ICP NCLEX QUESTIONS AND ANSWERS.Successful achievement of patient outcomes for the patient with cranial surgery would be best indicated by the
a. ability to return home in 6 days
b. ability to meet all self-care needs
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ICP NCLEX QUESTIONS AND ANSWERS.Successful achievement of patient outcomes for the patient with cranial surgery would be best indicated by the
a. ability to return home in 6 days
b. ability to meet all self-care needs
c. acceptance of residual neurologic deficits
d. absence of signs and symptoms of increased ICP
D. Absence of signs and symptoms of increased ICP- The primary goal after cranial surgery is prevention of increased ICP, and interventions to prevent ICP and infection postoperatively are nursing priorities. The residual deficits, rehabilitation potential, and ultimate function of the patient depend on the reason for surgery, the postoperative course, and the patient's general state of health
While the nurse performs ROM on an unconscious patient with increased ICP, the patient experiences severe decerebrate posturing reflexes. The nurse should
a. use restraints to protect the patient from injury
b. administers CNS depressants to lightly sedate the patient
c. performs the exercises less frequently because posturing can increase ICP
d. continues the exercises because they are necessary to maintain musculoskeletal function
C. Perform the exercises less frequently because posturing can increase ICP- If reflex posturing occurs during ROM or positioning of the patient, these activities should be done less frequently until the patient's condition stabilizes, because posturing can case increases in ICP. Neither restraints nor CNS depressants would be indicated.
A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. The nurse records the patients GCS score as
a. 6
b. 7
c. 9
d. 11
B. 7- no opening of eyes = 1; incomprehensible words= 2, flexion withdrawal = 4
Total = 7
The nurse plans care for a patient with increased ICP with the knowledge that the best way to position the patient is to
a. keep the head of the bed flat
b. elevate the head of the bed to 30 degrees
c. maintain patient on the left side with the head supported on a pillow
d. use a continuous rotation bed to continuously change patient position
B. elevate the head of the bed to 30 degrees
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