ICP Nclex Questions, ICP NCLEX style Questions, ICP Nclex Questions

ICP Nclex Questions, ICP NCLEX style Questions, ICP Nclex Questions ScienceMedicineNursing Mariko_Roberts Save ICP/head injury NCLEX style questio...50 terms Alix_VanderWiele Preview Nclex Questions for Shock - Critical ...32 terms karmageniePreview Spinal Cord Injury NCLEX Questions...Teacher 53 terms julia11213Preview Spinal 26 terms ET0 The nurse notes that a patient with a head injury has a clear nasal drainage. The most appropriate nursing action for this finding is to

• obtain a specimen of the fluid and send for culture and sensitivity.
• take the patient's temperature to determine whether a fever is present.
• check the nasal drainage for glucose with a Dextrostik or Testape.
• have the patient to blow the nose and then check the nares for redness.

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.Cognitive Level: Application Text Reference: p. 1481 Nursing Process: Implementation NCLEX: Physiological Integrity 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

• 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.Cognitive Level: Application Text Reference: p. 1469 Nursing Process: Assessment NCLEX: Physiological Integrity

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.Cognitive Level: Comprehension Text Reference: p. 1470 Nursing Process: Assessment NCLEX: Physiological Integrity A patient with a head injury has an arterial blood pressure is 92/50 mm Hg and an intracranial pressure of 18 mm Hg. Which action by the nurse is appropriate?

• Document and continue to monitor the parameters.
• Elevate the head of the patient's bed.
• Notify the health care provider about the assessments.
• Check the patient's pupillary response to light.

Correct Answer: C

Rationale: The patient's cerebral perfusion pressure is only 46 mm Hg, which will rapidly lead to cerebral ischemia and neuronal death unless rapid action is taken to reduce ICP and increase arterial BP. Documentation and monitoring are inadequate responses to the patient's problem.Elevating the head of the bed will lower the ICP but may also lower cerebral blood flow and further decrease CPP. Changes in pupil response to light are signs of increased ICP, so the nurse will only take more time doing this without adding any useful information.Cognitive Level: Analysis Text Reference: pp. 1468-1469 Nursing Process: Implementation NCLEX: Physiological Integrity A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial pressure of 24 mm Hg. The nurse determines that the cerebral perfusion pressure (CPP) of this patient indicates

• high blood flow to the brain.
• normal intracranial pressure (ICP).
• impaired brain blood flow.
• adequate cerebral perfusion.

Correct Answer: C

Rationale: The patient's CPP is 56, below the normal of 70 to 100 mm Hg and approaching the level of ischemia and neuronal death. The patient has low cerebral blood flow/perfusion. Normal ICP is 0 to 15 mm Hg.Cognitive Level: Application Text Reference: p. 1468 Nursing Process: Assessment NCLEX: Physiological Integrity

When caring for a patient who has had a head injury, which assessment information is of most concern to the nurse?

• The blood pressure increases from 120/54 to 136/62.
• The patient is more difficult to arouse.
• The patient complains of a headache at pain level 5 of a 10-point scale.
• The patient's apical pulse is slightly irregular.

Correct Answer: B

Rationale: The change in level of consciousness (LOC) is an indicator of increased ICP and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache is not unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual.Cognitive Level: Application Text Reference: p. 1470 Nursing Process: Assessment NCLEX: Physiological Integrity 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.Cognitive Level: Comprehension Text Reference: p. 1472 Nursing Process: Assessment NCLEX: Physiological Integrity A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L), a decreasing level of consciousness (LOC) and complains of a headache. All of the following orders have been received. Which one should the nurse accomplish first?

• Administer acetaminophen (Tylenol) 650 mg orally.
• Administer 5% hypertonic saline intravenously.
• Draw blood for arterial blood gases (ABGs).
• Send patient to radiology for computed tomography (CT) of the head.

Correct Answer: B

Rationale: The patient's low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse's first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased ICP. Drawing ABGs and obtaining a CT scan may add some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.Cognitive Level: Application Text Reference: p. 1470 Nursing Process: Implementation NCLEX: Physiological Integrity

Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a head injury. To evaluate the effectiveness of the therapy, the nurse should

• monitor oxygen saturation.
• check arterial blood gases (ABGs).
• monitor intracranial pressure (ICP).
• assess patient breath sounds.

Correct Answer: C

Rationale: The purpose of hyperventilation for a patient with a head injury is reduction of ICP, and ICP should be monitored to evaluate whether the therapy is effective. Although oxygen saturation and ABGs are monitored in patient's receiving hyperventilation, they do not provide data about whether the therapy is successful in reducing ICP. Breath sounds are assessed, but they are not helpful in determining whether the hyperventilation is effective.Cognitive Level: Application Text Reference: p. 1475 Nursing Process: Evaluation NCLEX: Physiological Integrity 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 Skull radiographs and a computed tomography (CT) scan provide evidence of a depressed parietal fracture with a subdural hematoma in a patient admitted to the emergency department following an automobile accident. In planning care for the patient, the nurse anticipates that

• the patient will receive life-support measures until the condition stabilizes
• immediate burr holes will be made to rapidly decompress the intracranial activity
• the patient will be treated conservatively with close monitoring for changes in neurologic condition
• the patient will be taken to surgery for a craniotomy for evacuation of blood and decompression of the cranium
• When there is a depressed fracture and fractures with loose fragments, a craniotomy is indicated to elevate the depressed bone and remove

free fragments. A craniotomy is also indicated in cases of acute subdural and epidural hematomas to remove the blood and control the bleeding. Burr holes may be used in an extreme emergency for rapid decompression, but with a depressed fracture, surgery would be the treatment of choice Metabolic and nutritional needs of the patient with increased ICP are best met with

• enteral feedings that are low in sodium
• the simple glucose available in D5W IV solutions
• a fluid restriction that promotes a moderate dehydration
• balanced, essential nutrition in a form that the patient can tolerate
• Balanced, essential nutrition in a form that the patient can tolerate= A patient with increased ICP is in a hypermetabolic and hypercatabolic

state and needs adequate glucose to maintain fuel for the brain and other nutrients to meet metabolic needs. Malnutrition promotes cerebral edema, and if a patient cannot take oral nutrition, other means of providing nutrition should be used, such as tube feedings or parenteral nutrition. Glucose alone is not adequate to meet nutritional requirements, and 5% dextrose solutions may increase cerebral edema by lowering serum osmolarity. Patients should remain in a normovolemic fluid state with close monitoring of clinical factors such as urine output, fluid intake, serum and urine osmolality, serum electrolytes, and insensible losses.