EXAM 4 NSG-4100 QUESTIONS AND ANSWERS A+ GRADED. Buy Quality Materials!

EXAM 4 NSG-4100 QUESTIONS AND ANSWERS A+ GRADED. Buy Quality Materials! halo sign blood stain surrounded by a yellowish stain; highly suggestive of a cerebrospinal fluid leak Battle's sign Bruising behind the ears, indicative of a basilar skull fracture Neuro exams after brain injury should include public dilation soft sensory response cardinal gazes Primary brain injury Focal (impact), polar (brain shift) or diffuse (brain movement in cranial cavity) Secondary brain injury Results in ischemia, increased ICP, altered vascular regulation Geriatric brain injury considerations Higher mortality rates, poorer functional outcomes Etiology of increased ICP swelling of brain tissue, increased blood volume, increased CSF stroke, tumor, trauma CM of increased ICP first indication is usually a decreasing level of consciousness or decreased responsiveness -Severe headache -Vomiting -Papilledema - pupils unequal Types of posturing for increased ICP decerebrate decorticate flaccid Nursing interventions for increased ICP Seizure precautions nutritional management elevate head of bed Treatment for increased ICP keep HOB 30, keep patient calm/quiet, avoid suctioning, avoid hip flexion, medications to decrease hypothermia, sedation, hypertonic solution ICP range 5-15 CPP range 60-100 Cushing's triad three classic signs—bradycardia, hypertension, and bradypnea—seen with pressure on the medulla as a result of brain stem herniation head trauma, tumor, or infection are the main causes medical interventions for increased ICP Osmotic diuretics (Mannitol), hypertonic saline (3%) Restrict fluids Drain CSF Control fever (decreases metabolic needs) Maintain BP Decrease metabolic demands: sedatives or barbiturates (comatose state) Burr holes Craniotomy(replace bone)/Craniectomy(leave open): watch for increasing BP Nursing interventions for increased ICP no flexion of neck or hips (increased intraabominal pressure) Stool softeners or laxatives if pupils become larger, this means that the ICP is increased Priority for any altered LOC is airway patency arms and legs held straight out, toes beingpointed downward, and the head and neck being archedbackward Decerebrate stiff with legs held out straight, fists clenched, and arms bent to hold the hands on the chest Decorticate no movement; most severe flaccidity Cause of cerebral aneurysms • High blood pressure • Acute intoxication • Recreational drug use (especially cocaine) • Congenital defects CM of cerebral aneurysm Stiff neck & vasospasm S/S of cerebral aneurysm Severe generalized headache, photophobia, N&V, stiff neck