Review terms and
definitions Focus your studying with a path Get faster at matching terms RATIONALE: The nurse should
assess the client for spinal shock, which is the immediate response to spinal cord transection. Hypotension occurs and the body loses core temperature to environmental temperature. The nurse must treat the client immediately to manage hypotension and hypothermia. The nurse should also ensure that there is an adequate airway and respirations; there may be respiratory compromise due to intercostal muscle involvement. Once the client is stable, the nurse should conduct a complete neurologic check.
The nurse should take all precautions to keep the client's head, neck, and spine position in straight alignment. If the client is conscious, the nurse should briefly assess major reflexes, such as the Achilles, patellar, biceps, and triceps tendons, and sensation of the perineum for bladder function. CORRECT ANSWER: C,D,E Sets found in the same folderWhat is contraindicated with increased ICP?Patients with increased ICP from mass lesions often display decreased levels of consciousness, focal neurological signs or papilledema on physical exam. Any of these findings make lumbar puncture contraindicated until further evaluation can be undertaken.
What should I avoid with ICP?Avoid processed meats like deli meats, bacon, hot dogs and sausage. Dairy products to reduce or avoid include full fat milk, cream and full fat cheeses such as cheddar. Avoid high amounts of caffeine.
What are interventions for increased intracranial pressure?Interventions to lower or stabilize ICP include elevating the head of the bed to thirty degrees, keeping the neck in a neutral position, maintaining a normal body temperature, and preventing volume overload. The patient must be stabilized before transport to radiology for brain imaging.
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Which intervention would be contraindicated for a client being treated for increased intracranial pressure ICP )?
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