Chapter 14 NCLEX questions

Class 15- Intracranial Regulation -Head Injury/Hydrocephalus Nclex Leave the first rating Students also studied Terms in this set (52) Science MedicineNeurology Save Chapter 14 NCLEX questions 32 terms brennaleestuard Preview ICP Nclex Questions, ICP NCLEX sty...120 terms Mariko_Roberts Preview Seizures NCLEX 12 terms murkacatPreview

Exam 1:

13 terms dan

• Select the main structures below that play a role with

altering intracranial pressure:*

• Brain
• Neurons
• Cerebrospinal Fluid
• Blood
• Periosteum
• Dura mater

The answers are A, C, and D. Inside the skull are three structures that can alter intracranial pressure. They are the brain, cerebrospinal fluid (CSF), and blood.

• The Monro-Kellie hypothesis explains the

compensatory relationship among the structures in the skull that play a role with intracranial pressure. Which of the following are NOT compensatory mechanisms performed by the body to decrease intracranial

pressure naturally? Select all that apply:*

• Shifting cerebrospinal fluid to other areas of the brain

and spinal cord

• Vasodilation of cerebral vessels
• Decreasing cerebrospinal fluid production
• Leaking proteins into the brain barrier

The answers are B and D. These are NOT compensatory mechanisms, but actions that will actually increase intracranial pressure. Vasoconstriction (not dilation) decreases blood flow and helps lower ICP. Leaking of protein actually leads to more swelling of the brain tissue. Remember water is attracted to protein (oncotic pressure).

• A patient is being treated for increased intracranial

pressure. Which activities below should the patient avoid performing?*

• Coughing
• Sneezing
• Talking
• Valsalva maneuver
• Vomiting
• Keeping the head of the bed between 30- 35 degrees

The answers are A, B, D, and E. These activities can increase ICP.

• A patient is experiencing hyperventilation and has a

PaCO2 level of 52. The patient has an ICP of 20 mmHg.As the nurse you know that the PaCO2 level will?*

• cause vasoconstriction and decrease the ICP
• promote diuresis and decrease the ICP
• cause vasodilation and increase the ICP
• cause vasodilation and decrease the ICP

The answer is C. An elevated carbon dioxide level in the blood will cause vasodilation (NOT constriction), which will increase ICP (normal ICP 5 to 15 mmHg). Therefore, many patients with severe ICP may need to be mechanical ventilated so PaCO2 levels can be lowered (30-35), which will lead to vasoconstriction and decrease ICP (with constriction there is less blood volume and flow going to the brain and this helps decrease pressure)....remember Monro- Kellie hypothesis.

• You're providing education to a group of nursing

students about ICP. You explain that when cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies. A student asks, "What is a normal cerebral perfusion pressure level?"

Your response is:*

• 5-15 mmHg
• 60-100 mmHg
• 30-45 mmHg
• >160 mmHg

The answer is B. This is a normal CPP. Option A represents a normal intracranial pressure.

• Which patient below is at MOST risk for increased

intracranial pressure?*

• A patient who is experiencing severe hypotension.
• A patient who is admitted with a traumatic brain injury.
• A patient who recently experienced a myocardial

infarction.

• A patient post-op from eye surgery.

The answer is B. Remember head trauma, cerebral hemorrhage, hematoma, hydrocephalus, tumor, encephalitis etc. can all increase ICP.

• A patient with increased ICP has the following vital

signs: blood pressure 99/60, HR 65, Temperature 101.6 'F,

respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these findings you would?*

• Administered PRN dose of a vasopressor
• Administer 2 L of oxygen
• Remove extra blankets and give the patient a cool

bath

• Perform suctioning

The answer is C. It is important to monitor the patient for hyperthermia (a fever). A fever increases ICP and cerebral blood volume, and metabolic needs of the patient. The nurse can administer antipyretics per MD order, remove extra blankets, decrease room temperature, give a cool bath or use a cooling system.Remember it is important to prevent shivering (this also increases metabolic needs and ICP).

• A patient has a ventriculostomy. Which finding would

you immediately report to the doctor?*

• Temperature 98.4 'F
• CPP 70 mmHg
• ICP 24 mmHg
• PaCO2 35

The answer is C. A ventriculostomy is a catheter inserted in the area of the lateral ventricle to assess ICP. It will help drain CSF during increase pressure readings and measure ICP. The nurse must monitor for ICP levels greater than 20 mmHg and report it to the doctor.

• External ventricular drains monitor ICP and are

inserted where?*

• Subarachnoid space
• Lateral Ventricle
• Epidural space
• Right Ventricle

The answer is B. External ventricular drains (also called ventriculostomy) are inserted in the lateral ventricle.

• Which of the following is contraindicated in a patient

with increased ICP?*

• Lumbar puncture
• Midline position of the head
• Hyperosmotic diuretics
• Barbiturates medications

The answer is A. LPs are avoided in patients with ICP because they can lead to possible brain herniation.

• You're collecting vital signs on a patient with ICP. The

patient has a Glascoma Scale rating of 4. How will you assess the patient's temperature?*

• Rectal
• Oral
• Axillary

The answer is A. This GCS rating demonstrates the patient is unconscious. If a patient is unconscious the nurse should take the patient's temperature either via the rectal, tympanic, or temporal method. Oral and axillary are not reliable.

• A patient who experienced a cerebral hemorrhage is

at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication?*

• Bradycardia
• Decerebrate posturing
• Restlessness
• Unequal pupil size

The answer is C. Mental status changes are the earliest indicator a patient is experiencing increased ICP. All the other signs and symptoms listed happen later.

• Select all the signs and symptoms that occur with

increased ICP:*

• Decorticate posturing
• Tachycardia
• Decrease in pulse pressure
• Cheyne-stokes
• Hemiplegia
• Decerebrate posturing

The answers are A, D, E, and F. Option B is wrong because bradycardia (not tachycardia) happens in the late stage along with an INCREASE (not decrease) in pulse pressure.

• You're maintaining an external ventricular drain. The

ICP readings should be?*

• 5 to 15 mmHg
• 20 to 35 mmHg
• 60 to 100 mmHg
• 5 to 25 mmHg

The answer is A. Normal ICP should be 5 to 15 mmHg.

• Which patient below with ICP is experiencing

Cushing's Triad? A patient with the following:*

A. BP 150/112, HR 110, RR 8

B. BP 90/60, HR 80, RR 22

C. BP 200/60, HR 50, RR 8

D. BP 80/40, HR 49, RR 12

The answer is C. These vital signs represent Cushing's triad. There is an increase in the systolic pressure, widening pulse pressure of 140 (200-60=140), bradycardia, and bradypnea.

• The patient has a blood pressure of 130/88 and ICP

reading of 12. What is the patient's cerebral perfusion pressure, and how do you interpret this as the nurse?*

• 90 mmHg, normal
• 62 mmHg, abnormal
• 36 mmHg, abnormal
• 56 mmHg, normal

The answer is A. CPP is calculated by the following formula: CPP=MAP-ICP. The

patient's CPP is 90 and this is normal. A normal CPP is 60-100 mmHg.

• According to question 16, the patient's blood

pressure is 130/88. What is the patient's mean arterial pressure (MAP)?*

• 42
• 74

C. 102

• 88

The answer is C. MAP is calculated by taking the DBP (88) and multiplying it by 2.This equals 176. Then take this number and add the SBP (130). This equals 306. Then take this number and divide by 3, which equal 102.

• During the assessment of a patient with increased

ICP, you note that the patient's arms are extended straight out and toes pointed downward. You will

document this as:*

• Decorticate posturing
• Decerebrate posturing
• Flaccid posturing

The answer is B.

• While positioning a patient in bed with increased ICP,

it important to avoid?*

• Midline positioning of the head
• Placing the HOB at 30-35 degrees
• Preventing flexion of the neck
• Flexion of the hips

The answer is D. Avoid flexing the hips because this can increase intra- abdominal/thoracic pressure, which will increase ICP.

• During the eye assessment of a patient with

increased ICP, you need to assess the oculocephalic reflex. If the patient has brain stem damage what response will you find?*

• The eyes will roll down as the head is moved side to

side.

• The eyes will move in the opposite direction as the

head is moved side to side.

• The eyes will roll back as the head is moved side to

side.

• The eyes will be in a fixed mid-line position as the head

is moved side to side.The answer is D. This is known as a negative doll's eye and represents brain stem damage. It is a very bad sign.