Registered NurseRN ICP Practice Questions

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HESI C

25 terms Ash The main structures below that play a role with altering

intracranial pressure:

Brain, CSF, blood 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
• Vasodilation of the cerebral vessels
• Leaking proteins into the brain barrier
• 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
• Coughing
• Sneezing
• Valsalva maneuver
• Vomiting

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:

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 increase the ICP 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.
• A patient who is admitted with a traumatic brain injury

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
• Remove extra blankets and give the patient a cool bath

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
• ICP of 24 mmHg

External ventricular drains monitor ICP and are inserted where?Lateral ventricle Which of the following is contraindicated in a patient with increased ICP?

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

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

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?Restlessness Select all the signs and symptoms that occur with

increased ICP:

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

You're maintaining an external ventricular drain. The ICP readings should be?0-15 mmHg 1Which 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. BP 200/60, HR 50, RR 8

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 The patient's blood pressure is 130/88. What is the patient's mean arterial pressure (MAP)?102 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:

Decerebrate posturing While positioning a patient in bed with increased ICP, it important to avoid?Flexion of the neck and hips 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 be in a fixed mid-line position as the head is moved side to side.

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.Mannitol will cause water and electrolyte reabsorption in the renal tubules.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
• Crackles throughout lung fields

The critical care nurse provides care for a client who is admitted for the treatment of head trauma and prescribed mannitol to reduce intracranial pressure (ICP).Which electrolyte is the priority for the nurse to monitor?Sodium - Mannitol causes the diuresis of sodium and water through the urination; therefore, the nurse monitors the client's serum sodium levels in the provision of client care based on the current clinical data.The nurse provides care for a pediatric client who is diagnosed with medulloblastoma and experiencing increased intracranial pressure (ICP). Which action by the nurse is appropriate?Keep the child's head in a neutral position A client who recently had a procedure to reduce intracranial pressure (ICP) suddenly begins to vomit violently. Which action should the nurse take next?Notify the provider