ICP NCLEX style Questions

ICP NCLEX style Questions 4.2 (5 reviews) Students also studied Terms in this set (36) George Brown College Nursing Save ICP Nclex Questions, ICP NCLEX sty...120 terms Mariko_Roberts Preview Seizures NCLEX 12 terms murkacatPreview ICP/head injury NCLEX style questio...50 terms Alix_VanderWiele Preview Spinal C 53 terms Ma Which components are able to change to adapt to small increases in intracranial pressure (ICP) (select all that apply)?

• Blood d. Scalp tissue
• Skull bone e. Cerebrospinal fluid (CSF)
• Brain tissue

a, c, e. Blood adapts with increased venous outflow, decreased cerebral blood flow (CBF), and collapse of veins and dural sinuses. Brain tissue adapts with distention of the dura, slight compression of tissue, or herniation.Cerebrospinal fluid (CSF) adapts with increased absorption, decreased production, and displacement into the spinal canal. Skull bone and scalp tissue do not adapt to changes in intracranial pressure (ICP).The cerebral perfusion pressure (CPP) is the pressure needed to ensure blood flow to the brain. Normal CPP is 60 to 100 mm Hg. Calculate the CPP of a patient whose blood pressure (BP) is 106/52 mm Hg and ICP is 14 mm Hg.mm Hg 56 mm Hg Mean arterial pressure (MAP) = diastolic blood pressure

(DBP) + 1

⁄3 (systolic blood pressure [SBP] - DBP) =

52 + 18 = 70

Cerebral per Calculate the CPP for the patient with an ICP of 34 mm Hg and a systemic BP of 108/64 mm Hg.mm Hg 45 mm Hg

MAP = DBP + 1

⁄3 (SBP − DBP) = 64 + 15 = 79

CPP = MAP − ICP = 79 − 34 = 45

Which factors decrease cerebral blood flow (select all that apply)?

• Increased ICP d. Arterial blood pH of 7.3
• PaO2 of 45 mm Hg e. Decreased mean arterial

pressure (MAP)

• PaCO2 of 30 mm Hg

c, e. Cerebral blood flow is decreased when the MAP and the PaCO2 are decreased. The other options increase cerebral blood flow.

What are causes of vasogenic cerebral edema (select all that apply)?

• Hydrocephalus
• Ingested toxins
• Destructive lesions or trauma
• Local disruption of cell membranes
• Fluid flowing from intravascular to extravascular space

b, e. Vasogenic cerebral edema, the most common type of edema, occurs mainly in the white matter and is characterized by leakage of macromolecules from the capillaries into the surrounding extracellular space. This results in an osmotic gradient that favors the flow of fluid from the intravascular to the extravascular space. A variety of insults, such as brain tumors, abscesses, and ingested toxins, may cause an increase in the permeability of the blood-brain barrier and produce an increase in the extracellular fluid volume. Hydrocephalus causes interstitial cerebral edema.Which events cause increased ICP (select all that apply)?

• Vasodilation d. Edema from initial brain insult
• Necrotic tissue edema e. Brainstem compression and

herniation

• Blood vessel compression

a, b, d. Increased ICP is caused by vasodilation and edema from the initial brain insult or necrotic tissue. Blood vessel compression and brainstem compression and herniation occur as a result of increased ICP.An early sign of increased ICP that the nurse should assess for is

• Cushing's triad. c. decreasing level of consciousness

(LOC).

• unexpected vomiting. d. dilated pupil with sluggish

response to light.. c. One of the most sensitive signs of increased ICP is a decreasing level of consciousness (LOC). A decrease in LOC will occur before changes in vital signs, ocular signs, or projectile vomiting occur.The nurse recognizes the presence of Cushing's triad in the patient with which vital sign changes?

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

systolic BP

• Decreased pulse, irregular respiration, widened pulse

pressure

• Increased pulse, decreased respiration, widened pulse

pressure

• Cushing's triad consists of three vital sign measures that

reflect ICP and its effect on the medulla, hypothalamus, pons, and thalamus. Because these structures are very deep, Cushing's triad is usually a late sign of ICP. The signs include an increasing SBP with a widening pulse pressure, a bradycardia with a full and bounding pulse, and irregular respirations.Increased ICP in the left cerebral cortex caused by intracranial bleeding causes displacement of brain tissue to the right hemisphere beneath the falx cerebri. The nurse knows that this is referred to as what?

• Uncal herniation c. Cingulate herniation
• Tentorial herniation d. Temporal lobe herniation
• The dural structures that separate the two hemispheres

and the cerebral hemispheres from the cerebellum influence the patterns of cerebral herniation. A cingulate herniation occurs where there is lateral displacement of brain tissue beneath the falx cerebri. Uncal herniation occurs when there is lateral and downward herniation. Tentorial herniation occurs when the brain herniates down through the opening created by the brainstem. The temporal lobe can be involved in central herniation

Priority Decision: A patient has ICP monitoring with an

intraventricular catheter. What is a priority nursing intervention for the patient?

• Aseptic technique to prevent infection c. Removal of

CSF to maintain normal ICP

• Constant monitoring of ICP waveforms d. Sampling

CSF to determine abnormalities

• 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.

When using intraventricular ICP monitoring, what should the nurse be aware of to prevent inaccurate readings?

• The P2 wave is higher than the P1 wave.
• CSF is leaking around the monitoring device.
• The transducer of the ventriculostomy monitor is at the

level of the upper ear.

• The drain of the CSF drainage device was closed for 6

minutes before taking the reading.

• An inaccurate ICP reading can be caused by CSF

leaks around the monitor device, obstruction of the intraventricular catheter, kinks or bubbles in the tubing, and incorrect height of the transducer or drainage system relative to the patient's reference point. The P2 wave being higher than the P1 wave indicates poor ventricular compliance. The transducer height should be at the tragus of the ear. The drain of the CSF drainage device should be closed for 6 minutes preceding the reading.The patient is being monitored long-term with a brain tissue oxygenation catheter. What range for the pressure of oxygen in brain tissue (PbtO2

• will maintain cerebral oxygen supply and demand?
• 55% to 75% c. 70 to 150 mm Hg
• 20 to 40 mm Hg d. 80 to 100 mm Hg
• The normal pressure of oxygen in brain tissue (PbtO2

) is 20 to 40 mm Hg. The normal jugular venous oxygen saturation (SjvO2

• is 55% to 75% and indicates total venous

brain tissue extraction of oxygen; this is used for short-term monitoring. The MAP of 70 to 150 mm Hg is needed for effective autoregulation of CBF. The normal range for PaO2 is 80 to 100 mm Hg.Which drug treatment helps to decrease ICP by expanding plasma and the osmotic effect to move fluid?

• Oxygen administration c. Mannitol (Osmitrol) (25%)
• Pentobarbital (Nembutal) d. Dexamethasone

(Decadron)

• Mannitol (Osmitrol) (25%) is an osmotic diuretic that

expands plasma and causes fluid to move from tissues into the blood vessels. Hypertonic saline reduces brain swelling by moving water out of brain tissue. Oxygen administration is done to maintain brain function. Pentobarbital (Nembutal) and other barbiturates are used to reduce cerebral metabolism. The corticosteroid dexamethasone (Decadron) is used to treat vasogenic edema to stabilize cell membranes and improve neuronal function by improving CBF and restoring autoregulation How are the metabolic and nutritional needs of the patient with increased ICP best met?

• Enteral feedings that are low in sodium
• Simple glucose available in D5

W IV solutions

• Fluid restriction that promotes a moderate dehydration
• 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.Why is the Glasgow Coma Scale (GCS) used?

• To quickly assess the LOC
• To assess the patient's ability to communicate
• To assess the patient's ability to respond to commands
• To assess the patient's coordination with motor

responses

• The Glasgow Coma Scale (GCS) is used to quickly assess

the LOC with a standardized system. The three areas assessed are the patient's ability to speak, obey commands, and open eyes to verbal or painful stimulus. Although best motor response is an indicator, it is not used to assess coordination.

A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. What should the nurse record as the patient's GCS score?

• 6 c. 9
• 7 d. 11
• No opening of eyes = 1; incomprehensible words = 2;

flexion withdrawal = 4. Total = 7

Priority Decision: When assessing the body functions of a

patient with increased ICP, what should the nurse assess first?

• Corneal reflex testing c. Extremity strength testing
• Pupillary reaction to light d. 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).How is cranial nerve (CN) III, originating in the midbrain, assessed by the nurse for an early indication of pressure on the brainstem?

• Assess for nystagmus c. Test pupillary reaction to light
• Test the corneal reflex d. Test for oculocephalic (doll's

eyes) reflex . c. One of the functions of cranial nerve (CN) III, the oculomotor nerve, is pupillary constriction and testing for pupillary constriction is important to identify patients at risk for brainstem herniation caused by increased ICP. The corneal reflex is used to assess the functions of CN V and VII and the oculocephalic reflex tests all cranial nerves involved with eye movement. Nystagmus is commonly associated with specific lesions or chemical toxicities and is not a definitive sign of ICP A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema. What is an appropriate nursing intervention for the patient?

• Avoid positioning the patient with neck and hip flexion.
• Maintain hyperventilation to a PaCO2

of 15 to 20 mm Hg.

• Cluster nursing activities to provide periods of

uninterrupted rest.

• Routinely suction to prevent accumulation of

respiratory secretions.

• 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 An unconscious patient with increased ICP is on ventilatory support. The nurse notifies the health care provider when arterial blood gas (ABG) measurement results reveal what?

• pH of 7.43 c. PaO2

of 70 mm Hg

• SaO2

of 94% d. PaCO2 of 35 mm Hg

• A PaO2

of 70 mm Hg reflects hypoxemia that may lead to further decreased cerebral perfusion. PaO2 should be maintained at greater than or equal to 100 mm Hg. The pH and SaO2 are within normal range and a PaCO2 of 35 mm Hg reflects a normal value.