ICP practice questions

ICP practice questions Leave the first rating Students also studied Terms in this set (20) Science MedicineNursing Save ICP NCLEX style Questions 36 terms Nurse_BrandyPreview ICP Nclex Questions 43 terms nurseathrtPreview Med Surg Gastrointestinal NCLEX Q...86 terms Jasmine_Lawson4 Preview Adult H 20 terms sup A patient is at risk for increased intracranial pressure.Which finding is the priority for the nurse to monitor?decreasing body temperature tachycardia unequal pupil size decreasing systolic blood pressure unequal pupil size The nurse is monitoring a patient with increased intracranial pressure. What indicators are the most critical for the nurse to monitor? (select all that apply) cerebral perfusion pressure level of pain urine output systolic blood pressure breath sounds cerebral perfusion pressure systolic blood pressure The nurse is assessing a patient for decerebrate posturing the nurse should assess the patient for back hunched over and rigid flexion of all four extremities with supination of arms and plantar flexion of feet internal rotation and adduction of arms with flexion of elbows, wrists, and fingers back arched and rigid extension of all four extremities supination of arms and dorsiflexion of the feet back arched and rigid extension of all four extremities

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) Leaking proteins into the brain barrier Decreasing cerebrospinal fluid production Vasodilation of cerebral vessels Shifting cerebrospinal fluid to other areas of the brain and spinal cord Leaking proteins into the brain barrier Vasodilation of cerebral vessels A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing? (select all that apply) vomiting talking valsalva maneuver coughing sneezing keeping the head of the bed at 30 degrees vomiting valsalva maneuver coughing sneezing 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:

30-45 mmHg >150 mmHg 5-15 mmHg 60-100 mmHg 60-100 mmHg 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 vasodilation and decrease the ICP cause vasodilation and increase the ICP cause vasoconstriction and decrease the ICP promote diuresis and decrease the ICP cause vasodilation and increase the ICP

A patient with a contusion has been admitted for observation following a motor vehicle accident when he was driving his pregnant wife to the hospital. The next morning, instead of asking about his wife and baby, he asked to see the football game on television that he thinks is starting in 5 minutes. He is agitated because the nurse will not turn on the television. What should the nurse do next?(select all that apply) arrange for the patient to be with his wife and baby administer a sedative determine if the patient's pupils are equal and react to light ask the patient if he has a headache find a television so the patient can watch the football game determine if the patient's pupils are equal and react to light ask the patient if he has a headache A patient has a ventriculostomy. Which finding would you immediately report to the doctor?ICP 24 mmHg PaCO2 35 CPP 70 mmHg Temperature 98.4 'F ICP 24 mmHg What are the main structures involved in maintaining consistent intracranial pressure? (select all that apply) brain periosteum blood dura mater cerebrospinal fluid neurons brain blood cerebrospinal fluid A patient has delirium following a head injury. The patient is disoriented and agitated. In which order from first to last (1-4) should the nurse initiate care for this patient. All options must be used.Request a prescription for a sedative maintain a quiet environment assure the patient's safety approach the patient using short sentences

• approach the patient using short sentences
• assure the patient's safety
• maintain a quiet environment
• request a prescription for a sedative

The nurse administers mannitol to a patient with increased intracranial pressure. Which parameter requires close monitoring?muscle relaxation intake and output widening pulse pressure pupil dilation intake and output

When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as decerebrate posturing decorticate posturing localization of pain flexion withdrawal decorticate posturing The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a patient who had a craniotomy 12 hours ago. Which of the following are appropriate nursing care for this patient(select all that apply)?elevate the head of the bed 30 degrees monitor neurologic status using the Glasgow Coma Scale contact the healthcare provider if the ICP is >15 mmHg Stimulate the client with active range-of-motion exercises encourage the patient to cough to expectorate secretions elevate the head of the bed 30 degrees monitor neurologic status using the Glasgow Coma Scale contact the healthcare provider if the ICP is >15 mmHg A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema. An appropriate nursing intervention for the patient is avoiding positioning the patient with neck and hip flexion maintaining hyperventilation to a PaCO2 of 15 to 20 mm Hg clustering nursing activities to provide periods of uninterrupted rest routine suctioning to prevent accumulation of respiratory secretions avoiding positioning the patient with neck and hip flexion The nurse is assessing the level of consciousness in a patient with a head injury who has been unresponsive for the last 8 hours. Using the Glasgow Coma Scale, the nurse notes that the patient opens the eyes only as a response to pain, responds with sounds that are not understandable, and has abnormal extension of the extremities. What should the nurse do (select all that apply)?attempt to arouse the client elevate the head of the bed to 90 degrees notify the healthcare provider chart the patient's level of consciousness as coma chart the patient's level of consciousness as coma