ICP Nclex Questions

ICP Nclex Questions Leave the first rating Students also studied Terms in this set (43) Science MedicineNursing Save Spinal Cord Injury NCLEX Questions...53 terms Maria_Coronado22 Preview ICP Nclex Questions, ICP NCLEX sty...120 terms Mariko_Roberts Preview Seizures - NCLEX 20 terms ccrox96Preview ICP/he 50 terms Alix 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 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.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?xtrose 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.

The nurse suspects the presence of an arterial epidural hematoma in the patient who experiences

• failure to regain consciousness following a head injury
• a rapid deterioration of neurologic function within 24

to 48 hours following a head injury

• nonspecific, nonlocalizing progression of alteration in

LOC occurring over weeks or months

• unconsciousness at the time of a head injury with a

brief period of consciousness followed by a decrease in LOC

• An arterial epidural hematoma is the most acute neurologic emergency, and

the typical symptoms include unconsciousness at the scene, with a brief lucid interval followed by a decrease in LOC. An acute subdural hematoma manifests signs within 48 hours of an injury; a chronic subdural hematoma develops over weeks or months The nurse on the clinical unit is assigned to four patients.Which patient should she assess first?

• patient with a skull fracture whose nose is bleeding
• elderly patient with a stroke who is confused and

whose daughter is present

• patient with meningitis who is suddenly agitated and

reporting a HA of 10 on a 0 to 10 scale

• patient who had a craniotomy for a brain tumor who is

now 3 days postoperative and has had continued emesis

• patient with meningitis who is suddenly agitated and reporting a HA of 10 on a
• to 10 scale

The nurse is monitoring a patient for increased ICP following a head injury. Which of the following manifestations indicate an increased ICP (select all that apply)

• fever
• oriented to name only
• narrowing pulse pressure
• dilated right pupil > left pupil
• decorticate posturing to painful stimulus

A, B, D, E- The first sign of increased ICP is a change in LOC. Other manifestations are dilated ipsilateral pupil, changes in motor response such as posturing, and fever, which may indicate pressure on the hypothalamus. Changes in vital signs would be an increased systolic BP with widened pulse pressure and bradycardia When assessing the body function of a patient with increased ICP, the nurse should initially assess

• corneal reflex testing
• extremity strength testing
• pupillary reaction to light
• circulatory and respiratory status
• Circulatory and respiratory status- Of the body functions that should be

assessed in an unconscious patient, cardiopulmonary status is the most vital function and gives priorities to the ABCs (airway, breathing, and circulation) 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