ICP Questions and Slide info

The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? Sternal rub Pressue on the orbital rim squeezing the sternocleidomastoid muscle Nail bed pressure

sternal rub

Which of the following values is considered normal for ICP? 5 to 15 mm Hg 25 mm Hg 35 to 45 mm Hg 120/80 mm Hg

5 to 15 mm Hg

Which of the following respiratory patterns indicate increasing ICP in the brain stem? Slow, irregular respirations Rapid, shallow respirations Asymmetric chest expansion Nasal flaring

Answers: Slow, irregular respirations

Which of the following signs and symptoms of increased ICP after head trauma would appear first? Bradycardia Restlessness and confusion Widened pulse pressure Large amounts of very dilute urine

Bradycardia

A male client has an impairment of cranial nerve II Specific to this impairment, the nurse would plan to do which of the following to ensure client to ensure client safety? Speak loudly to the client Test the temperature of the shower water Check the temperature of the food on the delivery tray Provide a clear path for ambulation without obstacles

Speak loudly to the client

Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? Give the client a warming blanket Administer low-dose barbiturate Encourage the client to hyperventilate Restrict fluids

Give the client a warming blanket

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure.

An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? Reposition the client to avoid neck flexion Administer 1 g Mannitol IV as ordered Increase the ventilator's respiratory rate to 20 breaths/minute Administer 100 mg of pentobarbital IV as ordered.

Reposition the client to avoid neck flexion

The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure? Side-lying, with legs pulled up and head bent down onto the chest Side-lying, with a pillow under the hip Prone, in a slight Trendelenburg's position Prone, with a pillow under the abdomen.

Side-lying, with legs pulled up and head bent down onto the chest

A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? Unequal pupil size Decreasing systolic blood pressure Tachycardia Decreasing body temperature

Unequal pupil size