Medical-Surgical Nursing Exam 1 Jersey College (longer flash cards) Questions and Answers Best rated A+ Guaranteed Success Latest Update

Strategies for reducing fever/hyperthermia treatment -removing all bedding over the patient (with the possible exception of a light sheet, towel, or small drape) -administering acetaminophen as prescribed -giving cool sponge baths and allowing an electric fan to blow over the patient to increase surface cooling -using a hypothermia blanket -frequent temperature monitoring to assess the patient's response to the therapy and to prevent an excessive decrease in temperature and shivering Early indicators of increasing ICP -change in LOC -agitation -slowing of speech -and delay in response to verbal suggestions are other early indicators GLASGOW COMA SCALE - Eye Opening 4 spontaneous 3 to voice 2 to pain 1 none 8/7/25, 8:06 PM Medical-Surgical Nursing Exam 1 Jersey College (longer flash cards) Flashcards | Quizlet -Best Verbal Response 5 oriented 4 confused 3 inappropriate words 2 incomprehensible sounds 1 none GLASGOW COMA SCALE - Best Motor Response 6 obeys commands 5 localizes pain 4 withdraws 3 flexion 2 extension 1 none How should the patient who is unconscious have their temperature taken? Rectally or tympanic. NEVER BY MOUTH. List interventions to decrease ventilatorassociated pneumonia. (4) -mouth care with antiseptic such as chlorhexidine -tongue scraper -electrical toothbrush -pharmacologic moisturizers Factors that contribute to impaired skin integrity (4) -incontinence -inadequate dietary intake -pressure on bony prominences -edema slow bounding pulse and respiratory irregularities suggest what? increased ICP An increase in the partial pressure of arterial carbon dioxide (PaCO2) causes ? cerebral vasodilation, leading to increased cerebral blood flow and increased ICP A decrease in PaCO2 causes? a vasocontrictive effect, limiting blood flow to the brain. Decreased venous outflow may also increase cerebral blood volume, thus raising the ICP 8/7/25, 8:06 PM Medical-Surgical Nursing Exam 1 Jersey College (longer flash cards) Flashcards | Quizlet Perfusion Pressure (CPP)? CPP = MAP - ICP MAP = mean arterial pressure ICP = intracranial pressure Homan's sign? Pain in the calf upon passive Dorsiflexion of the foot in DVT What are the three signs that make up Cushing's Triad? -bradycardia -hypertension -bradypnea Cessation of cerebral blood flow results in what three things? -cerebral ischemia -infarction -brain death What level should the pressure of the wall suction unit be set to when suctioning a trach patient? 80-120 Rolled towel support placed against the hips and upper leg to prevent external rotation of the leg ? trochanter roll How to preserve corneal integrity? (4) -eye may be cleansed with a cotton ball moistened with sterile NS -artificial tears -- if prescribed, can be instilled q2h -cold compresses -- ifprescribed care must be exerted to avoid contact with the cornea -eye patches -- use with caution to avoid corneal abrasion Signs of urinary infection? (4) -pain -cloudy urine -foul o