Global rationale cognitive level applying client need

Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 21-4
Question 20
Type: MCSA
A patient has experienced a subarachnoid hemorrhage and is at risk for increased intracranial pressure (ICP) due
to the initiation of the vasodilatory cascade. The nurse plans care for this patient to avoid which primary initiating
factor?
1. Vasoconstriction of cerebral vessels
2. Cerebral tissue ischemia
3. Decreased cerebral perfusion pressure
4. Cerebral edema
Correct Answer:
Rationale 1 : Vasoconstriction of cerebral blood vessels is not a cause of ICP.
Rationale 2 : The vasodilatory cascade is a series of events triggered by hypoxia, with the result being increased
ICP.
Rationale 3 : Depressed cerebral perfusion pressure (CPP) is a decrease in the pressure gradient that drives
cerebral blood flow.
Rationale 4 : Cerebral edema may be a result of the vasodilatory cascade but is not its cause.
2
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 21-2
Question 21
Type: MCMA
A patient at risk for increased intracranial pressure (ICP) is likely to experience involuntary compensatory
mechanisms. The nurse would monitor this patient for signs of which involuntary compensation?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 21-2