An interval when the client is alert but can’t recall recent events. Select all that apply. 22. 23. 3. After reviewing these notes, don’t forget to take the quiz that contains anaphylactic shock NCLEX questions and to watch the lecture. Laceration of the middle meningeal artery Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? Option B: Hypervolemia is indicated by rapid and bounding pulse and edema. NEW STUDY GUIDE In neurogenic shock, vasodilation occurs as a result of a loss of balance between parasympathetic and sympathetic stimulation. Option A: Somatropin or growth hormone, not Vasopressin is used to treat growth failure. 16. Which of the following observations by the nurse indicates that spinal shock persists? Key Concepts: Terms in this set (32) What will the nurse identify as symptoms of hypovolemic shock in a patient? Also, this page requires javascript. © 2021 Nurseslabs | Ut in Omnibus Glorificetur Deus! Option A: Hypertension, bradycardia, flushing, and sweating of the skin are seen with autonomic dysreflexia. Warm, dry skin is consistent with early neurogenic shock, but it does not indicate a need for a change in therapy or immediate action. if the LPN administer meds and lets say the patients seizures are non epilpetic (not sz) then giving phenytoin would be wrong. 4. Guaiac-positive stools Reposition the client to avoid neck flexion, Increase the ventilator’s respiratory rate to 20 breaths/minute. The client momentarily lost consciousness at the time of the injury and then regained it. Types of distributive shock include septic, neurogenic, and anaphylactic shock. Changes in LOC, such as restlessness and irritability, may be subtle. Frequent swallowing after brain surgery may indicate fluid or blood leaking from the sinuses into the oropharynx. Elevating the head of the bed to 30 degrees Craniotomy 4. 2. 1. 1. A client has signs of increased ICP. A nurse assesses a client who has episodes of autonomic dysreflexia. 1. The nurse would avoid which of the following measures to minimize the risk of recurrence? You are given 1 minute per question, a total of 50 minutes for this exam. Decerebrate posturing To hold bony fragments of the skull together. However, because it’s compatible with normal saline solution, it can be injected through an IV line containing normal saline. 2. Deep tendon reflexes Place her in a jacket restraint When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Frequent swallowing after brain surgery may indicate fluid or blood leaking from the sinuses into the oropharynx. 4. The airway doesn’t need to be opened since the client appears alert and not in respiratory distress. Log rolling or turning as a unit when turning If you leave this page, your progress will be lost. Feedback. Neurogenic shock nursing NCLEX review for students! Write. Mannitol (Osmitrol). A 28-mL urinary output over 1 hour would require the nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Answer: 3. Neurogenic shock is often a result of injury or trauma to the spinal cord. Schedule intermittent catheterization every 2 to 4 hours 4. Options B, C, and D: Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs? 3. 3. Option B: Oxygenation is evaluated through PaO2 and oxygen saturation. 20. CEN Neurogenic Shock – Causes. Answer: 3. Neurogenic Shock NCLEX Questions. 6. i agree. April 29, 2016 Staff 0 Comments. So while you’re studying for the NCLEX, don’t forget to be sure you have an understanding of how shock manifests within the human body and how to care for shock patients. 4. As a nursing student, you must be familiar with these neuro disease complications along with how to provide care to a patient experiencing one of these conditions. 3. He’s alert and oriented. Option C: Paraplegia occurs as a result of injury to the thoracic cord and below. Answer: 3. 1. Option A: Internal rotation and adduction of arms with flexion of the elbows, wrists, and fingers described decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres. Neurogenic shock can occur with high spinal cord injuries and other CNS issues – lack of innervation … 2. Option C: A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia. Only $2.99/month. The client has signs and symptoms of autonomic dysreflexia. Answers and rationales are given below. Which type of head injury does this finding suggest? Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation. Give one SL nitroglycerin tablet 2. You’re working on a neuro unit. Hematest positive nasogastric tube drainage. 46. Which of the following is an early indicator of deterioration in the client’s condition? NCLEX Pharmacology Quiz 21 Anesthetic And Narcotic Drugs. This leads to cell hypoxia and eventually multiple organ dysfunction…. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. Distributive shock, also known as vasodilatory shock, is one of the four broad classifications of disorders that cause inadequate tissue perfusion. The NCLEX exam includes many different types of questions including shock NCLEX questions. 38. Apply a wrist restraint to each arm. A client is admitted with a spinal cord injury at the level of T12. By inserting a oropharyngeal airway Anaphylactic Shock NCLEX Review, Lecture on Septic Shock Dilated nonreactive pupils 11. YES! 2. Epidural hematoma. Assess for bladder distention and bowel impaction. 2. He has limited movement of his upper extremities. Putting the client in the high-Fowler’s position will decrease cerebral blood flow, decreasing hypertension. After spinal cord injury, the client can develop paralytic ileus, which is characterized by the absence of bowel sounds and abdominal distention. Dilantin should be mixed in dextrose in water before administration. I have always heard that SATA are more than one choice. Teach patient about the need for good oral hygiene. I hear that if someone starts having a seizure a bystander can even note the length of time of seizure, what kind of behaviors (like jerking, eye rolling, etc) are occurring… Choice A was just documentation. Administer antihypertensive medication Neurogenic Shock NCLEX Review, Lecture on Hypovolemic Shock Knowing is not enough; we must apply. Results in decreased cardiac output. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury? Options A and C: After spinal cord injury, the client can develop paralytic ileus, which is characterized by the absence of bowel sounds and abdominal distention. Headache To prevent syndrome of inappropriate antidiuretic hormone (SIADH) Option D: A history of diarrhea is irrelevant. Which of the following conditions would the nurse anticipate during the acute phase? Answer: 2. Acetazolamide (Diamox) Document the onset time, nature of seizure activity, and postictal behaviors for all seizures. Lumbar spinal cord injury Provide emollients to the skin to prevent breakdown Option D: Crede’s maneuver is not used on people with spinal cord injury. Extent of intracranial bleeding Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? The client has signs and symptoms of autonomic dysreflexia. The nurse also would check for a fecal impaction and disimpact if necessary. 2. Chapter 66: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. Neurogenic shock Please wait while the activity loads. How long do I need to prepare for my NCLEX? A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. 2. Normal ICP is 15 mm Hg or less. Absent corneal reflexes, decerebrate posturing, and hemiplegia occur with brain injuries, not spinal cord injuries. Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce the anti-diuretic hormone. Answer: 2. Answer: 1. Learn. Internal rotation and adduction of arms with flexion of the elbows, wrists, and fingers described decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres. A keyhole pupil is found after iridectomy. A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases ICP. Today. D. Loosen tight clothing on the client Answer: 1. 4. 4. Option A: Garbled speech is known as dysarthria. We will discuss what is next for you after passing NCLEX. 3. Match. Which of the following conditions would most likely be suspected? His intracranial pressure (ICP) shows an upward trend. The client reports a severe, pounding headache. To prevent syndrome of inappropriate antidiuretic hormone (SIADH), To reduce cerebral edema and lower intracranial pressure. Epidural hematoma 4. B. Calcium-channel blocker. Quadriplegia and loss of respiratory function If the tongue or relaxed throat muscles are obstructing the airway, a nasopharyngeal or oropharyngeal airway can be inserted; however, the client must have spontaneous respirations when the airway is open. 2. You can view your scores and the answers to all the questions by clicking on the SHOW RESULT Sequential Easy First Hard First. Don’t forget to take the parkinson’s disease quiz. Which of the following symptoms would also be anticipated? Select all that apply: A. 26. Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Answer: 3. Place the client flat in bed A client with a C6 spinal injury would most likely have which of the following symptoms? 48. Option C: Spinal shock descends from the injury, and respiratory difficulties occur at C4 and above. This may resolve in time. The physician is contacted especially if these actions do not relieve the signs and symptoms. E. Administer an antihypertensive medication therapy is not indicated. (D) In neurogenic shock, there is no capillary delay, the vascular beds are dilated, and peripheral flow is good. Nursing resources for students and nurses. A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. Raise the HOB should be the first action right? Select all that apply: A. Perform Crede’s maneuver to the lower abdomen before the client voids. ... What class of drug is typically used to treat neurogenic shock? You have not finished your quiz. Type I, Immediate Hypersensitivity Disorder B. B. She states that she woke up and noticed that the left side of her face was "not responding" when she tried to blink, smile, or speak. A client with a brain injury Encourage the client to hyperventilate Strict adherence to a bowel retraining program (B) In hypovolemic shock, the client ishypotensive and tachycardiac with cool skin. The cause is a noxious stimulus, most often a distended bladder or constipation. Venous bleeding from the arachnoid space is usually observed with subdural hematoma. Check the fluid for dextrose with a dipstick, Suction the nose to maintain airway patency, Insert nasal and ear packing with sterile gauze. 47. 5. 4. Neurogenic shock; A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. To hold bony fragments of the skull together. 4. Option B: Injury levels C1 to C4 leads to quadriplegia with total loss of respiratory function. More improved and more comprehensive cheat sheets or summaries for normal values, diets, positioning, classic signs, sample calculation, etc. Experts also say that NCLEX tends to give you questions based on what your weakest subject is, say for instance the system detects you are weak on Medical-Surgical then they will give you more questions on that. STUDY. 45. Knowledge application - use your knowledge to answer questions about causes of neurogenic shock Making connections - understand the relationship between the nervous system and neurogenic shock Option B: Profuse or projectile vomiting is a symptom of increased ICP and should be reported immediately. A 20-year-old client who fell approximately 30’ is unresponsive and breathless. “Watch him for keyhole pupil the next 24 hours.” Options A, B, and C: Elevating the client’s legs, putting the client flat in bed, or putting the bed in the Trendelenburg’s position places the client in positions that improve cerebral blood flow, worsening hypertension. 3. Please correct the answer & rationale for 19. The underlying cause of epidural hematoma is usually related to which of the following conditions? Therapeutic Communication Techniques Quiz. Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. 1. Read each question carefully and choose the best answer. Nurseslabs.com is an education and nursing lifestyle website geared towards helping student nurses and registered nurses with knowledge for the progression and empowerment of their nursing careers. Administer an antihypertensive medication. A client is brought to the Emergency Department after sustaining a spinal injury in a boating accident. Wrap her hands in soft “mitten” restraints Which action would be most appropriate? 4. An epidural hematoma occurs when blood collects between the skull and the dura mater. 9. Place the client in a supine position with legs elevated. Reposition the client to avoid neck flexion Insert nasal and ear packing with sterile gauze. Be sure to read them. D. Answer: 3. This condition results from…. During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions? 1. The nurse would avoid which of the following measures to minimize the risk of recurrence? 1. Autonomic Dysreflexia 2. Which of the following symptoms would also be anticipated? 34. This activity contains 10 questions. Significant; the client has alveolar hypoventilation. Hemorrhagic shock 3. Hypovolemic Shock NCLEX Review, Lecture on Anaphylactic Shock Option B: Hemorrhagic shock presents with anxiety, tachycardia, and hypotension; this wouldn’t be suspected without an injury. Noxious stimuli, such as a full bladder, fecal impaction, or a decub ulcer, may cause autonomic dysreflexia. Elevating the head of the bed to 30 degrees. Question 40.. needs fixed, Raise the HOB is first priority!! This causes the cardiac output to fall below the parameters needed to maintain tissue perfusion. 2. 4. Practice Mode – Questions and choices are randomly arranged, the answer is revealed instantly after each question, and there is no time limit for the exam. b. A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. The nurse suspects which of the following conditions? A decrease in the client’s LOC is an early indicator of deterioration of the client’s neurological status. Skip to content. Which intervention should the nurse perform first? The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. Rapid administration can depress the myocardium, causing arrhythmias. ... shock due to a flood of toxins and inflammatory markers. If a Stryker frame is not available, a firm mattress with a bed board should be used. 1. Refer patients with an increased heart becomes unable to support the nurse that mr. Students in patients with an ancc exam score. This was helpful to know how to answer the blessed NCLEX style questions that we were being subjected to. 4. While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. Rapid administration can depress the myocardium, causing arrhythmias. Put the client in the Trendelenburg’s position, Put the client in the high-Fowler’s position. ROM would be contraindicated at this time. There’s no evidence that the client is experiencing renal failure. Post-Traumatic Stress Disorders Practice Tests for NCLEX/CGFNS. Noxious stimuli. A CT scan of the head shows a collection of blood between the skull and dura mater. Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to the loss of adrenergic stimulation below the level of the lesion. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage. What is hypovolemic shock? Neurogenic Shock Nursing NCLEX (Distributive) Treatment, Interventions, Signs and Symptoms . Dilantin should be administered through an IV catheter in the client’s hand. Check deep tendon reflexes to determine the best motor response. 4. Which of the following instructions should be given? Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mm Hg. Neurogenic Shock NCLEX Questions. The nurse minimizes the risk of compounding the injury most effectively by: 1. Focus topic: Emergency Nursing. 1. Settings. Option A: ROM would be contraindicated at this time. After reviewing these notes, don’t forget to take the quiz that contains stages of shock NCLEX questions and to watch the lecture. You are given one minute per question. When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Another nurse needs to assess vital signs and score the client according to the GCS, but time is also of the essence. This medication may be ordered for the head injured patient. Wrap her hands in soft “mitten” restraints, Tuck her arms and hands under the draw sheet. 4. Resolution of spinal shock is occurring when there is a return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, reflex emptying of the bladder, and a positive Babinski’s reflex. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. Comparison of Different Types of Shock. The client’s feelings about the injury. The diaphragm is stimulated by nerves at the level of C4. Answer: 1. If loading fails, click here to try again. 8. Learn vocabulary, terms, and more with flashcards, games, and other study tools. In this review, you will learn about neurogenic shock. 4. A complication of a head injury is diabetes insipidus, which can occur with insult to the hypothalamus, the antidiuretic storage vesicles, or the posterior pituitary gland. Which of the following conditions would the nurse anticipate during the acute phase? ~ Johann Wolfgang von Goethe. 20 Questions: Shock 1. The physician is notified immediately so that treatment can begin before respirations cease. Reflex vasodilation below the level of the spinal cord injury places the client at risk for orthostatic hypotension, which may be profound. Which other findings should the nurse expect? The changes in neurological signs from an epidural hematoma begin with a loss of consciousness as arterial blood collects in the epidural space and exerts pressure. 2. An interval when the client is oriented but then becomes somnolent Spinal or neurogenic shock is characterized by hypotension, bradycardia, dry skin, flaccid paralysis, or the absence of reflexes below the level of injury. Start studying Shock NCLEX style questions. Anaphylactic shock nursing NCLEX review for students! Seizures 10. Answer: 4. Contact the physician The nurse minimizes the risk of compounding the injury most effectively by: The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. Laceration of the middle meningeal artery. 3. Which of the following is an early indicator of deterioration in the client’s condition? Transsphenoidal Hypophysectomy A sudden depression of reflex activity in the spinal cord occurs below the level of injury (areflexia). LPN should not administer phenytoin because it has to be verified if it is a seizure or not which will be verified by the doctor. A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. Which nursing activities included in the patient’s care will be best to delegate to an LPN/LVN whom you are supervising? 19. Feedback. A flattened abdomen 41. 36. Blood or fluid draining from the ear may indicate a basilar skull fracture. 4. Decrease in the pulse rate Nothing is inserted into the ears or nose of a client with a skull fracture because of the risk of infection. Loss of sympathetic control and unopposed vagal stimulation below the level of injury typically cause hypotension, bradycardia, pallor, flaccid paralysis, and warm, dry skin in the client in neurogenic shock. Perform Crede’s maneuver to the lower abdomen before the client voids. Article by Nursing KAMP. Injury levels C1 to C4 leads to quadriplegia with total loss of respiratory function. Whenever possible, the client is placed on a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility, while maintaining alignment of the spine. c. The patient has an apical pulse rate of 58 beats/min. Options C and D: Ethacrynic acid and mannitol are diuretics, which would be contraindicated. The patient’s IV infusion site is cool and pale. A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Mannitol or corticosteroids are used to decrease cerebral edema. Percent of functional brain tissue would be determined by a series of tests. A 22-year-old client has suffered a spinal cord injury in which he is experiencing spinal shock and cannot feel his legs. A. 2. 3. Which of the following nursing interventions should be done first? This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. Example Question #4 : Neural And Psychological Conditions A 27 year old female presents complaining of an inability to "smile normally" or close her left eye. The nurse notes clear fluid draining from his ears and nose. Take this quiz and see your capability to conquer the NCLEX! CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. 10. If you need more clarifications, please direct them to the comments section. Option A: The meatus is always cleaned from front to back in a woman, or in expanding circles working outward from the meatus in a man. Deterioration and pressure produce irregular respiratory patterns. Um, I see that question 50 is a SATA. Sodium bicarbonate. 4. An interval when the client has a “warning” symptom, such as an odor or visual disturbance. 1. Answer: 4. 3. 27. A client has a cervical spine injury at the level of C5. ANS: A The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. 3. Rapid Dilantin administration can cause cardiac arrhythmias. However, cells are experiencing... 3. My name is Sarah and I'm a registered nurse. A nurse is applying for a position at a facility where care is provided to clients who have incomplete spinal cord injuries. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. Pulmonary embolism presents with chest pain, hypotension, hypoxemia, tachycardia, and hemoptysis; this may be a later complication of spinal cord injury due to immobility. Option A: Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. The client now has lost consciousness again. Urinary continence. Thanks. Option B: Vasopressor medications are administered per protocol. 24. Reposition the client to avoid neck flexion. 2. Hypervolemia Absent corneal reflex. Which of the following instructions should be given? The absence of pain sensation in the chest doesn’t apply to spinal shock. It occurs when there is LOW fluid volume in the intravascular system. D. Vasopressor. An LPN/LVN would know to call the supervising RN immediately if a patient started to seize. Septic shock occurs due to sepsis and leads to a major decrease in tissue perfusion to organs and tissues. Percent of functional brain tissue. Distributive shock also leads to leakage of fluid from capillaries into the surrounding tissues, further complicating the … Search for: Recent Posts. Hypertension and bradycardia. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. Option D: Warning symptoms or auras typically occur before seizures. Warm, dry skin is consistent with early neurogenic shock, but it does not indicate a need for a change in therapy or immediate action. Share This Cheatsheet with Someone Who Also Could Use Help . “Measure the quantity of urine.” A client with a high cervical spine injury The other drugs aren’t indicated in this circumstance. Option A: Placing the client flat in bed may increase ICP and promote pulmonary aspiration. 2. 29. Answer: 2. Answer: 3. After hypophysectomy or removal of the pituitary gland, the body can’t synthesize ADH. 44. Option D: A slight headache may last for several days after concussion; severe or worsening headaches should be reported. Chapter 66: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome. 1. Movement of only the right or left half of the body Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? In this review, you will learn about anaphylactic shock. A client who is brain dead typically demonstrates nonreactive dilated pupils and nonreactive or absent corneal and gag reflexes. “Clean the meatus with soap and water.”. To hasten wound healing During the __________ stage of shock, the signs and symptoms are very subtle. An 18-year-old client was hit in the head with a baseball during practice. Spinal or neurogenic shock is characterized by hypotension, bradycardia, dry skin, flaccid paralysis, or the absence of reflexes below the level of injury. Be sure to read them. Quadriplegia with gross arm movement and diaphragmatic breathing, Quadriplegia and loss of respiratory function. Skull fracture An interval when the client is oriented but then becomes somnolent. Dexamethasone (Decadron) Option C: Providing emollients to prevent skin breakdown is important, but doesn’t need to be performed immediately. A client has been pronounced brain dead. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the feet The client now has lost consciousness again. After falling 20’, a 36-year-old man sustains a C6 fracture with spinal cord transaction. Perform a straight catheterization every 8 hours while awake :). The nurse is planning care for the client in neurogenic shock. A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). Neurogenic Shock. Assess patency of the indwelling urinary catheter 1. Create. 2. 47. All questions are given in a single page and correct answers, rationales or explanations (if any) are immediately shown after you have selected an answer. 291. Knowledge application - use your knowledge to answer questions about causes of neurogenic shock Making connections - understand the relationship between the nervous system and neurogenic shock Which of the following responses best describes this result? Take Practice Question # 469 Nclex free Quiz) Spinal shock. In a subarachnoid hemorrhage, blood collects between the pia mater and arachnoid membrane. 37 Questions | By Kblackburn0021 | Last updated: Mar 22, 2015 | Total Attempts: 2518 . We have received excellent feedback of the old version of the Roadmap to NCLEX from our passers, and that’s why Jay Padong, previously an IPASS Reviewer, instructor, who is now in the USA and working as a nurse, went beyond to add more beneficial information to assist you in your NCLEX review. Injuries below L2 cause paraplegia and loss of bowel and bladder control. 616 views 0 … 2. 1. Cardiogenic Shock NCLEX Review. Answer: 2. Option A: In a subdural hematoma, venous blood collects between the dura mater and the arachnoid mater. Sequential Easy First Hard First. High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? 1. She states that she woke up and noticed that the left side of her face was "not responding" when she tried to blink, smile, or speak. Autonomic dysreflexia Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers, Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the feet. An interval when the client has a “warning” symptom, such as an odor or visual disturbance. Stages of shock nursing NCLEX review for nursing students! An EEG measures the electrical activity of the brain. 2. 3. Dilantin shouldn’t be mixed in solution for administration. Put the client in the high-Fowler’s position. 1. Option C: The nose wouldn’t be suctioned because of the risk for suctioning brain tissue through the sinuses.
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