A nurse is assisting a neurosurgeon who is monitoring a client's ...

[geoffrey]

A nurse is assisting a neurosurgeon who is monitoring a client's intracranial pressure (ICP) in the intensive care unit. Which measure is most critical in monitoring the client's intracranial pressure?
 
  A) Monitor and document the client's vital and neurologic signs.
  B) Stop immediately if there is a break in the ICP monitoring system.
  C) Avoid moving the client's head up or down without physician orders.
  D) Observe the client's general appearance as well as mobility level.

Question 2

The nurse is facilitating weaning of a client from mechanical ventilation. The nurse uses ventilation that allows inspiratory and expiratory airway pressures to be maintained above atmospheric pressure and helps keep the client's lungs inflated.
 
  This method tends to improve lung function, even though breathing is spontaneous. What is the term for this mode of ventilation? A) Synchronized intermittent mandatory ventilation (SIMV).
  B) Pressure support ventilation (PSV).
  C) Continuous positive airway pressure (CPAP)
  D) Volume ventilation

[bookworm410]

Answer to Question 1

C
Feedback:
The nurse should take care not to move the client's head up or down without specific orders from the physician. Monitoring and documenting the client's vital signs and neurologic signs are specifically important when assisting during a lumbar puncture; they are not specific measures during ICP monitoring. The nurse should report any break in an ICP monitoring system to the neurosurgeon immediately and not stop it on their own. Observing the client's general appearance and mobility level are important during neurologic nursing assessment, but not specific to ICP monitoring.

Answer to Question 2

C
Feedback:
CPAP allows inspiratory and expiratory airway pressures to be maintained above atmospheric pressure. CPAP helps keep the client's lungs inflated and tends to improve lung function, even though breathing is spontaneous. SIMV gives the client a preset number of mechanical breaths at a certain volume. In addition, the client can take as many breaths at his or her own volume as desired. In PSV, constant pressure is applied as the person inspires, which lessens the inspiratory effort or work needed. Volume ventilation delivers a consistent, preset volume of air with each breath, ensuring adequate breathing.