GIDDENS CONCEPTS OF NURSING PRACTICE | Intracranial Regulation

1. The nurse is caring for a patient with increased intracranial pressure. Which action is considered unsafe? a. Aligning the neck with the body b.Clustering many nursing activities ANS: It is important to minimize stress and activities that could increase intracranial pressure. Combining many nursing activities could increase oxygen demand and intracranial pressure. This would not be safe. Interventions which can promote venous outflow can help decrease intracranial pressure. The stress of constipation or bowel movements can increase intracranial pressure; stool softeners or laxatives can minimize this. 2. The earliest and most sensitive assessment finding that would indicate an alteration in intracranial regulation would be a. change in level of consciousness. b. inability to focus visually. c. loss of primitive reflexes. d. unequal pupil size. ANS: A change in level of consciousness is the earliest and most sensitive indication of a change in intracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which assesses eye opening and verbal and motor response. The inability to focus may indicate a change, but it is not one of the earliest indicators or a component of the GCS. Primitive reflexes refers to those reflexes found in a normal infant that disappear with maturation. These reflexes may reappear with frontal lobe dysfunction and may be tested for with a suspected brain injury, so it would be the reappearance of primitive reflexes. A change in pupil size or unequal pupils may indicate a change, but they are not one of the earliest indicators or a component of the GCS. REF: 107 OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation 3. When caring for the patient aft...

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