ICP NCLEX Qs

ICP NCLEX Qs Leave the first rating Students also studied Terms in this set (22) Science MedicineNursing Save ICP Nclex Questions, ICP NCLEX sty...120 terms Mariko_Roberts Preview

EXAM 5

166 terms JenniferlagaPreview Increased Intracranial Pressure Quiz...13 terms sarah413162Preview NCLEX 10 terms thia Select the main structures below that play a role with

altering intracranial pressure:

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

A C D 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

B D 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

A B D E

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

C 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

B 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.

B

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

C 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

C External ventricular drains monitor ICP and are inserted where?

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

B

Which of the following is contraindicated in a patient with increased ICP?

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

A 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

A 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

C Select all the signs and symptoms that occur with

increased ICP:

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

ADEF 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

A 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

C 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

A

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

C 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

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

D 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.D A patient is receiving Mannitol for increased ICP. Which statement is INCORRECT about this medication?

• Mannitol will remove water from the brain and place it

in the blood to be removed from the body.

• Mannitol will cause water and electrolyte reabsorption

in the renal tubules.

• When a patient receives Mannitol the nurse must

monitor the patient for both fluid volume overload and depletion.

• Mannitol is not for patients who are experiencing

anuria.B What assessment finding requires immediate intervention if found while a patient is receiving Mannitol?

• An ICP of 10 mmHg
• Crackles throughout lung fields

C. BP 110/72

• Patient complains of dry mouth and thirst

B