Increased Intracranial Pressure chp 57
b (Using the medication-calculation equation of dose desired (8 mg) divided by dose on hand (20 mg) and multiplied by the quantity (1 mL), the answer is 0.4 mL. Text Reference - p. 1364)
A dose of dexamethasone 8 mg intravenous (IV) is prescribed. The unit stock medication has a concentration of 20 mg/mL. How many mL should be drawn up to administer this dose? A 0.2 mL B 0.4 mL C 1 mL D 2 mL
A ( normal intracranial pressure (ICP) reading is 5 to 15 mm Hg. Any ICP value greater than 25 mm Hg represents a life-threatening condition requiring immediate intervention. Text Reference - p. 1357)
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? A 5 to 15 mm Hg B 25 to 35 mm Hg C 45 to 60 mm Hg D 80 to 120 mm Hg
c (Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = systolic blood pressure (SBP) + 2 (diastolic blood pressure [DBP])/3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP-ICP: 80mm Hg - 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24, it is elevated and requires treatment. Text Reference - p. 1357)
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? A High blood flow to the brain B Normal intracranial pressure C Impaired blood flow to the brain D Adequate autoregulation of blood flow
ABC (A GCS score of 8 or less (4, 5, and 6) generally indicates coma. Scores of 9 or 11 are greater than 8 and do not indicate coma. Text Reference - p. 1365)
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? Select all that apply. A 4 B 5 C 6 D 9 E 11
ABE (The patient's ability to obey, the patient's ability to speak, and to open the eyes to verbal or painful stimulus are assessed with the GCS. This scale does not include the assessment of patient's ability to swallow or assessment of digestion capacity. Text Reference - p. 1365)
A patient has increased intracranial pressure (ICP). What will the nurse assess using the Glasgow Coma Scale (GCS)? Select all that apply. A Patient's ability to obey B Patient's ability to speak C Patient's ability to swallow D Patient's digestion capacity E Patient's ability to open eyes in response to painful stimulus
D (Late signs of increased intracranial pressure include an increased systolic blood pressure and decreasing diastolic blood pressure (widening pulse pressure), bradycardia, and decreased respirations. The patient may also display a decreased level of consciousness, seizures, or both. These symptoms represent the Cushing's triad and require immediate intervention. Not remembering what happened, a sleeping patient who awakens in response to painful stimuli, and a blood pressure of 110/80 mm Hg, pulse of 78 beats/minute, and respirations of 20 breaths/minute do not necessarily indicate deterioration in the patient's condition. Text Reference - p. 1360)
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 a deterioration in the patient's condition? A The patient does not remember what happened. B The patient is sleeping but awakens in response to painful stimuli. C Blood pressure is 110/80 mm Hg. pulse is 78 beats/minute, and respirations are 20 breaths/minute. D Blood pressure is 160/74 mm Hg, pulse is 53 beats/minute, and respirations are 10 breaths/minute.
125 (Pain and agitation cause rapid movements, which may increase the ICP. Extreme hip flexion may raise the intraabdominal pressure, which increases the ICP. Increased intrathoracic pressure may increase ICP by impeding the venous return. Slow and gentle movements will provide comfort to the patient and will not increase the ICP. Elevation of the head of the bed promotes drainage from the head, decreases the vascular congestion, and therefore decreases ICP. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation.Text Reference - p. 1368)
A patient is admitted with elevated intracranial pressure (ICP). What factors may create further elevation in intracranial pressure? Select all that apply. 1 Pain and agitation 2 Extreme hip flexion 3 Slow and gentle movements 4 Elevation of head of the bed 5 Increased intrathoracic pressure
2 (Dexmedetomidine is an α2-adrenergic agonist used for continuous intravenous sedation of intubated and mechanically ventilated patients. It activates the receptors in the brain and spinal cord and inhibits neuronal firing, which causes hypotension. Dexmedetomidine does not cause insomnia, hyperanxiety, or sedation. It is used in neurologic assessment because of its anxiolytic activities. ) Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect. Text Reference - p. 1367
A patient is intubated and mechanically ventilated and is ordered dexmedetomidine. To what side effect of the medication should the nurse be alert? 1 Insomnia 2 Hypotension 3 Hyperanxiety 4 Sedative effect
ABE (To prevent the patient from injury, the nurse should consider the use of light sedation agents, as prescribed by the health care provider. Skin area under the restraints should be checked for signs of irritation, because it 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. Family members should not be prevented from visiting the patient. Instead allowing a family member to visit may help to calm the patient. Text Reference - p. 1368)
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? Select all that apply. A. Consider the use of light sedation agents. B. Observe the skin area under the restraints. C. Use a stimulating environment in the room. D. Keep family members away from the patient. E.Use effective restraints in an agitated patient.
bde (Blurred vision, headache and vomiting, and a decreased level of consciousness are manifestations of shunt malfunction related to an increase in ICP. Cough and gaseous distention are not relevant. Text Reference - p. 1377)
A patient presents with a shunt malfunction related to increased intracranial pressure (ICP). On examination, which findings would the nurse observe? Select all that apply. A Cough B Blurred vision C Gaseous distention D Headache and vomiting E Decreased level of consciousness
BCE (The patient should be turned and positioned appropriately and carefully to prevent increase in ICP. Frequent assessment of the patient's neurologic status is essential during the first 48 hours after the cranial surgery. Close monitoring of fluid and electrolyte levels and serum osmolality are done to detect changes in sodium regulation, the onset of diabetes insipidus, or severe hypovolemia. Assessing the patient's weight loss after surgery and monitoring the patient's serum creatinine and lipid profile are not the prime interventions after any cranial surgery, because they do not affect the ICP. STUDY TIP: Enhance your time-management abilities by designing a study program that best suits your needs and current daily routines by considering issues such as the following: (1) Amount of time needed; (2) Amount of time available; (3) "Best" time to study; (4) Time for emergencies and relaxation. Text Reference - p. 1379)
A patient underwent cranial surgery. What actions should the nurse perform to prevent increased intracranial pressure (ICP)? Select all that apply. A. Assess the patient's weight loss after surgery. B. Turn and position the patient appropriately. C. Frequently assess the patient's neurologic status. D. Monitor the patient's serum creatinine and lipid profile. E. Closely monitor fluid and electrolyte levels and serum osmolality.
d (One classic sign of increasing intracranial pressure and neurologic deterioration is increased systolic blood pressure and decreased diastolic blood pressure (resulting in a widening pulse pressure) accompanied by bradycardia. Hypertension, bradycardia, and bradypnea together are known as the Cushing's triad. Increased systolic blood pressure, increased pulse, and GCS of 12 and decreased diastolic blood pressure, decreased pulse, and GCS of 13 do not indicate deterioration in neurologic status. Increased systolic and diastolic blood pressure, increased pulse, and GCS of 9 indicate that the patient requires continued assessment. Although the blood pressure 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. Anything less than 8 is considered a coma. Text Reference - p. 1360)
A patient who sustained a head injury in a motorcycle accident 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? A Increased systolic blood pressure, increased pulse, GCS score of 12 B Decreased diastolic blood pressure, decreased pulse, and GCS score of 13 C Increased systolic and diastolic blood pressure, increased pulse, GCS score of 9 D Increased systolic blood pressure, decreased pulse, widening pulse pressure, GCS score of 4
60 (Patients with elevated ICP are at risk for lower CPP during suctioning. CPP must be maintained above 60 mm Hg to preserve cerebral perfusion. Text Reference - p. 1357)
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? Fill in the blank using a whole number. ____
1 (Reading that the ICP is above the indicated level is the first step. If ICP is above the indicated level, opening the ventriculostomy system at the indicated ICP is the next step. Once the stopcock is opened, allowing CSF to drain for two to three minutes helps to relieve the pressure in the cranial vault. Closing the stopcock to return the ventriculostomy to a closed system is the final step. Text Reference - p. 1363)
A patient with increased intracranial pressure (ICP) will undergo lumbar puncture for cerebrospinal fluid (CSF) drainage. In which order are the necessary actions performed for intermittent CSF drainage? 1. Determine that the ICP is above the indicated level. 2. Allow CSF to drain for two to three minutes. 3. Open the ventriculostomy system at the indicated ICP. 4. Close the stopcock to return the ventriculostomy to a closed system.
c (A blood pressure with a widening pulse pressure, bradycardia, and irregular respirations are associated with increasing intracranial pressure (ICP). This is known as the Cushing's triad and should be reported immediately. Presence of a gag reflex, urine output of 50 mL over an hour, and temperature of 99.8° F (37.6° C) and pulse of 96 beats/minute are acceptable assessment findings in a postoperative patient. Text Reference - p. 1360)
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? A Presence of a gag reflex B Urine output of 50 mL during the past hour C Blood pressure of 148/58 mm Hg and pulse 48 beats/minute D Temperature of 99.8° F (37.6° C) and pulse of 96 beats/minute
B (Change in vital signs is caused by increasing pressure on the thalamus, hypothalamus, pons, and medulla. Manifestations, such as Cushing's triad (systolic hypertension with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations), are often late signs of markedly increased intracranial pressure (ICP). The nurse should compare the vital signs obtained with baseline vital signs recorded. If there is a deviation from baseline, the nurse should assess the patient, including a repeat set of VS to validate findings. More than just the blood pressure can change with increased intracranial pressure; therefore, asking the UAP to repeat the blood pressure only will not provide any further data. An elevated temperature in a patient with a head injury may indicate a hypothalamic response from injury. The nurse should gather all assessment data before administering antipyretic. Text Reference - p. 1360)
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? A. Ask the UAP to repeat the blood pressure. B. Compare the current VS to baseline VS recorded. C. Validate the VS by repeating the VS measurements. D. Administer prescribed acetaminophen (Tylenol) for fever.
D (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 often are 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, narcotics are avoided in pain management, because they can mask the signs of impending complications, particularly alteration in level of consciousness. Text Reference - p. 1360)
The novice nurse is assigned a patient who was admitted earlier in the day with a diagnosis of post-head injury concussion. The novice nurse has a good understanding of head injuries when telling the supervising nurse: A "I can expect the pupils to be unequal in size and sluggish to respond." B "I will delegate to the unlicensed assistive personnel (UAP) to keep the patient awake for the next eight hours." C "To help with post-head injury headaches, I will ask the health care provider to prescribe morphine intravenously (IV)." D "I need to assess the patient's level of consciousness frequently because that is the first indication of complications."
d (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 often are 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, narcotics are avoided in pain management, because they can mask the signs of impending complications, particularly alteration in level of consciousness. Text Reference - p. 1360)
The novice nurse is assigned a patient who was admitted earlier in the day with a diagnosis of post-head injury concussion. The novice nurse has a good understanding of head injuries when telling the supervising nurse: A "I can expect the pupils to be unequal in size and sluggish to respond." B "I will delegate to the unlicensed assistive personnel (UAP) to keep the patient awake for the next eight hours." C "To help with post-head injury headaches, I will ask the health care provider to prescribe morphine intravenously (IV)." D "I need to assess the patient's level of consciousness frequently because that is the first indication of complications."
c (Mannitol (Osmitrol) is an osmotic diuretic that increases osmotic pressure in the renal tubules. This increases uptake of water and diuresis, which specifically helps relieve cerebral edema, thereby decreasing intracranial pressure. Increased urine output, decreased blood pressure, and increased intracranial perfusion are secondary outcomes of administration of mannitol (Osmitrol). Of these, increased intracranial perfusion is most desirable because it reduces intracranial pressure. Blood pressure must be monitored closely because an extreme decrease in blood pressure may occur, resulting in decreased intracranial perfusion. Text Reference - p. 1364)
The nurse administers mannitol that has been prescribed for a patient with increased intracranial pressure. What is the primary expected outcome? A Increased urine output B Decreased blood pressure C Reduced intracranial pressure D Increased intracranial perfusion
c (Decorticate posturing, described as flexion of the arms, wrists, and fingers and adduction of the upper extremities, indicates damage to the primary motor areas of the sensorimotor cortex, both anterior and posterior. The assessment findings described are not specifically related to a stroke or cerebrovascular accident and are not commonly seen in patients with epileptic seizure disorders. Decerebrate posturing is described as rigid extension of all four extremities with hyperpronation of the forearms and flexion of the feet. Decerebrate posturing, which may indicate more serious damage, results from disruption of motor fibers in the midbrain and brainstem. Text Reference - p. 1360)
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? A Stroke B Epileptic seizure C Decorticate posturing D Decerebrate posturing
b (Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with increased ICP. They consist of increasing systolic pressure (not hypotension) with a widening pulse pressure (not narrowing), bradycardia with a full and bounding pulse, and irregular respirations (not tachypnea). Test-Taking Tip: The most reliable way to ensure that you select the correct response to a multiple-choice question is to recall it. Depend on your learning and memory to furnish the answer to the question. To do this, read the stem, and then stop! Do not look at the response options yet. Try to recall what you know and, based on this, what you would give as the answer. After you have taken a few seconds to do this, then look at all of the choices and select the one that most nearly matches the answer you recalled. It is important that you consider all the choices and not just choose the first option that seems to fit the answer you recall. Remember the distractors. The second choice may look okay, but the fourth choice may be worded in a way that makes it a slightly better choice. If you do not weigh all the choices, you are not maximizing your chances of correctly answering each question. Text Reference - p. 1360)
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)? A Tachypnea B Bradycardia C Hypotension D Narrowing pulse pressure
1 (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. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Text Reference - p. 1366)
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? 1 Presence of fixed unresponsive pupils 2 Sluggish reaction of pupil in response to light 3 Brisk constriction of pupil in response to light 4 Slight constriction in the opposite pupil in response to light
1 (An increase in ICP because of a mass lesion such as a tumor or hematoma can be treated by surgery. Cimetidine is an antihistamine that prevents gastrointestinal bleeding and ulcers associated with corticosteroids. Craniectomy is a treatment done only in very aggressive situations. Corticosteroids are used to treat cerebral edema. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Text Reference - p. 1364)
The nurse is caring for a patient with increased intracranial pressure (ICP) resulting from a mass lesion in the brain. About what treatment option does the nurse educate the patient that will have the best outcome? 1 Surgery 2 Cimetidine 3 Craniectomy 4 Corticosteroids
4 (Benzodiazepine can cause hypotension as a side effect and may worsen the patient's condition by causing a sudden decrease in blood pressure. Benzodiazepines are used as sedatives; however, they are not avoided because of their sedative action. Benzodiazepines do not cause pain and anxiety. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation.)
The nurse is caring for a patient with increased intracranial pressure (ICP). An order for a benzodiazepine is given. Why should the benzodiazepine be excluded for treating increased intracranial pressure (ICP) in a patient? 1 It may cause sedation. 2 It may increase the pain. 3 It increases anxiety levels. 4 It causes a hypotensive effect.
3 (Ventriculostomy is a gold standard procedure for monitoring the intracranial pressure (ICP). In this procedure, the catheter is positioned to directly measure the pressure within the ventricles. In ventriculostomy, the transducer is external. It facilitates sampling of cerebrospinal fluid and allows for intraventricular drug administration. Text Reference - p. 1361)
The nurse is educating a patient scheduled for a ventriculostomy. What statement by the patient demonstrates an understanding of the procedure? 1 "I will have an internal transducer in my head." 2 "The primary health care provider won't be able to get samples of my cerebrospinal fluid." 3 "It will directly measure the pressure within the ventricles of my brain." 4 "I won't be able to have drugs instilled through this procedure."
4 (Intravenous (IV) anesthetic propofol has gained popularity in management of anxiety and agitation because it has a short half-life, which facilitates faster therapeutic action of the drug in the body. The side effect of propofol is hypotension and it limits the use of propofol in hypotensive patients. Propofol does not have effect on fluid replacement or electrolyte balance in the body. Text Reference - p. 1367)
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? 1 It reduces blood pressure in the body. 2 It causes fluid replacement effectively. 3 It maintains electrolyte balance effectively. 4 It has a short half-life and rapid onset of action.
3 (A doll's eye reflex test is performed to determine the oculocephalic reflex. It increases the risk of brain stem injury with a cervical spine problem. A doll's eye reflex test can be performed in an unconscious and uncooperative patient. This test is used to determine the presence of intracranial lesions due to increased intracranial pressure. Text Reference - p. 1366)
The nurse is performing a neurologic assessment for a patient after a motor vehicle crash. Which patient condition may be a contraindication for testing the doll's eye reflex? 1 An unconscious patient 2 An uncooperative patient 3 A patient with cervical spine injury 4 A patient who has intracranial lesion
4 (A palmar drift test is an excellent measure of the strength in the upper extremities. In this test, the patient extends their arms up in front of the body, with eyes closed. Eye movements are tested by examining the cranial nerve functioning. Pupillary reactions are tested with a penlight. Strength of legs is tested by asking the patient to pull the knees up in bed. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer. Text Reference - p. 1366)
The nurse is performing a neurologic assessment for a patient. When performing a palmar drift test, what is the nurse attempting to determine? 1 Eye movements 2 Pupillary reaction 3 Strength of the legs 4 Strength of the hands
c (The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection. IV mannitol or hypertonic saline will be administered as prescribed. Ventilators may be used to maintain oxygenation. CSF leaks may cause inaccurate ICP readings, or CSF may be drained to decrease ICP, but strict aseptic technique to prevent infection is the nurse's priority of care. Text Reference - p. 1362)
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? A Administer intravenous (IV) mannitol B Use ventilator to hyperoxygenate the patient C Use strict aseptic technique with dressing changes D Be aware of changes in ICP related to leaking cerebrospinal fluid (CSF)
1 (Lumbar puncture may cause cerebral herniation due to the sudden release of pressure in the skull from the area above the punctured site and is contraindicated in a patient with increased ICP, so it should be cancelled. Scheduling the lumbar puncture for the next day may not reduce the risk of cerebral herniation. Performing the lumbar puncture immediately may cause cerebral herniation. Administering intravenous fluids does not reduce the risk of cerebral herniation. Test-Taking Tip: You should recollect the conditions that are contraindicated for lumbar puncturing. Text Reference - p. 1361)
What is the appropriate action by the nurse if an assessment of a patient scheduled for a lumbar puncture reveals increased intracranial pressure (ICP)? 1 Cancel the lumber puncture. 2 Schedule the lumbar puncture for the next day. 3 Perform the lumbar puncture immediately. 4 Administer intravenous fluids before the lumber puncture.
4 (Hydrocephalus, or an abnormal accumulation of cerebrospinal fluid in the brain, is characterized by a building up of fluid in the brain, resulting in interstitial cerebral edema. Abscesses cause vasogenic cerebral edema. Leakages of macromolecules cause vasogenic cerebral edema. Destructive lesions cause cytotoxic cerebral edema. Text Reference - p. 1360)
What is the cause of interstitial cerebral edema? 1 Abscess formation in the brain 2 Leakage of macromolecules in the brain 3 Presence of destructive lesions in the brain 4 Abnormal accumulation of cerebrospinal fluid in the brain
2 (High doses of barbiturates are used in patients with increased intracranial pressure. Barbiturates decrease cerebral metabolism, helping to reduce ICP. Corticosteroids are used to reduce vasogenic edema. Mannitol acts to decrease ICP through plasma expansion and osmotic effect. Hypertonic saline solution causes massive movement of water out of the brain cells into the blood vessels. Test-Taking Tip: Recall the actions and uses of barbiturates to answer this question accurately. Text Reference - p. 1364)
What medicinal reaction will the nurse anticipate in a patient with increased intracranial pressure (ICP) who is prescribed a high dose of barbiturates)? 1 Reduces vasogenic edema 2 Decreases cerebral metabolism 3 Causes plasma expansion and osmotic effect 4 Brings massive movement of water out of brain cells
a (Fluid and electrolyte disturbances can have an adverse effect on ICP, and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors typically are not administered in the treatment of ICP. Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten. Text Reference - p. 1367)
What nursing intervention should be implemented in the care of a patient who is experiencing increased intracranial pressure (ICP)? A Monitor fluid and electrolyte status carefully. B Position the patient in a high-Fowler's position. C Administer vasoconstrictors to maintain cerebral perfusion. D Maintain physical restraints to prevent episodes of agitation.
BCD (Using padded side rails helps to prevent injury from falling. Keeping an airway at the bedside and suction equipment readily available is helpful in managing seizures if they occur. Prophylactic antiseizure therapy can be used during the first seven days after injury to prevent seizures. Providing stimulation to the patient may aggravate his condition; therefore, the environment should be quiet. Seizure treatment should be used prophylactically; instead of waiting for the confirmation of diagnosis or the seizures to happen, the nurse should administer antiseizure treatment in such a situation. Text Reference - p. 1368)
When caring for a patient with increased intracranial pressure (ICP), what seizure precautions should the nurse take to protect the patient? Select all that apply. A Provide sufficient stimulation to the patient. B Use padded side rails and maintain an airway at the bedside. C Keep suction equipment readily available. D Use prophylactic antiseizure therapy during first seven days after injury. E Use seizure treatment only after confirming the diagnosis.
A.B.D (The nurse should avoid extreme hip flexion of the patient to decrease the risk of raising the intraabdominal pressure, which increases ICP. The patient should be moved with slow and gentle movements because rapid changes in position may increase the ICP. The patient must be turned every 2 hours to prevent pressure ulcers. The patient should not be moved quickly, as rapid changes can increase ICP and discomfort. Turning and positioning the patient can cause pain or agitation that increases ICP. The patient should not remain in the same position for a long time.)
When changing the position of a patient with increased intracranial pressure (ICP), what precautions should the nurse take? Select all that apply. A. The nurse should avoid extreme hip flexion of the patient. B. The patient should be moved with slow and gentle movements. C. The patient should be repositioned with jerky movements. D. The patient must be turned every two hours. E. The patient should remain in the same position for at least eight hours.
BCE (For a patient with increased ICP, parenteral nutrition should be started if oral intake is not adequate. Nutritional replacement should begin within three days after injury. The patient's urine output, fluid loss, and electrolyte balance should be monitored to evaluate the effectiveness of nutritional therapy. The patient should not be kept in a hypovolemic fluid state; the patient needs to be in a normovolemic state. Instead of waiting, full nutritional replacement should be reached within seven days after injury. Text Reference - p. 1365)
When managing a patient with increased intracranial pressure (ICP), what actions should the nurse perform as a part of nutritional therapy? Select all that apply. A Keep the patient in a hypovolemic fluid state. B Begin parenteral nutrition if oral intake is not adequate. C Begin nutritional replacement within three days after injury. D Wait for at least seven days to begin nutritional replacement. E Evaluate the patient's urine output, fluid loss, and electrolyte balance.
ABD (When managing the patient with increased ICP, procedures that can produce agitation should be avoided. The patient should be observed for signs of agitation or irritation. The environment should be quiet and calm to provide minimal stimulation to the patient. The stimulation levels should be decreased, and patient's family should be instructed to decrease stimulation and reduce noise. Test-Taking Tip: Look for options that are similar in nature. If all are correct, either the question is poor or all options are incorrect, the latter of which is more likely. Example: If the answer you are seeking is directed to a specific treatment and all but one option deal with signs and symptoms, you would be correct in choosing the treatment-specific option. Text Reference - p. 1368)
When managing a patient with increased intracranial pressure (ICP), what actions should the nurse perform to provide comfort to the patient? Select all that apply. A. Minimize procedures that can produce agitation. B. Observe the patient for signs of agitation or irritation. C. Teach the patient's family about increasing stimulation. D. Make the patient remain in a quiet and calm environment. E. Allow the patient's family to visit the patient more often.
ACE (Intubation and mechanical ventilation, maintenance of fluid balance and assessment of osmolality, and elevation of head of bed to 30 degrees with head in a neutral position are the appropriate actions to be performed when managing a patient with increased intracranial pressure (ICP). Waiting for the respiration to improve may be life threatening. Lowering of the head of the bed and turning the patient to one side may further increase the intracranial pressure. Text Reference - p. 1367)
When managing a patient with increased intracranial pressure, which actions should the nurse perform? Select all that apply. A. Administer intubation and mechanical ventilation B. Wait for the respiration to improve before beginning with ventilation. C. Maintain fluid balance and assess osmolality. D .Lower the head of the bed and turn the patient to one side. E. Elevate the head of the bed to 30 degrees with the head in a neutral position.
2 (Monitoring for more than five days- The intracranial device used for monitoring ICP should not be used for more than five days because it can lead to severe infection.)
Which action of the student nurse should be corrected while caring for a patient who is undergoing intracranial pressure (ICP) monitoring through an intracranial device? 1 Using aseptic technique 2 Monitoring for more than five days 3 Assessing the insertion site routinely 4 Monitoring the cerebrospinal fluid (CSF) for a change in color
2 (The P2 wave represents the intracranial compliance. It should be lower than the P1 wave. The presence of a higher P2 wave than the P1 wave indicates increased intracranial pressure and compromised intracranial compliance. During normal conditions, the P3 wave is the lowest wave; the P2 wave is higher than the P3 wave and P1, P2, and P3 waves are in order and resemble a staircase. Text Reference - p. 1362)
Which finding in the intracranial pressure waveforms supports the nurse's conclusion that a patient's intracranial compliance is compromised? 1 P3 wave is lower than P1 wave 2 P2 wave is higher than P1 wave 3 P2 wave is higher than P3 wave 4 P1, P2, and P3 resemble a staircase