Increased Intracranial pressure- Exam 4 Adaptive quizzing

Which potential factors would the nurse associate with explaining a patient's pupils becoming fixed and unresponsive to light stimulus? Select all that apply. Previous eye surgery Administration of diuretics Increased intraocular pressure Increased intracranial pressure (ICP) Direct injury to the third cranial nerve (CN III)

- Previous eye surgery - Increased intracranial pressure (ICP) - Direct injury to the third cranial nerve (CN III) A fixed pupil unresponsive to light stimulus usually indicates a previous eye surgery, increased ICP, direct injury to CN III, administration of atropine, and use of mydriatic eyedrops. Administration of diuretics and increased intraocular pressure do not cause fixed pupils.

While providing care for a patient with a closed head injury and increasing intracranial pressures, which clinical manifestations represent Cushing's triad and require notifying the health care provider? Select all that apply. Bradycardia Weak pulse Irregular respirations Increasing systolic BP Decreasing systolic BP

- Bradycardia - Irregular respirations - Increasing systolic BP Cushing's triad consists of bradycardia, irregular respiration, and a widening pulse pressure (increasing systolic pressure). The pulse is full and bounding, not weak. The systolic BP increases, not decreases.

Which interventions would the nurse implement to prevent injury to the patient with an increased intracranial pressure (ICP) and a decreased level of consciousness in the intensive care unit? Select all that apply. Consider administering light sedation agents. Observe the skin area under the restraints. Use a stimulating environment in the room. Keep family members away from the patient. Use effective restraints in an agitated patient.

- Consider administering light sedation agents. - Observe the skin area under the restraints. - Use effective restraints in an agitated patient. To prevent injury to the patient, the nurse should consider the use of light sedation agents, as prescribed by the health care provider. Check skin area under the restraints for signs of irritation because the irritation can increase the patient's agitation. Using effective restraints in an agitated patient is advisable to ensure a secure outcome. The room should not have a stimulating environment; a calm, nonstimulating environment will help. Do not prevent family members from visiting the patient; instead, allow a family member to visit to assist in calming the patient.

For the patient with an increased intracranial pressure (ICP), which precautions would the nurse implement to protect the patient from potential seizure activity? Select all that apply. Keep suction equipment readily available at the patient's bedside. Provide sufficient stimulation of the patient to avoid comatose behaviors. Implement seizure treatment only after confirming the seizure diagnosis. Pad side rails and maintain an airway at the bedside per facility protocol. Use prophylactic antiseizure therapy during first seven days after injury.

- Keep suction equipment readily available at the patient's bedside. - Pad side rails and maintain an airway at the bedside per facility protocol. - Use prophylactic antiseizure therapy during first seven days after injury.

When assessing a patient's level of consciousness, which potential Glasgow Coma Scale (GCS) scores indicate the patient is in a comatose state? Select all that apply. 4 5 6 9 11

4 5 6 A GCS score of 8 or less generally indicates coma. Scores of 9 or 11 are greater than 8, and do not indicate coma.

Which disorder would the nurse associate with a patient who has meningitis with seizures, cranial nerve (CN) III palsy, and bradycardia? Cerebral abscess Subdural effusion Acute cerebral edema Increased intracranial pressure

Acute cerebral edema Acute cerebral edema is a complication of meningitis that causes seizures, CN III palsy, and bradycardia. Cerebral abscess, subdural effusion, and increased intracranial pressure are complications of meningitis, but they do not cause the aforementioned symptoms.

For the patient who sustained a head trauma and has an increased intracranial pressure, which cranial nerve (CN) would the nurse assess to determine the patient's papillary response? CN X CN V CN III CNXII

CN III CN III controls oculomotor function, so when the nurse assesses pupillary response, he or she is checking the viability of this nerve. CN XII controls tongue movement, CN X is the vagus nerve, and CN V is the trigeminal nerve.

Which clinical manifestations would the nurse monitor to assess the development of increasing intracranial pressures in a patient who sustained a head injury and has a baseline Glasgow Coma Scale (GCS) score of 14? Increased systolic BP, increased pulse, GCS score of 12 Decreased diastolic BP, decreased pulse, and GCS score of 13 Increased systolic and diastolic BP, increased pulse, GCS score of 9 Increased systolic BP, decreased pulse, widening pulse pressure, GCS score of 4

Increased systolic BP, decreased pulse, widening pulse pressure, GCS score of 4 One classic sign of increasing intracranial pressure and neurologic deterioration is an increased systolic BP and decreased diastolic BP (resulting in a widening pulse pressure) accompanied by bradycardia. Cushing's triad includes hypertension (elevated systolic pressure and widening pulse pressure), bradycardia, and bradypnea. Increased systolic BP, increased pulse, and GCS of 12 and decreased diastolic BP, decreased pulse, and GCS of 13 do not indicate deterioration in neurologic status. Increased systolic and diastolic BP, increased pulse, and GCS of 9 indicate that the patient requires continued assessment. Although the BP and pulse may be stable, the GCS has decreased from 14 to 9. A GCS of 15 is the best score, reflecting a fully awake, alert, and oriented patient. Any patient scoring less than 8 on the GCS is comatose.

For which complication would the nurse monitor potential development while providing care for a patient with meningitis and ventricle adhesions that prevent the normal flow of cerebrospinal fluid? Cerebral abscess Acute cerebral edema Cranial nerve irritation Noncommunicating hydrocephalus

Noncommunicating hydrocephalus Adhesions preventing the normal flow of cerebrospinal fluid lead to an obstruction of the foramen magnum, which causes noncommunicating hydrocephalus. Cerebral abscess is an accumulation of pus within the brain tissue. An acute cerebral edema is an abnormal increase in water content within the extracellular fluid of the brain. The condition occurs due to hydrocephalus. Cranial nerve irritation is caused by neurologic dysfunctions because of increased intracranial pressure.

For the patient with an increased intracranial pressure, who required a tracheostomy to help to maintain adequate ventilation, which postprocedural outcomes indicate an effective intervention? Select all that apply. PaO 2 of the patient is 80 mm Hg. PaO 2 of the patient is 90 mm Hg. PaO 2 of the patient is 110 mm Hg. PaCO 2 of the patient is 40 mm Hg. PaCO 2 of the patient is 30 mm Hg.

PaO 2 of the patient is 110 mm Hg. PaCO 2 of the patient is 40 mm Hg. The goal of maintaining adequate ventilation through tracheostomy is to maintain PaO 2 of the patient greater than or equal to 100 mm Hg with PaCO 2 in the range of 35 to 45 mm Hg. Therefore the PaO 2 value of 110 mm Hg and PaCO 2 value of 40 mm Hg indicate effective treatment. A PaO 2 of less than 100 and PaCO 2 of less than 35 mm Hg indicate ineffective treatment.

The nurse suspects that a patient with bacterial meningitis is experiencing cranial nerve II irritation based on which assessment finding? Facial paresis Papilledema and blindness Ptosis, unequal pupils, and diplopia Sensory loss and loss of corneal reflex

Papilledema and blindness Irritation of cranial nerve II can cause papilledema and blindness. Facial paresis would result from irritation of cranial nerve VII. Ptosis, unequal pupils, and diplopia can indicate involvement of cranial nerves III, IV, and VI. Sensory loss and loss of corneal reflex can occur with irritation of cranial nerve V.

Which clinical manifestation would the nurse report immediately to the health care provider when providing care for a patient with a traumatic brain injury and an increased intracranial pressure (ICP)? ICP of 20 mm Hg Urine output of 1000 mL in one hour Respiratory rate of 24 breaths/minute Pulse of 100 beats/minute

Urine output of 1000 mL in one hour An increased urine output of 1000 mL in one hour could cause critical fluid and electrolyte imbalance issues and needs prompt attention; this indicates a decline in the patient's condition. An ICP of 20 mm Hg, respiratory rate of 24 breaths/minute, and pulse of 100 beats/minute do not indicate a need for the nurse to call the health care provider.

When assessing a patient's intracranial pressure (ICP) after they sustained a head trauma, which normative value would the nurse utilize to compare the assessment data? 5 to 15 mm Hg 25 to 35 mm Hg 45 to 60 mm Hg 80 to 120 mm Hg

5 to 15 mm Hg A normal ICP reading is 5 to 15 mm Hg. Any ICP value greater than 25 mm Hg represents a life-threatening condition requiring immediate intervention.

The nurse reviews the laboratory results of a patient with a cerebral inflammatory condition and notes that glucose was absent in the patient's cerebrospinal fluid. The nurse recognizes that the finding is consistent with which condition? Encephalitis Brain abscess Viral meningitis Bacterial meningitis

Brain abscess The absence of glucose in cerebrospinal fluid indicates a brain abscess. The glucose would be normal in encephalitis, would be normal or low (>40 mg/dL) in viral meningitis, and would be decreased (5 to 40 mg/dL) in bacterial meningitis.

To preserve cerebral perfusion of a patient with an elevated intracranial pressure (ICP), which cerebral perfusion pressure (CPP) would the nurse maintain when suctioning the patient? 20 mm Hg 40 mm Hg 60 mm Hg 80 mm Hg

80 mm Hg Patients with elevated ICP are at risk for lower CPP during suctioning. When suctioning, maintain the patient's CPP above 60 mm Hg to preserve cerebral perfusion.

Which factors would the nurse consider prior to repositioning a patient with an increased intracranial pressure (ICP)? Select all that apply. Raise the head of bed above 30 degrees Take care to prevent extreme neck flexion of patient. Adjust body position to decrease ICP. Rotate the patient to a side-lying position to prevent skin breakdown. Follow protocol standards to maintain a head-up position for the patient.

- Take care to prevent extreme neck flexion of patient. - Adjust body position to decrease ICP. - Follow protocol standards to maintain a head-up position for the patient.

Which term would the nurse use to document a patient who is comatose from a head injury and displays flexion of the arms, wrists, and fingers, as well as adduction of the upper extremities? Stroke Epileptic seizure Decorticate posturing Decerebrate posturing

Decorticate posturing Decorticate posturing—described as flexion of the arms, wrists, and fingers—and adduction of the upper extremities indicate damage to the primary motor areas of the sensorimotor cortex, both anterior and posterior. The described assessment findings do not specifically relate to describing a stroke or cerebrovascular accident and are not commonly seen in patients with epileptic seizure disorders. A nurse would describe decerebrate posturing as rigid extension of all four extremities with hyperpronation of the forearms and flexion of the feet. Decerebrate posturing results from disruption of motor fibers in the midbrain and brainstem and indicates serious tissue damage.

Which type of brain injury would the nurse associate with the patient who sustained a subdural hematoma from a motor vehicle crash? Anoxia Primary Cerebral Secondary

Primary Primary injuries are those that occur at the time of the injury (e.g., blunt force trauma, car accident); the subdural hematoma is itself an example of this. Secondary injuries are those injuries resulting from the primary injury; for instance, increased intracranial pressure may result from the hematoma. A cerebral injury is damage to the cerebrum, and an anoxia injury results from a lack of oxygen to the brain.

Which outcome would the nurse expect after administration of IV mannitol (Osmitrol) prescribed for a patient experiencing an increased intracranial pressure (ICP)? Increased urine output Decreased BP Reduced ICP Increased intracranial perfusion

Reduced ICP Mannitol is an osmotic diuretic that increases osmotic pressure in the renal tubules to increase the uptake of water and dieresis by the kidneys, which specifically helps to relieve cerebral edema, thereby decreasing ICP. Increased urine output, decreased BP, and increased intracranial perfusion are secondary outcomes of administration of mannitol. Of these, increased intracranial perfusion is most desirable because it reduces ICP. Monitor BPs closely because an extreme decrease in BP may occur, resulting in decreased intracranial perfusion.

Which components would the nurse assess when using the Glasgow Coma Scale (GCS) to assess a patient who sustained a head injury and subsequently developed an increased intracranial pressure (ICP)? Swallowing, speaking, and following verbal commands Swallowing, pupillary response, and following verbal commands Speaking, responding to stimuli, and following verbal commands Responding to stimuli, swallowing, and following verbal commands

Speaking, responding to stimuli, and following verbal commands The GSC assesses a patient's ability to respond to stimuli, speak, and follow verbal commands. Swallowing and pupillary response are not components of the GSC.

Which response would the nurse document when a patient with a brain injury experiences the motor function changes depicted in the image? Decorticate posturing Decerebrate posturing Sinusoidal posturing Opisthotonic posturing

Decorticate posturing Decorticate posture involves internal rotation and adduction of the arms with extension of the elbows, wrists, and fingers, as illustrated in the image. This results from interruption of voluntary motor tracts in the cerebral cortex. The patient may also demonstrate an extension of the legs. A decerebrate posture may indicate more serious damage and results from disruption of motor fibers in the midbrain and brainstem. In this position, the arms are stiffly extended, adducted, and hyperpronated. There is also hyperextension of the legs with plantar extension of the feet. Sinusoidal posturing does not exist. Opisthotonic posturing consists of the head, neck, and spinal column in an arching position.

Which data, obtained during the nurse's assessment of the patient, indicates that the patient in the neurologic intensive care unit with an increased intracranial pressure (ICP) is deteriorating? Presence of fixed unresponsive pupils Sluggish reaction of pupil in response to light Brisk constriction of pupil in response to light Slight constriction in the opposite pupil in response to light

Presence of fixed unresponsive pupils A penlight is used to test the papillary reaction. Fixed pupils that are unresponsive to light indicate ICP. An increase in the ICP causes suppression of nerves, which leads to fixed unresponsive pupils. Sluggish reaction of the pupil indicates an early pressure. Brisk constriction of the pupils is a normal reaction. Slight constriction in the opposite pupil is a consensual response, which is a normal finding.

Which statement by the novice nurse demonstrates understanding of the care required for a patient admitted earlier today with a diagnosis of post-head injury concussion? "I can expect the pupils to be unequal in size and sluggish to respond to my pen light." "I will delegate keeping the patient awake for the next eight hours to my unlicensed assistive personnel (UAP)." "To help with post-head injury headaches, I will contact the health care provider about prescribing morphine IV." "I need to assess the patient's level of consciousness frequently because changes are the first indication of complications."

"I need to assess the patient's level of consciousness frequently because changes are the first indication of complications." The first indication of increased intracranial pressure (ICP) is a change in the patient's level of consciousness. Pupil changes are not an immediate assessment finding following a concussion; in fact, pupil changes are often a late sign of neurologic complications. Keeping the patient awake following a head injury is not necessary. Arousing the patient frequently to assess arousal and level of consciousness is an appropriate plan of care following a head injury. Although headache can be common following a head injury, avoid narcotics for pain management because they can mask the signs of impending complications, particularly alteration in level of consciousness.

Which factors would the nurse associate with the use of hypertonic saline as a treatment for the patient with an increased intracranial pressure (ICP)? Select all that apply. The nurse would closely monitor the patient's blood sugar levels. The nurse would frequently monitor the BP and sodium levels. Hypertonic saline treatment provides massive movement of water out of the swollen brain cells. Hypertonic saline treatment works similarly to mannitol (Osmitrol) when treating increased ICP. The nurse should ensure administration of an antacid prior to administration to prevent gastrointestinal complications.

- The nurse would frequently monitor the BP and sodium levels. - Hypertonic saline treatment provides massive movement of water out of the swollen brain cells. - Hypertonic saline treatment works similarly to mannitol (Osmitrol) when treating increased ICP. Hypertonic saline provides massive movement of water out of swollen brain cells and into blood vessels. When the patient is on this treatment, frequent monitoring of BP and sodium levels is required because intravascular fluid volume excess can occur. Hypertonic saline is as effective as mannitol in treating increased ICP. The treatment does not require monitoring of blood sugar levels and does not require administration of antacids. IV medications may be administered to prevent gastric ulcers, but not because of the use of mannitol.

A patient's systemic BP is 120/60 mm Hg and the intracranial pressure (ICP) is 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), which interpretation would the nurse apply to the results? High blood flow to the brain Normal ICP Impaired blood flow to the brain Adequate autoregulation of blood flow

Impaired blood flow to the brain A normal CPP is 60 to 100 mm Hg. Determine the calculated CPP by subtracting the ICP from the mean arterial pressure (MAP). MAP = (systolic blood pressure [SBP] + 2[diastolic blood pressure (DBP)])/3: (120 mm Hg + 2[60 mm Hg])/3 = 120 mm Hg + 120 mm Hg = 240 mm Hg; 240/3 = 80 mm Hg. MAP-ICP: 80 mm Hg (MAP) - 24 mm Hg (ICP) = a CPP of 56 mm Hg. The decreased CPP (<60 mm Hg) indicates an impaired cerebral blood flow and impaired autoregulation of the CPP. Because the ICP is 24 mm Hg, the pressure is elevated, preventing perfusion of the brain, and requires treatment.