covers critical concepts related to ICP management, assessment of brain function, and early indicators of increased ICP. Prepare to test your understanding of essential clinical practices in neuroscience.