Global Rationale Cognitive Level Applying Client Need Physiological Integrity

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 20Type: MCSAA 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 vessels2. Cerebral tissue ischemia3. Decreased cerebral perfusion pressure4. Cerebral edemaCorrect 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 21Type: MCMAA 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