ICP practice questions (Test #2, Fall 2020)

The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Select all that apply. 1.Systolic blood pressure. 2.Urine output. 3.Breath sounds. 4.Cerebral perfusion pressure. 5.Level of pain.

1, 4. The nurse must monitor the systolic and diastolic blood pressure to obtain the mean arterial pressure (MAP), which represents the pressure needed for each cardiac cycle to perfuse the brain. The nurse must also monitor the cerebral perfusion pressure (CPP), which is obtained from the ICP and the MAP. The nurse should also monitor urine output, respirations, and pain; however, crucial measurements needed to maintain CPP are ICP and MAP. When ICP equals MAP, there is no CPP

Which intervention should the nurse implement to decrease increased intracranial pressure (ICP) for a client on a ventilator? Select all that apply. 1. Position the client with the head of the bed up 30 degrees. 2. Cluster activities of care. 3. Suction the client every three (3) hours. 4. Administer soapsuds enemas until clear. 5. Place the client in Trendelenburg position.

1,2 1. Elevating the head of the bed 30 degrees will decrease ICP by using gravity to drain cerebrospinal fluid. 2. Minimizing disturbing the client and allowing rest in between activities will decrease ICP. 3. Suctioning increases ICP and should not be performed unless absolutely necessary. 4. Soapsuds enemas increase intra-abdominal pressure, which, in turn, increases ICP. 5. Trendelenburg position is head down, feet up. This would increase ICP.

Which of the following respiratory patterns indicates increasing intracranial pressure in the brain stem? 1.Slow, irregular respirations. 2.Rapid, shallow respirations. 3.Asymmetric chest excursion. 4.Nasal flaring

1. Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.

The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate? 1.The head of the bed elevated 30 to 45 degrees. 2.Trendelenburg's position. 3.Left Sims' position. 4.The head elevated on two pillows

1. The client's ICP is elevated, and the client should be positioned to avoid extreme neck flexion or extension. The head of the bed is usually elevated 30 to 45 degrees to drain the venous sinuses and thus decrease the ICP. Trendelenburg's position places the client's head lower than the body, which would increase ICP. Sims' position (side lying) and elevating the head on two pillows may extend or flex the neck, which increases ICP

A client is at risk for increased intracranial pressure (ICP). Which of the following would be the priority for the nurse to monitor? 1.Unequal pupil size. 2.Decreasing systolic blood pressure. 3.Tachycardia. 4.Decreasing body temperature.

1. Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage

An unconscious client with multiple injuries arrives in the emergency department. Which nursing intervention receives the highest priority? 1.Establishing an airway. 2.Replacing blood loss. 3.Stopping bleeding from open wounds. 4.Checking for a neck fracture.

1. The highest priority for a client with multiple injuries is to establish an open airway for effective ventilation and oxygenation. Unless the client has a patent airway, other care measures will be futile. Replacing blood loss, stopping bleeding from open wounds, and checking for a neck fracture are important nursing interventions to be completed after the airway and ventilation are established

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply. 1.Encourage the client to cough to expectorate secretions. 2.Elevate the head of the bed 15 to 30 degrees. 3.Contact the health care provider if ICP is greater than 20 mm Hg. 4.Monitor neurologic status using the Glasgow Coma Scale. 5.Stimulate the client with active range-of-motion exercises.

2, 3, 4. The nurse should maintain ICP by elevating the head of the bed and monitoring neurologic status. An ICP greater than 20 mm Hg indicates increased ICP, and the nurse should notify the health care provider. Coughing and range-of-motion exercises will increase ICP and should be avoided in the early postoperative stage.

A client with a contusion has been admitted for observation following a motor vehicle accident when he was driving his wife to the hospital to deliver their child. The next morning, instead of asking about his wife and baby, he asked to see the football game on television that he thinks is starting in 5 minutes. He is agitated because the nurse will not turn on the television. What should the nurse do next? Select all that apply. 1.Find a television so the client can view the football game. 2.Determine if the client's pupils are equal and react to light. 3.Ask the client if he has a headache. 4.Arrange for the client to be with his wife and baby. 5.Administer a sedative.

2, 3. The nurse should determine if the client's pupils are equal and react to light, and ask the client if he has a headache. Confusion, agitation, and restlessness are subtle clinical manifestations of increased intracranial pressure (ICP). At this time, it is not appropriate for the nurse to find a television or arrange for the client to see his wife and baby. Administering a sedative at this time will obscure assessment of increased ICP

A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the IV line. Which nursing intervention protects the client without increasing the intracranial pressure (ICP)? 1.Place in a jacket restraint. 2.Wrap the hands in soft "mitten" restraints. 3.Tuck the arms and hands under the drawsheet. 4.Apply a wrist restraint to each arm.

2. It is best for the client to wear mitts, which help prevent the client from pulling on the IV without causing additional agitation. Using a jacket or wrist restraint or tucking the client's arms and hands under the drawsheet restrict movement and add to feelings of being confined, all of which would increase her agitation and increase ICP

The nurse administers mannitol (Osmitrol) to the client with increased intracranial pressure. Which parameter requires close monitoring? 1.Muscle relaxation. 2.Intake and output. 3.Widening of the pulse pressure. 4.Pupil dilation.

2. After administering mannitol, the nurse closely monitors intake and output because mannitol promotes diuresis and is given primarily to pull water from the extracellular fluid of the edematous brain. Mannitol can cause hypokalemia and may lead to muscle contractions, not muscle relaxation. Signs and symptoms, such as widening pulse pressure and pupil dilation, should not occur because mannitol serves to decrease ICP

A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. The nurse should: 1.Count the rate to be sure that ventilations are deep enough to be sufficient. 2.Notify the physician of the client's breathing pattern. 3.Increase the rate of ventilations. 4.Increase the tidal volume on the ventilator.

2. Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is just superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The nurse should notify the physician immediately so that treatment can begin before respirations cease. The client is not obtaining sufficient oxygen and the depth of breathing is assisted by the ventilator. The health care provider will determine changes in the ventilator settings.

The nurse is caring for a client with increased intracranial pressure (ICP) who has secretions pooled in the throat. Which intervention should the nurse implement first? 1. Set the ventilator to hyperventilate the client in preparation for suctioning. 2. Assess the client's lung sounds and check for peripheral cyanosis. 3. Turn the client to the side to allow the secretions to drain from the mouth. 4. Suction the client using the in-line suction, wait 30 seconds, and repeat.

3 1. When suctioning a client on a ventilator it is good to hyperventilate the client before suctioning because suctioning the secretions would also suction the oxygen from the client. However, suctioning a client who has ICP increases the ICP. The nurse should attempt to remove the secretions without having to suction the client. 2. The secretions pooling in the back of the throat would not be assessed by listening to lung sounds or checking for peripheral perfusion. 3. Secretions can drain if the client is turned to the side unless the secretions are too heavy. The first action is to attempt to relieve the situation without increasing the ICP even further. 4. If suctioning is absolutely needed, then a minimum of 1 minute is needed between attempts to suction. TEST TAKING HINT: The test taker can eliminate options or decide between two of the options based on the fact that options "1" and "4" both involve suctioning the client. Either the nurse will perform suctioning or it is contraindicated. Assessment is the first step of the nursing process but the test taker must decide if the nurse is assessing the correct situation. Pooled oral secretion is not lung sounds.

A client who had a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which of the following rehabilitation outcomes would be appropriate for the client? The client will: 1.Exhibit no further episodes of short-term memory loss. 2.Be able to return to his construction job in 3 weeks. 3.Actively participate in the rehabilitation process as appropriate. 4.Be emotionally stable and display preinjury personality traits.

3. Recovery from a serious head injury is a long-term process that may continue for months or years. Depending on the extent of the injury, clients who are transferred to rehabilitation facilities most likely will continue to exhibit cognitive and mobility impairments as well as behavior and personality changes. The client would be expected to participate in the rehabilitation efforts to the extent he is capable. Family members and significant others will need long-term support to help them cope with the changes that have occurred in the client

Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)? 1.Deep breathing. 2.Turning. 3.Coughing. 4.Passive range-of-motion (ROM) exercises.

3. Coughing is contraindicated for a client at risk for increased ICP because coughing increases ICP. Deep breathing can be continued. Turning and passive ROM exercises can be continued with care not to extend or flex the neck

Which of the following nursing interventions is appropriate for a client with an increased intracranial pressure (ICP) of 20 mm Hg? 1.Give the client a warming blanket. 2.Administer low-dose barbiturates. 3.Encourage the client to hyperventilate. 4.Restrict fluids.

3. Normal ICP is 15 mm Hg or less for 15 to 30 seconds or longer. Hyperventilation causes vasoconstriction, which reduces cerebrospinal fluid and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg. A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases ICP. High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mm Hg.

What should the nurse do first when a client with a head injury begins to have clear drainage from the nose? 1.Compress the nares. 2.Tilt the head back. 3.Give the client tissues to collect the fluid. 4.Administer an antihistamine for postnasal drip.

3. The clear drainage must be analyzed to determine whether it is nasal drainage or cerebrospinal fluid (CSF). The nurse should not give the client tissues because it is important to know how much leakage of CSF is occurring. Compressing the nares will obstruct the drainage flow. It is inappropriate to tilt the head back, which would allow the fluid to drain down the throat and not be collected for a sample. It is inappropriate to administer an antihistamine because the drainage may not be from postnasal drip

The nurse is assessing the level of consciousness in a client with a head injury who has been unresponsive for the last 8 hours. Using the Glasgow Coma Scale the nurse notes that the client opens the eyes only as a response to pain, responds with sounds that are not understandable, and has abnormal extension of the extremities. The nurse should 1.Attempt to arouse the client. 2.Reposition the client with the extremities in normal alignment. 3.Chart the client's level of consciousness as coma. 4.Notify the physician.

3. The client has a score of 6 (eye opening to pain = 2; verbal response, incomprehensible sounds = 2; best motor response, abnormal extension = 2); a score less than 7 is indicative of coma. While the nurse should continue to speak to the client, at this time the client will not be able to be aroused. The nurse should continue to provide skin care and appropriate alignment, but the client will continue to have a motor response of limb extension. It is not necessary to notify the physician as this assessment does not represent a significant change in neurological status

The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider about which of the following changes in the client's condition? 1.Widening pulse pressure. 2.Decrease in the pulse rate. 3.Dilated, fixed pupils. 4.Decrease in level of consciousness (LOC).

4. A decrease in the client's LOC is an early indicator of deterioration of the client's neurologic status. Changes in LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated.

Which of the following describes decerebrate posturing? 1.Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers. 2.Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of feet. 3.Supination of arms, dorsiflexion of the feet. 4.Back arched, rigid extension of all four extremities.

4. Decerebrate posturing occurs in clients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers describes decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres.

A nurse is assessing a client with increasing intracranial pressure. What is a client's mean arterial pressure (MAP) in mm Hg when blood pressure (BP) is 120/60 mm Hg? __________________________ mm Hg.

80

A client has delirium following a head injury. The client is disoriented and agitated. In which order from first to last should the nurse do the following as a part of a plan to care for this client? 1. Request a prescription for haloperidol (Haldol). 2. Maintain a quiet environment. 3. Assure client's safety. 4. Approach the client using short sentences.

Approach the client using short sentences Assure client's safety Maintain a quiet environment Request a prescription for haloperidol (Haldol) the first step in providing care for a client with delirium is to approach the client calmly, introduce oneself, and use short sentences when explaining the care given. The nurse should also assure the client's safety by protecting the client from injury. Maintaining a quiet and calm environment by removing extraneous noises will prevent overstimulation. Pharmacologic intervention is used only when other plans for care are not effective. When the underlying problems related to the head injury are resolved, the delirium likely will improve

The client diagnosed with a brain abscess is experiencing a tonic-clonic seizure. Which interventions should the nurse implement? Rank in order of performance. 1. Assess the client's mouth. 2. Loosen restrictive clothing. 3. Administer phenytoin IVP. 4. Turn the client to the side. 5. Protect the client's head from injury

In order of priority: 4, 5, 2, 3, 1. 4. The client should be turned to the side to prevent the tongue from falling back into the throat and occluding the airway. (Padded tongue blades are NOT forced into the mouth because they can break teeth and cause aspiration of the teeth.) 5. The client's head should be protected from hitting the side rails or other objects. 2. Clothing should be loosened to prevent airway difficulties. 3. The medications to control the seizures should be administered to stop the seizure. 1. Assessment in this instance is last because of the crisis that is occurring. The nurse should assess the mouth to determine if the client bit the tongue or buccal mucosa during the seizure or if teeth were chipped or broken. TEST TAKING HINT: Rank order questions can be difficult to answer. The test taker should remember safety. Which intervention will keep the client safe the fastest? Also important is if in stress, do not assess: Perform an intervention