Which intervention would the nurse implement as the priority when providing care for a patient with a ventriculostomy to measure increased intra-cranial pressure (ICP) caused by a brain tumor?

Beware of changes in ICP related to leaking cerebrospinal fluid (CSF)

Maintain hyper-oxygenation through use of a ventilator

Use strict aseptic technique with all procedural dressing changes

Administer IV mannitol (Osmitrol)

Answer and Explanation

The Correct Answer is C

A.   Monitoring for CSF leakage is crucial to avoid infection and to maintain ICP accuracy.
B.   Hyper-oxygenation may be used in certain cases but is not the priority.
C.   Aseptic technique for all procedures and dressing changes is critical to prevent infection.
D.   Administering IV mannitol can be important, but aseptic technique is the priority to prevent infection.

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Correct Answer is A

Explanation

A. After retinal detachment surgery, it is essential to restrict head movement to avoid further damage to the retina or to ensure proper healing post-surgery.
B. Apply cool compresses is not typically recommended before or after retinal detachment surgery, as it could cause discomfort or worsen symptoms.
C. Keep both eyes patched is not necessary unless specifically instructed by the surgeon.
D. Eye drops to constrict the pupils are generally used after surgery but are not a preoperative measure.

A. Decreasing Glasgow Coma scores B. Swelling of the optic nerve C. Respiratory rate of 12/min D. Changes to pupil size and shape E. Blood pressure of 108/74 mm Hg

Correct Answer is ["A","B","D"]

Explanation

A. Decreasing Glasgow Coma scores indicate a worsening neurological status and reduced consciousness.
B. Swelling of the optic nerve (papilledema) is a sign of increased ICP and indicates worsening conditions.
C. A respiratory rate of 12/min may be within normal range for some individuals but can also be a sign of impending respiratory depression in cases of severe ICP. However, it is not as immediately concerning as the other options in this case.
D. Changes in pupil size and shape are classic signs of worsening ICP. Unequal or nonreactive pupils are a key indicator.
E. Blood pressure of 108/74 mm Hg is not concerning unless it represents a significant drop from the baseline; other signs of worsening ICP are more critical in this case.

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Which intervention would the nurse implement as the priority when providing care for a patient with a ventriculostomy to measure increased intra-cranial pressure (ICP) caused by a brain tumor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following preoperative instructions should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for a client who has increased intracranial pressure and has a worsening neurologic condition. Which of the following cues should the nurse recognize as a worsening condition? (Select All that Apply.)

Correct Answer is ["A","B","D"]

Explanation

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