Evolve - Increased ICP

The novice nurse is assigned a patient who was admitted earlier in the day with a diagnosis of post-head injury concussion. What statement made by the nurse demonstrates an understanding of the care of the patient's injuries?

"I need to assess the patient's level of consciousness frequently because that is the first indication of complications."

A patient has increased intracranial pressure (ICP). The nurse evaluates the patient's level of consciousness and records a Glasgow Coma Scale (GCS) score that indicates the patient is in a comatose state. What would be an appropriate GCS score?

4 5 6

A nurse assesses the intracranial pressure (ICP) of a patient with head trauma. The nurse compares the assessment data with which normative value for ICP?

5 to 15 mm Hg

The nurse is assessing the breathing patterns of four patients. Which patient does the nurse suspect may have a lesion in the medulla of brain?

A patient with cluster breathing

A patient with meningitis has seizures, cranial nerve (CN) III palsy, and bradycardia. What is the most likely cause for the development of these symptoms?

Acute cerebral edema

The nurse is caring for a patient with increased intracranial pressure (ICP). What actions should the nurse perform as a part of nutritional therapy?

Begin parenteral nutrition if oral intake is not adequate. Begin nutritional replacement within three days after injury. Evaluate the patient's urine output, fluid loss, and electrolyte balance.

One of the unlicensed assistive personnel (UAP) reports the following vital signs (VS) obtained from a patient with a suspected brain injury: temperature = 101.6° F orally, heart rate = 58, R = 14, and blood pressure = 162/48. What is the nurse's priority response?

Compare the current VS to baseline VS recorded.

Which nursing intervention is the priority when caring for a patient who has increased intracranial pressure (ICP)?

Continuous ICP monitoring

A patient was ejected from a car during a motor vehicle crash and has a diagnosis of subdural hematoma. Which type of brain injury does this represent?

Primary

The nurse administers mannitol that has been prescribed for a patient with increased intracranial pressure. What outcome does the nurse expect after administration?

Reduced intracranial pressure

The nurse is positioning a patient who has increased intracranial pressure (ICP). Which is the most appropriate position for this patient?

Semi-Fowler's

The nurse is caring for a patient admitted with a subdural hematoma following a motor vehicle accident. Which change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)?

bradycardia

The nurse is educating a patient scheduled for a ventriculostomy. What statement by the patient demonstrates an understanding of the procedure?

"It will directly measure the pressure within the ventricles of my brain."

A dose of dexamethasone 8 mg intravenous (IV) is prescribed. The unit stock medication has a concentration of 20 mg/mL. How many milliliters will the nurse will draw up to administer this dose?

0.4

Fill in the blank The nurse is calculating the cerebral perfusion pressure (CPP) of an unconscious patient. The patient's blood pressure is 162/58 mm Hg and intracranial pressure (ICP) is 35 mm Hg. What is the patient's CPP?

58 mm Hg

A patient with elevated intracranial pressure (ICP) is at risk for lower cerebral perfusion pressure (CPP) during suctioning. The nurse should maintain CPP above how many mm Hg to preserve cerebral perfusion?

60

A nurse is caring for a patient with a brain injury as a result of a car accident. On admission, the patient's vital signs are blood pressure (BP), 132/72; pulse 100 beats/minute; and respirations 24. Later, the nurse reassesses the patient's vital signs. Which set of vital signs should the nurse report to the physician immediately?

Blood pressure 172/54, pulse 58 beats/minute, respirations 10

A patient is admitted to the emergency department with a closed head injury. The patient is awake but lethargic, and the baseline vital signs include a blood pressure of 120/80 mm Hg, pulse of 78 beats/minute, and respirations of 20 breaths/minute. Two hours later the nurse assesses the patient. Which finding indicates deterioration in the patient's condition?

Blood pressure is 160/74 mm Hg, pulse is 53 beats/minute, and respirations are 10 breaths/minute.

After undergoing surgery for resection of a brain tumor, a patient arrives in the postanesthesia care unit with a temperature of 100° F (37.7° C), blood pressure of 130/76 mm Hg, pulse 64 beats/minute, a urinary catheter in place, and oxygen being administered at a rate of 2 L/min by way of a nasal cannula. One hour later, the nurse assesses the patient. Which assessment finding does the nurse realize should be reported immediately to the surgeon?

Blood pressure of 148/58 mm Hg and pulse 48 beats/minute

A nurse is educating a patient's family about intracranial pressure (ICP). The nurse explains that normal ICP is a balance of which three components?

Blood pressure, brain tissue, and cerebrospinal fluid

A patient presents with a shunt malfunction related to increased intracranial pressure (ICP). On examination, which findings would the nurse observe?

Blurred vision Headache and vomiting Decreased level of consciousness

A nurse is caring for a patient with a closed head injury and increasing intracranial pressure. Which of the following manifestations does the nurse report to the health care provider that represent Cushing's triad?

Bradycardia Irregular respirations Increasing systolic blood pressure

A patient on the intensive care unit has increased intracranial pressure (ICP) and a decreased level of consciousness. What actions should the nurse perform to prevent injury to the patient?

Consider the use of light sedation agents. Observe the skin area under the restraints. Use effective restraints in an agitated patient.

A patient with a brain injury is experiencing a change in motor function. Which motor function response is depicted in the image?

Decorticate posturing

The nurse assesses a comatose head-injured patient and finds flexion of the arms, wrists, and fingers and adduction of the upper extremities. How can the findings be described?

Decorticate posturing

The nurse is administering mannitol intravenously to a patient with a head injury. Which assessment will help the nurse determine if the medication is having the desired outcome?

Decreased intracranial pressure

A patient with increased intracranial pressure (ICP) is prescribed a high dose of barbiturates. What outcome does the nurse anticipate the patient will have after administration of the medication?

Decreases cerebral metabolism

When evaluating level of consciousness on the basis of the Glasgow Coma Scale (GCS), which possible responses could be scored under best motor response?

Flexion withdrawal Localization of pain Obedience of command

What inflammatory condition is the most common cause of acute nonepidemic encephalitis?

Herpes simplex virus encephalitis

A nurse should assess pupillary response in a patient with a head trauma and suspected intracranial pressure to evaluate the functioning of which cranial nerve?

III

A patient has a systemic blood pressure of 120/60 and an intracranial pressure (ICP) of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results?

Impaired blood flow to the brain

After assessing the patient, the nurse declines to administer mannitol to the patient. Which condition supports this nursing intervention?

Increased serum osmolality

A patient who sustained a head injury in a motorcycle crash has a baseline Glasgow Coma Scale (GCS) score of 14. The nurse recognizes signs of increasing intracranial pressure on the basis of what assessment findings?

Increased systolic blood pressure, decreased pulse, widening pulse pressure, GCS score of 4

A patient being treated for viral meningitis arrives at the hospital reporting a persistent severe headache. Which nursing intervention is most appropriate for the patient?

Informing the patient that headaches can occur after recovery

A patient has been diagnosed with a right-sided brain tumor resulting in significant increased intracranial pressure (ICP). The nurse can expect to document which assessment findings?

Ipsilateral pupil dilation Contralateral hemiparesis Altered level of consciousness

The nurse is maintaining a propofol drip in the intensive care unit for a patient on a mechanical ventilator. What does the nurse inform the family about the benefit of the drug regarding managing anxiety and agitation?

It has a short half-life and rapid onset of action.

The nurse is caring for a patient with increased intracranial pressure (ICP). What seizure precautions should the nurse take to protect the patient?

Keep suction equipment readily available. Use padded side rails and maintain an airway at the bedside. Use prophylactic antiseizure therapy during first seven days after injury.

The nurse is caring for a patient with increased intracranial pressure. Which actions should the nurse perform to promote optimal outcomes for the patient?

Maintain fluid balance and assess osmolality. Maintain intubation and mechanical ventilation. Elevate the head of the bed to 30 degrees with the head in a neutral position.

The nurse is preparing to change the body position of a patient with increased intracranial pressure (ICP). Which factors should the nurse consider prior to changing the position?

Maintaining a head-up position for the patient Taking care to prevent extreme neck flexion of patient Adjusting the patient's body position to decrease intracranial pressure (ICP)

The nurse is planning the care for a patient with increased intracranial pressure (ICP). What actions should the nurse plan to perform to provide the most comfort for the patient?

Minimize procedures that can produce agitation. Observe the patient for signs of agitation or irritation. Make the patient remain in a quiet and calm environment.

The nurse is caring for a patient experiencing increased intracranial pressure (ICP). What is the priority nursing action in the care of this patient?

Monitor fluid and electrolyte status carefully.

A patient with increased intracranial pressure (ICP) is being treated with corticosteroids. What actions should the nurse perform to avoid complications due to corticosteroid treatment?

Monitor fluid intake and sodium levels regularly. Perform blood glucose monitoring at least every six hours. Start concurrent treatment with antacids or proton pump inhibitors.

The nurse is planning to administer pharmacologic therapy for a patient with increased intracranial pressure (ICP). Which factors should the nurse consider?

Monitor for hypotension when using opioids to manage anxiety. Monitor for hypotension when using continuous intravenous sedatives. Use sedatives or analgesics with nondepolarizing neuromuscular blocking agents.

Following an assessment of the oculocephalic reflex, the nurse suspects that the patient has an intracranial lesion. Which behavior of the patient supports the nurse's conclusion?

Movement of the eye in the sideward direction when the neck is extended

A patient with meningitis has adhesions that prevent the normal flow of cerebrospinal fluid from the ventricles. Which complication might be observed first?

Noncommunicating hydrocephalus

Which finding in the intracranial pressure waveforms supports the nurse's conclusion that a patient's intracranial compliance is compromised?

P2 wave is higher than P1 wave

Which outcomes indicate effective treatment in a patient with increased intracranial pressure who underwent a tracheostomy to help maintain adequate ventilation?

PaO 2 of the patient is 110 mm Hg PaCO 2 of the patient is 40 mm Hg

The nurse is caring for a patient in the neurologic intensive care unit with increased intracranial pressure (ICP). What assessment data obtained by the nurse indicates a worsening of the patient's condition?

Presence of fixed unresponsive pupils

When performing a neurologic assessment on a patient, the nurse notes fixed pupils that are unresponsive to a light stimulus. Which causes of fixed pupils should the nurse consider during this assessment?

Previous eye surgery Increased intracranial pressure (ICP) Direct injury to the third cranial nerve (CN III)

A nurse is using the Glasgow Coma Scale (GCS) to assess a patient who fell out of a tree and sustained a head injury and developed increased intracranial pressure. Which components will the nurse assess?

Speaking, responding to stimuli, and following verbal commands

The nurse is performing a neurologic assessment for a patient. When performing a palmar drift test, what is the nurse attempting to determine?

Strength of the hands

A nurse is providing a community presentation on causes of brain injury. Which would the nurse include as possible causes for increased intracranial pressure?

Subdural hematoma

When considering the use of hypertonic saline treatment in a patient with increased intracranial pressure (ICP), which factors should the nurse consider?

The nurse should frequently monitor the blood pressure and sodium levels. Hypertonic saline treatment works similarly to mannitol in treating increased ICP. Hypertonic saline treatment provides massive movement of water out of swollen brain cells.

The nurse suspects a patient has increased intracranial pressure. Which assessment findings may indicate this condition?

The patient is experiencing hemiplegia. The patient has unilateral pupil dilation. The patient is vomiting without preceding nausea.

A patient underwent cranial surgery. What actions should the nurse perform to prevent increased intracranial pressure (ICP)?

Turn and position the patient appropriately. Frequently assess the patient's neurologic status. Closely monitor fluid and electrolyte levels and serum osmolality.

A nurse is caring for a patient with a traumatic brain injury and increased intracranial pressure (ICP). Which symptom would the nurse report to the physician immediately?

Urine output of 1000 mL in 1 hr

The patient with increased intracranial pressure (ICP) resulting from a brain tumor is being monitored with a ventriculostomy. What nursing intervention is the priority in caring for this patient?

Use strict aseptic technique with dressing changes.