M.11-1: Exemplar: Increased Intracranial Pressure

The nurse is planning care for a client who is experiencing increased intracranial pressure​ (IICP) secondary to a head injury sustained during a motor vehicle crash. Which intervention is a priority for this​ client? A. Ensuring adequate oxygenation B. Controlling pain C. Maintaining a calm environment D. Monitoring for nausea and vomiting

A. Ensuring adequate oxygenation

The nurse is providing care for a client with a head injury and wants to decrease the​ client's risk for developing increased intracranial pressure​ (IICP). Which assessment data indicates that the nurse is​ successful? A. Pupils equal and reactive to light B. Absent gag reflex C. Sluggish response to verbal stimuli D. Body temperature elevated 1 degree in 4 hours

A. Pupils equal and reactive to light

A​ school-age client loses consciousness after being hit in the head with a bat at baseball practice. The child was not wearing a helmet. The last set of vital signs showed heart rate​ 48, blood pressure​ 132/58 mmHg, and respiratory rate 28 and irregular. Based on this​ data, which conclusion by the nurse is the most​ appropriate? A. These vital signs indicate increased intracranial pressure. B. These vital signs indicate cardiovascular disease. C. These vital signs indicate that this child has a spinal cord injury. D. These vital signs indicate respiratory distress.

A. These vital signs indicate increased intracranial pressure.

The nurse is drawing an arterial blood sample from a patient diagnosed with a traumatic brain injury. The spouse asks, "What is the purpose of this test?" How should the nurse respond? A. "It measures the amount of carbon dioxide in the blood to predict the presence of increased intracranial pressure." B."It estimates the length of time it will take for the patient to resume consciousness." C."It predicts the number and depth of respirations that the patient will have during a period of 1 minute." D."It determines the response of medications to remove excess fluid from the brain tissue and reduce swelling."

A. "It measures the amount of carbon dioxide in the blood to predict the presence of increased intracranial pressure." Measuring the arterial blood gases of a patient with an alteration in intracranial regulation is used to determine the level of carbon dioxide because, as carbon dioxide levels increase, blood vessels dilate, leading to an increase in intracranial pressure. There is no blood test that can determine the length of time until a patient returns to consciousness. Respirations are measured by visual observation of the number and depth of respirations that the patient has during a period of 1 minute. Therapeutic drug level monitoring is used to determine if a medication has reached a therapeutic level in the body

The nurse is assessing a patient with increased intracranial pressure who is receiving mechanical ventilation. Which arterial blood gas result indicates optimal oxygenation for the patient? A. Arterial oxygen 100 mmHg and arterial carbon dioxide 35 mmHg B.Arterial oxygen 50 mmHg and arterial carbon dioxide 75 mmHg C.Arterial oxygen 600 mmHg and arterial carbon dioxide 35 mmHg D.Arterial oxygen 25 mmHg and arterial carbon dioxide 25 mmHg

A. Arterial oxygen 100 mmHg and arterial carbon dioxide 35 mmHg Adequate oxygenation should be maintained with a partial pressure of oxygen and carbon dioxide, thus preventing hypoxemia and hypercapnia. A low oxygen level can cause oxygen deprivation to the brain. A high carbon dioxide level can trigger an increase in respirations.

The nurse caring for a patient with increased intracranial pressure (IICP) should implement which intervention? A.Elevate the head of the bed to 30 degrees B.Instruct the patient to move up in the bed by pushing on the footboard C.Utilize the Trendelenburg position. D.Place the patient into the prone position.

A.Elevate the head of the bed to 30 degrees One simple way to reduce IICP is to elevate the head of the bed to 30 degrees unless this in contraindicated. Maintain alignment of the head and neck to avoid hyperextension or exaggerated neck flexion. Avoid the prone position. Keeping the head in the elevated position facilitates venous drainage from the cerebrum. Obstruction of the jugular veins can impede venous drainage from the brain. The Trendelenburg position places the head lower than the shoulders and is contraindicated. If the patient is alert, assist in moving them up in the bed. Do not ask the patient to push with the heels or arms or push against a footboard. Helping the patient to move prevents initiation of the Valsalva maneuver, which increases ICP.

The nurse is repositioning a patient with increased intracranial pressure (IICP). Which is the optimal position in which the nurse should place the patient's head and neck? A.In normal body alignment B.Slight hyperextension of the neck C.Lateral rotation of the head to either side D.Slight flexion of the neck

A.In normal body alignment Having the head and neck in normal body alignment promotes venous drainage from the veins of the cerebral tissue. Positions of hyperextension, flexion, and rotation may reduce venous drainage by applying a twisting pressure on the veins of the neck.

An adult patient is being treated for increased intracranial pressure. Which manifestation indicates to the nurse that the outcomes are being met? A.Intracranial pressure of 14 mmHg B.Verbalizing need to increase stimuli C.Lethargy D.Blood pressure 152/92 mmHg

A.Intracranial pressure of 14 mmHg The adult patient should maintain intracranial pressure (ICP) at 5-15 mmHg. The blood pressure should be normal. The patient and significant others will verbalize the reasons for, and how to maintain, a low-stimulus environment, not a high-stimulus one. The patient will remain free of infection, including redness and drainage at the sites of insertion. The patient will maintain adequate cerebral perfusion, level of consciousness should return to normal, and the patient should not be lethargic.

Which of the following statements best describes the state of dynamic equilibrium of the​ Monro-Kellie hypothesis? A. Normal intracranial pressure requires that the volumes of the​ brain, blood, and CSF are low. B. An imbalance in the volumes of the​ brain, blood, and cerebrospinal fluid​ (CSF) will trigger a compensatory response. C. The brain can compress dynamically to compensate for an increase in blood or CSF volume. D. The volume of the blood must remain constant regardless of the volume of the brain and CSF.

B. An imbalance in the volumes of the​ brain, blood, and cerebrospinal fluid​ (CSF) will trigger a compensatory response.

Hydrocephalus results from an imbalance between production and absorption of which of the​ following? A. Oxygen B. Cerebrospinal fluid C. Blood D. Water

B. Cerebrospinal fluid

The nurse is reviewing medications with a client. The nurse should teach the client that which medication may cause drowsiness and increase the risk for a​ fall? A. Antihypertensive B. Narcotic analgesic C. Antipruritic D. Anticoagulant

B. Narcotic analgesic

The nurse is requesting collaborative therapy from physical therapy for a client with increased intracranial pressure. Which reason supports this​ request? A. To determine if transfer to a skilled nursing facility is required B. To recommend interventions for resulting hemiparesis or hemiplegia C. To work with the nutritionist to determine effective methods to meet nutritional needs D. To assess the living accommodations before the​ client's discharge to home

B. To recommend interventions for resulting hemiparesis or hemiplegia

The nurse is caring for a client with increased intracranial pressure​ (IICP) from a cervical injury. Which statement by the nurse indicates an understanding of how to position the​ client? A. ​"I will ask the client to assist by pushing on the bed with their feet and​ hands." B. ​"I will ask another nurse to help me lift the client toward the head of the​ bed." C. ​"The head of the bed should be kept flat to make it easier to move the​ client." D. ​"The head of the bed should be kept at 90 degrees to assist with venous drainage from the​ brain."

B. ​"I will ask another nurse to help me lift the client toward the head of the​ bed."

The nurse is caring for a​ school-age client who will be discharged from the hospital after receiving a ventriculoperitoneal​ (VP) shunt as treatment for increased intracranial pressure​ (IICP). The nurse has taught the parents to monitor the child for shunt malfunction. Which statement by the parents regarding when to notify the healthcare provider indicates that learning goals have been​ met? A. ​"If our child​ vomits, we will call the​ doctor." B. ​"If our child develops an altered level of​ consciousness, we will notify the​ doctor." C. ​"If we notice our​ child's head is​ expanding, we will notify the​ doctor." D. ​"If our child has a bulging soft​ spot, we will call the​ doctor."

B. ​"If our child develops an altered level of​ consciousness, we will notify the​ doctor.

The nurse caring for a child with increased intracranial pressure provided teaching to the parents about seizures. Which statement by the parent reflects an understanding of the teaching? A."I will make sure that a flat position is maintained." B."I will clear the area of any objects that might cause harm." C."I will put something into the mouth to prevent swallowing the tongue. D."I will maintain a rigid position until the seizure passes."

B."I will clear the area of any objects that might cause harm." Ensuring safety during a seizure is vital to reducing complications associated with the seizure. In case of seizure, do not place anything in the person's mouth, because loose teeth may be knocked out or aspirated. Do not restrain the person during a seizure. This can result in injury or asphyxiation. A person who has a seizure when standing should be gently assisted to the floor and placed in a side-lying position. Clear the area of any objects that may cause harm.

The parent of a pediatric patient who was admitted for a head injury asks the nurse, "Why are the side rails padded?" Which statement by the nurse is an appropriate response? A.The padded side rails are there in case of emergency." B."The side rails are padded to provide safety in the event of a seizure. C."The padded side rails will prevent the patient from falling." D."We pad the side rails for every patient's comfort."

B."The side rails are padded to provide safety in the event of a seizure. Most patients can be in bed safely without side rails. There is no need to pad the side rails of every patient. Although side rails can be used in an emergency, padded side rails are most commonly used for patients who are prone to seizures, providing added cushioning to help reduce inadvertent injuries. Padding the side rails does not prevent falls.

The nurse caring for a patient who has been intubated and placed on a ventilator for increased intracranial pressure (IICP) is describing the patient's treatment to a family member. Which statement by the nurse is correct? A."Your dad is very ill and may not recover so the machine is doing the breathing for him." B."This treatment is for airway protection and respiratory management." C."The pressure in your dad's brain is low, and the ventilator will help him breathe." D."The tube in your dad's airway provides extra carbon dioxide to decrease the pressure in his brain."

B."This treatment is for airway protection and respiratory management." Intubation and mechanical ventilation are used to maintain partial pressure of oxygen and carbon dioxide, thus preventing hypoxemia and hypercapnia. Patients with IICP have increased pressure in the brain and often require intubation and are placed on a ventilator for airway protection and respiratory management. Although the patient is ill, the nurse does not know the outcome of the illness and should not make statements reflecting any particular outcome.

A child is brought to the emergency department after hitting his head following a fall from a skateboard. Which score on the Glasgow Coma Scale represents no deficit? A.8 B.15 C.10 D.5

B.15 The patient's level of consciousness is assessed by using the Glasgow Coma Scale. Any score lower than 15 indicates a decrease in the patient's level of consciousness.

The nurse is caring for an older adult patient diagnosed with increased intracranial pressure (IICP). Which reason should the nurse suspect to be the most likely cause of the patient's IICP? A.Diabetes B.A recent fall C.Elevated triglycerides D.Tumor

B.A recent fall Older adults are prone to falls that can result in IICP. While tumors can cause IICP, falls remain a greater incidence in this age group. Diabetes and elevated triglycerides do not have a direct correlation to IICP

Which assessment finding is an early manifestation that the nurse should expect to observe in a patient with increased intracranial pressure (IICP)? A.Increased heart rate B.Change in personality C.Increased cerebrospinal fluid D.Seizure activity

B.Change in personality One of the earliest indicators of an increased intracranial pressure (ICP) is a change in level of consciousness or personality. Cushing triad is a set of signs that indicate increasing ICP: bradycardia (not tachycardia), irregular respirations, and widening pulse pressure. In IICP, there is a decrease in cerebrospinal fluid to make room in the cranial vault. Seizure activity is not known to be caused by IICP.

The nurse is planning care for a patient with a diagnosis of increased intracranial pressure (IICP). Which intervention should the nurse include? A.Increasing stimuli B.Implementing seizure precautions C.Monitoring creatinine level D.Placing the patient in the Trendelenburg position

B.Implementing seizure precautions

The nurse is discussing risk factors that put older adults at risk for falls that can result in increased intracranial pressure. Which risk factors should the nurse include? A.Increased visual acuity B.Medications C.Increased muscle mass D.Other medical conditions

B.Medications Older adults may take medications that increase their risk for falls and trauma. Sensory losses such as decreased visual acuity and instabilities due to decreased muscle mass can increase the risk for falls. Not all medical conditions put the patient at risk. Undiagnosed or poorly controlled arrhythmias may cause a decrease in cerebral blood flow, which can lead to vertigo and falls.

The nurse is providing care for a patient with increased intracranial pressure (IICP). Which manifestation of IICP should the nurse monitor A.Decreased blood pressure B.Projectile vomiting C.Increased heart rate D.Decreased respirations

B.Projectile vomiting Projectile vomiting is a manifestation of increased intracranial pressure. This is caused by pressure on the brainstem from swollen brain tissue. Increased intracranial pressure causes increased blood pressure, especially the systolic blood pressure. This worsens until there is a wide difference between the systolic blood pressure and the diastolic blood pressure. Increased intracranial pressure causes lowered heart rate. This is caused by the body's attempt to compensate for increased blood pressure. The respiratory system is not directly affected by IICP.

Which collaborative intervention should the nurse expect for a patient with suspected increased intracranial pressure (IICP)? A.Lumbar puncture B.Serum osmolality C.Stool guaiac test D.Chest x-ray

B.Serum osmolality Some tests taken in patients with increased intracranial pressure (IICP) will be expected to be normal: a chest x-ray and a stool guaiac test. Other tests, such as a CT scan, arterial blood gases, and serum osmolality can often produce valuable information about the cause of IICP and the treatment. A lumbar puncture is not performed when IICP is suspected because a sudden release of pressure in the skull may cause cerebral herniation.

Which is the most frequent cause of increased intracranial pressure (IICP)? A.Tumors B.Tissue ischemia C.Hemorrhage D.Abscesses

B.Tissue ischemia The pressure exerted by cerebral edema, the increase in fluid that is retained in brain tissue, is the most common cause of increased intracranial pressure. When the intracranial pressure rises dramatically or for a sustained period of time, significant tissue ischemia and damage to the neural tissue may result. Tumors and abscesses are space-taking lesions that increase the pressure within the cranial cavity. Hemorrhage, the pooling of blood within the cranial cavity, also exerts additional intracranial pressure.

The nurse selects the diagnosis of Risk of Infection for a child who sustained a brain injury during an automobile accident. Which nursing intervention would be appropriate to include in this​ client's plan of care related to this​ diagnosis? A. Refer the family to support services in the community. B. Explain rules for visiting in the Intensive Care Unit. C. Change the​ client's dressings on a prescribed basis. D. Teach the family the importance of using seat belts.

C. Change the​ client's dressings on a prescribed basis.

When a nurse provides a client with the guidance to wear seat belts and avoid mobile device use while​ driving, this measure is intended to lower the risk of which of the​ following? A. Intracranial tumors B. Hydrocephalus C. Head trauma D. Cerebral edema

C. Head trauma

Which nursing goal is appropriate for a client with increased intracranial pressure​ (IICP)? A. Protection from increases in cerebral blood flow B. Protection from risk factors C. Protection from sudden increases in intracranial pressure D. Protection from sudden decreases in intracranial pressure

C. Protection from sudden increases in intracranial pressure

A parent brings a​ 12-year-old to the clinic after a fall from a bicycle. Which statement by the nurse is a health promotion intervention to minimize future risk of increased intracranial​ pressure? A. ​"What will you do in the future to prevent this from​ happening?" B. ​"Thank goodness your child sustained only a few cuts and​ bruises." C. ​"How do you feel about your child wearing a helmet while riding their​ bicycle?" D. ​"Let's hope this​ doesn't happen​ again."

C. ​"How do you feel about your child wearing a helmet while riding their​ bicycle?"

The nurse is caring for a client in the neurologic intensive care unit​ (ICU) with head trauma. The client is being monitored for increased intracranial pressure​ (IICP). Using the​ Monro-Kellie hypothesis as a basis for​ explanation, which comment by the nurse to the​ client's family would be most​ appropriate? A. ​"Because there is more pressure in the​ brain, the blood flow is also​ increasing." B. ​"The pressure in the brain is increasing because the brain is​ shrinking." C. ​"Increasing brain pressure decreases the amount of blood flow to the brain​ itself." D. ​"It is normal for brain pressure to increase in times of​ stress."

C. ​"Increasing brain pressure decreases the amount of blood flow to the brain​ itself."

An older woman who was hospitalized for increased intracranial pressure is being discharged into the care of her daughter. Which statement by the patient's daughter reflects an understanding of the care for her mother? A.I should expect my mother to have some nausea and vomiting." B."I should expect her to complain of visual changes." C."If my mother is hard to wake up, I should call 911." D."My mother will probably have severe headaches."

C."If my mother is hard to wake up, I should call 911." Any change in the level of consciousness, such as difficulty to awaken or increased confusion, can mean that the pressure is increasing and indicate a medical emergency. If the patient complains of a stiff neck, severe headache, or nausea and vomiting, take the patient to the emergency department. Changes in vision or motor control should be reported immediately.

The nurse is caring for a patient with a diagnosis of increased intracranial pressure (IICP). The unlicensed assistive personnel (UAP) asks, "Are special precautions to be taken when caring for a patient with IICP?" Which response by the nurse is accurate? A."Yes, be sure to leave the TV on at all times." B."No, there are no special precautions." C."Yes, raise the pads and bedrails." D.Yes, keep the bed flat."

C."Yes, raise the pads and bedrails." If the patient is suspected of having IICP, it is recommended to raise pads and bedrails, as seizures may occur due to increased pressure. Other methods for keeping the pressure from increasing further include elevating the patient's head to 30 degrees, keeping their neck in a neutral position, decreasing stimuli (thus, having the TV on at all times would be overstimulating), avoiding overhydration, maintaining a normal body temperature, and maintaining a normal oxygen level.

The nurse is planning care for a patient diagnosed with increased intracranial pressure (IICP) who is experiencing a decreasing level of consciousness. Which collaborative treatment should the nurse question for this patient? A.Intubating the patient with an endotracheal tube B.Administering intravenous mannitol C.Administering intravenous 0.45% saline infusion D. Placing the patient on a mechanical ventilator

C.Administering intravenous 0.45% saline infusion The nurse should not administer hypotonic intravenous fluids for this patient. 0.45% saline is a hypotonic fluid and will cause water to move into the brain cells. This will increase intracranial pressure. The other interventions are expected and appropriate for patients with IICP.

The nurse is teaching the caregiver of a patient diagnosed with increased intracranial pressure about care while at home. Which instruction should the nurse include? A.Be aware that the patient's neck may be stiff. B.Increase environmental stimuli. C.Call 911 if the patient is difficult to awaken. D.Understand that there are no restrictions.

C.Call 911 if the patient is difficult to awaken As increased intracranial pressure can cause changes in the patient's level of consciousness. Any change, such as being difficult to awaken, requires immediate medical attention. Environmental stimuli can raise intracranial pressure. It is advisable to encourage the patient and the family members to reduce environmental stimuli. Advise the patient to maintain head and neck alignment when turning in bed, which helps to decrease intracranial pressure.

The nurse assesses a patient and finds a cerebral perfusion pressure of 40 mmHg. Which pathologic process is a consequence of this finding? A.An obstruction will occur. B.Level of consciousness will increase. C.Cerebral blood flow will decrease D.Brain tissue will grow.

C.Cerebral blood flow will decrease Cerebral perfusion pressure (CPP) should ideally be maintained between 50-100 mmHg in adults. When a patient's CPP falls below 50 mmHg, compensatory changes within the brain might not occur, and cerebral blood flow will decrease. Brain tissue does not grow in adults. As pressure increases on the brain, the level of consciousness will decrease. Increased pressure in the brain is not caused by obstruction.

The nurse should expect which treatment to be implemented for a newborn with increased intracranial pressure (IICP)? A.Lowering the body temperature B.Applying a warming blanket C.Inserting a shunt system D.Withdrawing blood

C.Inserting a shunt system IICP in newborns can be relieved by performing a lumbar puncture or inserting a shunt system. Alteration in body temperature is not relative to the reduction of intracranial pressure. Although withdrawing blood might occur as a part of diagnostic testing, it is not a treatment for IICP.

Which is a risk factor for increased intracranial pressure? A. Overnutrition B.Wearing safety equipment C.Trauma D.Use of vitamin supplements

C.Trauma Any factor that increases the patient's risk of trauma increases the risk of cerebral trauma, resulting in increased intracranial pressure. Risk factors for cerebral trauma are plentiful but increase when normal safety precautions, such as wearing protective equipment, are ignored. Undernutrition also puts a patient at risk. Overnutrition and the use of vitamin supplements have no bearing on increased intracranial pressure.

An adult patient's spouse reports to the nurse that their husband appears more alert than before. The spouse asks, "Is he getting better?" Which response by the nurse is accurate A."Your husband's intracranial pressure is 40 mmHg and within normal limits." B."Your husband's intracranial pressure is 25 mmHg and within normal limits." C.Your husband's intracranial pressure is 14 mmHg and within normal limits." D."Your husband's intracranial pressure is 60 mmHg and within normal limits."

C.Your husband's intracranial pressure is 14 mmHg and within normal limits." The normal range for intracranial pressure (ICP) is typically 1.5-15 mmHg, but it can vary based on measurement techniques and age. Normal ranges across the lifespan are as follows: 1.5-6 mmHg in infants, 3-7 mmHg in children, and 5-15 mmHg in adults.

The nurse is preparing to discharge an older adult who was admitted to the hospital after hitting their head during a fall. Which service is most important for the client when at​ home? A. Meals on Wheels B. ​In-home blood draws C. Home pharmacy delivery D. Home assessment

D. Home assessment

Which events are associated with the loss of​ autoregulation? A. Both intracranial pressure and cerebral perfusion decrease. B. Intracranial pressure decreases and cerebral perfusion increases. C. Both intracranial pressure and cerebral perfusion increase. D. Intracranial pressure increases and cerebral perfusion decreases

D. Intracranial pressure increases and cerebral perfusion decreases

Which collaborative therapy should the nurse request when a client needs to learn to swallow following damage to the associated area of the​ brain? A. Recreational therapy B. Physical therapy C. Occupational therapy D. Speech therapy

D. Speech therapy

The nurse is caring for a pregnant client with a history of idiopathic intracranial hypertension​ (IIH) and optic neuritis. What should the nurse least assume regarding this​ client? A. The second stage of labor should not be prolonged. B. ​Pregnancy-related weight gain should be kept to no more than 9 kg. C. The client has been prescribed a medication to treat the IIH. D. The client will deliver her baby via cesarean birth.

D. The client will deliver her baby via cesarean birth.

A client with increased intracranial pressure is prescribed mannitol. The family​ asks, "What is the purpose of this​ medication?" The​ nurse's response should be based on which action of the​ drug? A. To prevent tiny stress hemorrhages in the brain B. To enhance renal excretion of retained protein C. To create a sodium and potassium balance D. To draw fluid from the brain tissue

D. To draw fluid from the brain tissue

A client is ready for discharge from the hospital after being treated for increased intracranial pressure. Which statement confirms that the​ client's spouse understands the discharge​ instructions? A. ​"My spouse can continue to use a nicotine​ patch." B. ​"My spouse can take any​ over-the-counter medication." C. ​"My spouse does not need to do anything differently when we get​ home." D. ​"My spouse should avoid alcohol as it can increase the risk of​ injury."

D. ​"My spouse should avoid alcohol as it can increase the risk of​ injury."

The nurse is talking to the spouse of a patient who has increased intracranial pressure. Which statement confirms that the spouse understands what is happening with the patient? A."The blood flow to the brain has increased and is causing an increased pressure. B."Low blood pressure is causing the brain to have too much fluid in it, causing a decrease in blood flow and the amount of oxygen reaching the brain. C."There is a tumor in the brain causing pressure on the blood vessels." D."As pressure in the brain increases, the fluid surrounding the brain decreases and blood flow is decreased, resulting in less oxygen to the brain."

D."As pressure in the brain increases, the fluid surrounding the brain decreases and blood flow is decreased, resulting in less oxygen to the brain." Three components make up the pressure-volume equilibrium—the brain, the blood, and the cerebrospinal fluid. Any of these components can change and affect the other two and cause an imbalance and resulting increase in pressure. Low blood pressure and increased blood flow to the brain would not affect the pressure in the brain and cause it to increase. Tumors may be involved, but there is no information to confirm this.

An older adult with increased intracranial pressure is being cared for by their granddaughter. The granddaughter asks the nurse, "How do I know which medication might be causing my grandmother to fall, so I can stop her from taking it?" How should the nurse respond? A."Don't worry about the medications she takes, they should be all safe." B."You should ask the healthcare provider to prescribe another medication that prevents dizziness." C."If you look at the label on the bottle, there may be a warning about causing dizziness." D."You should not stop her from taking any medication without first consulting her healthcare provider."

D."You should not stop her from taking any medication without first consulting her healthcare provider." Older adults may take medications that increase their risk for falls and trauma. Any change of medication must first be discussed with the healthcare provider. Some medications cannot be stopped without repercussions. A prescription label may have a warning that it may cause dizziness, but medications act differently on different people. Dizziness can present as a side effect of most medications. Although there are medications that can help with dizziness, adding another medication to the regimen may not be the best solution. All medication questions should be addressed with the healthcare provider.

The nurse is preparing a plan of care for a patient recovering from an injury that has caused increased intracranial pressure (IICP). Which action should the nurse plan to include to help reduce cerebral edema? A.Applying a cooling blanket B.Regulating the infusion of a proton pump inhibitor C.Raising the head of the bed 30° D.Administering prescribed loop diruetic

D.Administering prescribed loop diruetic A pharmacologic collaborative intervention is to administer a medication used to manage IICP, such as a loop diuretic medication. Applying a cooling blanket is an independent intervention used to control hyperthermia. Raising the head of the bed is an indendent nursing action to help decrease IICP. Regulating the infusion of a proton pump inhibitor is a pharmacologic collaborative intervention to manage gastric ulcer formation after a trauma.

The nurse is caring for a patient with increased intracranial pressure (IICP). The nurse should monitor the patient for which complication? A.Improved memory and judgment B.Increased visual acuity C. Nausea D.Changes in level of consciousness (LOC)

D.Changes in level of consciousness (LOC) Oxygen deficit causes changes in LOC as well as impaired memory and judgment. Prolonged oxygen deficit can result in tissue death. Projectile vomiting is common, but without nausea. Visual abnormalities occur, including decreased visual acuity, blurred vision, and diplopia.

A patient has increased intracranial pressure. The patient's wife asks the nurse, "What is causing this?" Which response by the nurse is appropriate? A."The blood flow to the brain has increased and is causing an increased pressure." B."He must have a tumor causing the increase in pressure that we are seeing." C."Your husband's low blood pressure is causing the brain to have too much fluid in it." D.His body's compensatory mechanisms have failed."

D.His body's compensatory mechanisms have failed." Three components make up the pressure-volume equilibrium: the brain, the blood, and the cerebrospinal fluid. Any of these components can change and affect the other two and cause an imbalance and resulting increase in pressure. Low blood pressure and increased blood flow to the brain would not affect the pressure in the brain and cause it to increase. Tumors may be involved, but without knowing the facts, the nurse should not mention this.

The nurse is assessing an obese pregnant woman. The nurse should monitor the patient for which condition? A.Traumatic brain injury B.Seizures C.Tremors D.Idiopathic intracranial hypertension

D.Idiopathic intracranial hypertension The physiologic status of pregnancy does not directly affect intracranial pressure. However, a condition called idiopathic intracranial hypertension (IIH) exists and is common in obese women of childbearing age. If the patient with IIH becomes pregnant, neurology and obstetrics should work together closely to ensure safety for both the mother and the fetus. Seizures and tremors are not common in obese women. Traumatic brain injury occurs only when a trauma occurs to the brain.

For which purpose would a serum osmolality test be implemented for a patient with increased intracranial pressure? A.To assess serum pH B.To identify serum lactic acid levels C.To indicate adequacy of serum protein levels D.To determine hydration status

D.To determine hydration status For a patient with an altered intracranial pressure, serum osmolality measures hydration status. Overly hydrated patients have additional pressure within the intracranial cavity. Serum osmolality does not measure serum protein levels, lactic acid levels, or serum pH.

While caring for a client with increased intracranial pressure​ (IICP), a family member asks to assist. Which interventions are appropriate for the nurse to teach the family member regarding this​ client's care? Select all that apply. A. Keep bedrails raised. T B. Keep the client in a stationary position. C. Position client in a supine position. D. Maintain head of the bed elevated to 30 degrees. E. Decrease stimuli.

a, d, e

The nurse is caring for a client who has increased intracranial pressure from a traumatic brain injury. Which diagnostic test should the nurse anticipate being​ ordered? (Select all that​ apply.) A. Cardiac monitoring B. Arterial blood gas C. Computerized tomography​ (CT) scan of the head D. Intracranial pressure monitor E. Electromyogram

a,b,c,d

Which client is most at risk for increased intracranial​ pressure? (Select all that​ apply.) A. Older adult B. Newborn infant C. ​School-aged child D. Pregnant obese woman E. Adolescent

a,b,c,d, e

The nurse is assessing a client with a traumatic head injury and suspects increased intracranial pressure​ (IICP). Which assessment finding supports this​ suspicion? (Select all that​ apply.) A. Blurred vision B. Drowsiness C. Hemiparesis D. Increased heart rate E. Double vision

a,b,c,e

A client is demonstrating signs of increasing intracranial pressure. Which intervention should the nurse​ implement? (Select all that​ apply.) A. Assessing vital signs B. Assessing cranial nerve function C. Providing hypotonic fluids D. Monitoring pupillary response E. Reducing environmental stimuli

a,b,d,e

Which assessment finding for a client should the nurse attribute to increased intracranial​ pressure? (Select all that​ apply.) A. Slowed pupillary responses to light B. Decreased heart rate C. Fluid intake for the past 24 hours D. Decreased motor status and strength E. Altered level of consciousness

a,b,d,e

The nurse assessing a client who presents with an altered level of consciousness​ (LOC) should suspect which​ condition? (Select all that​ apply.) A. Seizure activity B. Cerebral infarction C. Sciatica D. Hematoma E. Traumatic brain injury

a,b,d,e,

The nurse is caring for a client with increased intracranial pressure​ (IICP) who is supported with mechanical ventilation. Which intervention should the nurse implement to ensure adequate oxygenation for this​ client? (Select all that​ apply.) A. Implementing measures to prevent atelectasis and fluid accumulation B. Initiating hyperventilation C. Performing suctioning as needed D. Maintaining partial pressure of arterial carbon dioxide of 35 mmHg E. Maintaining partial pressure of arterial oxygen of 100 mmHg

a,c,d,e

The nurse caring for a client with increased intracranial pressure should recognize that which compensatory mechanism stimulates the cerebral blood vessels to regulate cerebral​ pressure? (Select all that​ apply.) A. Lactic acid B. Serum uric acid C. Potassium D. Carbonic acid E. Carbon dioxide

a,d,e

The nurse is caring for a client who has increased intracranial pressure and a fever of​ 102°F. Which nursing intervention promotes normal intracranial​ pressure? (Select all that​ apply.) A. Providing supplemental oxygen B. Flexing the neck to open the airway C. Increasing environmental stimuli D. Monitoring level of consciousness E. Administering acetaminophen per order

a,d,e

An alert client presents at the urgent care center after a fall. Which assessment should the nurse​ perform? (Select all that​ apply.) A. Anthropometric measurements B. Level of consciousness​ (LOC) C. Vital signs D. Pupillary size and reaction to light E. Body mass index

b,c,d

A​ 35-year-old client has been in the hospital for 2 weeks recovering from increased intracranial pressure. Which instruction should the nurse provide to the​ client? (Select all that​ apply.) A. Wear a helmet to prevent head injury. B. Take all medications as prescribed. C. Remain on bedrest at all times of the day. D. Discuss the care plan at the workplace. E. Purchase a medical alert bracelet.

b,d,e