Adult Health 2 - Increased ICP NCLEX

Adult Health 2 - Increased ICP NCLEX 5.0 (1 review) Students also studied Terms in this set (20) Science MedicineNursing Save ICP Nclex Questions, ICP NCLEX sty...120 terms Mariko_Roberts Preview ICP NCLEX style Questions 36 terms Nurse_BrandyPreview Seizures NCLEX 12 terms murkacatPreview SIADH 10 terms flor The nurse is caring for a patient with increased intracranial pressure (IICP). The nurse realizes that some nursing actions are contraindicated with IICP. Which nursing action should be avoided?

• Reposition the patient every two hours.
• Position the patient with the head elevated 30 degrees.
• Suction the airway every two hours per standing

orders.

• Provide continuous oxygen as ordered.

Correct Answer: C

Rationale: If the drainage is cerebrospinal fluid (CSF) leakage from a dural tear, glucose will be present. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. A dural tear does increase the risk for infections such as meningitis, but the nurse should first determine whether the clear drainage is CSF. Blowing the nose is avoided to prevent CSF leakage.A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?

• Blood pressure 130/72, pulse 90, respirations 32
• Blood pressure 148/78, pulse 112, respirations 28
• Blood pressure 156/60, pulse 60, respirations 14
• Blood pressure 110/70, pulse 120, respirations 30

Correct Answer: C

Rationale: Systolic hypertension with widening pulse pressure, bradycardia, and

respiratory changes represent Cushing's triad and indicate that the ICP has increased and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.When assessing a patient with a head injury, the nurse recognizes that the earliest indication of increased intracranial pressure (ICP) is

• vomiting.
• headache.
• change in level of consciousness (LOC).
• sluggish pupil response to light.

Correct Answer: C

Rationale: LOC is the most sensitive indicator of the patient's neurologic status and possible changes in ICP. Vomiting and sluggish pupil response to light are later signs of increased ICP. A headache can be caused by compression of intracranial structures as the brain swells, but it is not unexpected after a head injury.

When the nurse applies a painful stimulus to the nailbeds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as

• decorticate posturing.
• decerebrate posturing.
• localization of pain.
• flexion withdrawal.

Correct Answer: A

Rationale: Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is general, it does not indicate localization of pain or flexion withdrawal.A patient has ICP monitoring with an intraventricular catheter. A priority nursing intervention for the patient is

• aseptic technique to prevent infection
• constant monitoring of ICP waveforms
• removal of CSF to maintain normal ICP
• sampling CSF to determine abnormalities
• Aseptic technique to prevent infection

An intraventricular catheter is a fluid coupled system that can provide direct access for microorganisms to enter the ventricles of the brain, and aseptic technique is a very high nursing priority to decrease the risk for infection.Constant monitoring of ICP waveforms is not usually necessary, and removal of CSF for sampling or to maintain normal ICP is done only when specifically ordered A patient with ICP monitoring has pressure of 12 mm Hg.The nurse understand that this pressure reflects

• a severe decrease in cerebral perfusion pressure
• an alteration in the production of CSF
• the loss of autoregulatory control of ICP
• a normal balance between brain tissue, blood, and CSF
• A normal balance between brain tissue, blood, and CSF- normal is 10- 15 mm

Hg During admission of a patient with a severe head injury to the ED, the nurse places highest priority on assessment for

• patency of of airway
• presence of a neck injury
• neurologic status with Glascow Coma Scale
• CSF leakage from ears and nose
• Patency of airway is the #1 priority with all head injuries

When a patient is admitted to the emergency department following a head injury, the nurse's first priority in management of the patient once a patent airway is confirmed is

• maintaining cervical spine precautions
• determining the presence of increased ICP
• monitoring for changes in neurologic status
• establishing IV access with a large-bore catheter
• In addition to monitoring for a patent airway during emergency care of the

patient with a head injury, the nurse must always assume that a patient with a head injury may have a cervical spine injury. Maintaining cervical spine precautions in all assessment and treatment activities with the patient is essential to prevent additional neurologic damage.The nurse recognizes the presence of Cushing's triad in the patient with

• Increased pulse, irregular respiration, increased BP
• decreased pulse, irregular respiration, increased pulse

pressure

• increased pulse, decreased respiration, increased

pulse pressure

• decreased pulse, increased respiration, decreased

systolic BP

• Cushing's triad consists of three vital sign measures that reflect ICP and its

effect on the medulla, the hypothalamus, the pons, and the thalamus. Because these structures are very deep, Cushing's triad is usually a late sign of ICP. The signs include an increasing systolic BP with a widening pulse pressure, a bradycardia with a full and bounding pulse, and irregular respirations.

A nurse is positioning a client with increased ICP. Which position would the nurse avoid?

• head midline
• head turned to the side
• neck in neutral position
• head of bed elevated 30-45 degrees
• head turned to the side

The head of a client with increased ICP should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the neck or turning the head side to side . The head of the bed should be raised 30-45 degrees . Use of proper position promotes venous drainage from the cranium to keep ICP down A patient with a head injury has bloody drainage from the ear. To determine whether CSF is present in the drainage, the nurse

• examines the tympanic membrane for a tear
• tests the fluid for a halo sign on a white dressing
• tests the fluid with a glucose identifying strip or stick
• collects 5 mL of fluid in a test tube and sends it to the

laboratory for analysis

• Tests the fluid for a halo sing on a white dressing- Testing clear drainage for CSF

in nasal or ear drainage may be done with a Dextrostik or Tes-Tape strip, but if blood is present, the glucose in the blood will produce and unreliable result. To test bloody drainage, the nurse should test the fluid for a halo or ring that occurs when a yellowish ring encircles blood dripped onto a white pad or towel A client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which of the following activities?

• blowing the nose
• isometric exercises
• coughing vigorously
• exhaling during repositioning
• exhaling during repositioning

(activities that increase intra-throacic and intra-abdominal pressures cause indirect elevation of the ICP. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intra-thoracic pressure from rising).The earliest signs of increased ICP the nurse should assess for include

• Cushing's triad
• unexpected vomiting
• decreasing level of consciousness (LOC)
• dilated pupil with sluggish response to light
• One of the most sensitive signs of increased intracranial pressure (ICP) is a

decreasing LOC. A decrease in LOC will occur before changes in vital signs, ocular signs, and projectile vomiting occur A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema. An appropriate nursing intervention for the patient is

• avoiding positioning the patient with neck and hip

flexion

• maintaining hyperventilation to a PaCO2 of 15 to 20

mm Hg

• clustering nursing activities to provide periods of

uninterrupted rest

• routine suctioning to prevent accumulation of

respiratory secretions

• Avoiding positioning the patient with neck and hip flexion- Nursing care

activities that increase ICP include hip and neck flexion, suctioning, clustering care activities, and noxious stimuli; they should be avoided or performed as little as possible in the patient with increased ICP. Lowering the PaCO2 below 20 mm Hg can cause ischemia and worsening of ICP; the PaCO2 should be maintained at 30 to 35 mm Hg.A patient with increased ICP has mannitol (Osmitrol) prescribed. Which option is the best indication that the drug is achieving the desired therapeutic effects?

• Urine output increases from 30 mL to 50 mL/hour.
• Blood pressure remains less than 150/90 mm Hg.
• The LOC improves.
• No crackles are auscultated in the lung fields.

C LOC is the most sensitive indicator of ICP. Mannitol is an osmotic diuretic that works to decrease the ICP by plasma expansion and an osmotic effect. Although the other options may indicate a therapeutic effect of a diuretic, they are not the main reason this drug is given.

You are providing care for a patient who has been admitted to the hospital with a head injury who requires regular neurologic vital signs. Which assessments are components of the patient's score on the Glasgow Coma Scale (select all that apply)?

• Eye opening
• Abstract reasoning
• Best verbal response
• Best motor response
• Cranial nerve function

A,C,D The three dimensions of the Glasgow Coma Scale are eye opening, best verbal response, and best motor response.Which option indicates a sign of Cushing's triad, an indication of increased intracranial pressure (ICP)?

• Heart rate increases from 90 to 110 beats/minute
• Kussmaul respirations
• Temperature over 100.4° F (38° C)
• Heart rate decreases from 75 to 55 beats/minute

.

• Heart rate decreases from 75 to 55 beats/minute

Cushing's triad is systolic hypertension with a widening pulse pressure, bradycardia with a full and bounding pulse, and slowed respirations. The rise in blood pressure is an attempt to maintain cerebral perfusion, and it is a neurologic emergency because decompensation is imminent. The other options are not part of Cushing's triad The patient has rhinorrhea after a head injury. What action should you take?

• Pack the nares with sterile gauze.
• A loose collection pad may be placed under the nose.
• Suction the drainage with an inline suction catheter.
• Obtain a sample for culture.
• A loose collection pad may be placed under the nose.

A loose collection pad may be placed under the nose. Do not place a dressing in the nasal cavity, and nothing should be placed inside the nostril. There is no need to culture the drainage. The concern is whether it is spinal fluid, which is determined by a test for glucose or the halo or ring sign.You plan care for the patient with increased ICP with the knowledge that the best way to position the patient is to

• keep the head of the bed flat.
• elevate the head of the bed to 30 degrees.
• maintain patient on the left side with the head

supported on a pillow.

• use a continuous-rotation bed to continuously change

patient position.

• elevate the head of the bed to 30 degrees.

You should maintain the patient with increased ICP in the head-up position.Elevation of the head of the bed to 30 degrees enhances respiratory exchange and aids in decreasing cerebral edema. You should position the patient to prevent extreme neck flexion, which can cause venous obstruction and contribute to elevated ICP. Elevation of the head of the bed reduces sagittal sinus pressure, promotes drainage from the head through the valveless venous system in the jugular veins, and decreases the vascular congestion that can produce cerebral edema. However, raising the head of the bed above 30 degrees may decrease the cerebral perfusion pressure (CPP) by lowering systemic blood pressure.Careful evaluation of the effects of elevation of the head of the bed on the ICP and the CPP is required.You are caring for a patient admitted with a subdural hematoma after a motor vehicle accident. Which change in vital signs would you interpret as a manifestation of increased intracranial pressure?

• Tachypnea
• Bradycardia
• Hypotension
• Narrowing pulse pressure
• Bradycardia

Changes in vital signs indicative of increased ICP are known as Cushing's triad, which consists of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.