Intracranial Pressure
A nurse in the emergency department has assessed a client's airway, breathing, and circulation (ABC) following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next?
Immobilize the client's cervical spine The greatest risk to this client is an injury from a cervical spine dislocation and spinal cord compression following a traumatic head injury. Therefore, the priority action the nurse should take after assessing the client's ABC is immobilizing the client's neck with a cervical collar. A client who has head trauma might also have damage to the cervical spine. This is an essential component of the initial stabilization of a client who has a head injury.
The nurse should monitor the child's pupillary response every 15 to 30 minutes immediately following neurological surgery.
Increased intracranial pressure can put pressure on the oculomotor nerve, causing unilateral pupil dilation.
A halo sign is a clear or yellow ring surrounding a spot of fluid or blood from the nose or ear. The ring indicates leakage of cerebral spinal fluid that can occur with a skull fracture.
It does not indicate increased intracranial pressure.
Battle's sign is bruising behind the ears and lower jaw that can occur from the trauma of a skull fracture.
It does not indicate increased intracranial pressure.
Brain herniation can occur as a result of untreated increased intracranial pressure and can lead to death.
It is not a cause of increased intracranial pressure.
Unequal peripheral pulses can occur following a cardiac catheterization.
It is not associated with the insertion of a VP shunt.
A nurse is planning care for a preschooler who is immediately postoperative following the placement of a ventriculoperitoneal shunt. Which of the following interventions should the nurse include in the plan?
Lay the preschooler on the nonoperative side The preschooler should not be positioned on the shunt side postoperatively to avoid putting pressure on the shunt or surgical site.
A nurse is caring for an older adult client who is having a stroke. After assessing the client's airway, breathing, and circulation, which of the following assessments is the nurse's priority?
Level of consciousness The nurse should apply the urgent versus nonurgent priority-setting framework. Using this framework, the nurse should consider urgent needs to be the priority because they pose more of a threat to the client. The nurse may also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent. The nurse should assess the client's level of consciousness to evaluate increases in intracranial pressure that might have occurred. The nurse should use the NIH stroke scale or the Glasgow coma scale to evaluate the client's level of consciousness.
A nurse is assessing a client who was admitted to the facility for observation following a closed head injury. Which of the following is the priority assessment the nurse should perform to determine a change in the client's neurological status?
Level of consciousness When applying the urgent vs. nonurgent priority-setting framework, the nurse should consider urgent needs to be the priority because they pose more of a risk to the client. The nurse might also use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify the most urgent finding. Therefore, the priority assessment is level of consciousness. A change in the client's level of consciousness can be the first indication of a change in neurologic status.
A nurse is caring for an infant who is postoperative following a myelomeningocele repair. Which of the following is the priority action the nurse should take?
Measure the infant's head circumference Increased head circumference is an indication that the infant is at greater risk of increased intracranial pressure; therefore, measuring the infant's head circumference is the priority nursing action. Hydrocephalus can occur as a complication of a myelomeningocele repair and is monitored using head circumference measurements.
A nurse is caring for a preschooler who is immediately postoperative following the removal of a brainstem tumor. Which of the following actions should the nurse take?
Monitor the child's temperature every 30 minutes The nurse should monitor the child's temperature every 15 to 30 minutes. Surgery on the brainstem can cause hyperthermia.
A nurse is planning care for a client following a stroke. Which of the following interventions should the nurse identify as the priority in the client's plan of care?
Monitor the client for increased intracranial pressure (ICP) The greatest risk to this client is an injury from increased ICP, which can result in decreased cerebral perfusion and neurological injury. Therefore, the priority intervention the nurse should include in the plan of care is monitoring the client for increased ICP. Manifestations of increased ICP include a decreased level of consciousness and a change in pupils.
A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the following actions should the nurse take? (Select all that apply.)
Monitor vital signs every 2 hr ✔︎ Assess neurological status every 4 hr ✔︎ Keep the client's room darkened ✔︎ The nurse should monitor the client's vital signs to assess for changes consistent with increased intracranial pressure. In addition, the nurse should monitor the client's neurological status at least every 4 hours or more frequently if the client's status indicates. The course of encephalitis is unpredictable, so the client should be monitored closely for any indications of deteriorating neurological functioning. The nurse should provide the client with a low-stimulation environment to promote comfort and decrease agitation.
A nurse is assessing a client who has cataracts. Which of the following findings should the nurse expect?
Opacity visible behind the pupil With a cataract, the lens of the eye becomes thick and opaque with age and appears as opacity behind the pupil when the nurse shines a light on the area.
Frontal bossing can be observed in infants with hydrocephalus.
Open cranial sutures allow for excess cerebral spinal fluid to cause head enlargement. Frontal bossing describes the protruding frontal skull bones that can occur in severe cases of hydrocephalus.
A nurse is caring for a toddler who has a fever, a high-pitched cry, irritability, and vomiting. Which of the following actions should the nurse take?
Pad the rails of the toddler's bed When caring for a toddler who has manifestations of bacterial meningitis, the nurse should implement seizure precautions, which includes padding the side rails of the bed.
When caring for a toddler who has a fever, the nurse should avoid giving the toddler a cold bath because
it can cause shivering and discomfort
Immediately postoperative following the removal of a brainstem tumor, the nurse should not place the child in the Trendelenburg position because
it increases intracranial pressure and raises the risk of postoperative hemorrhage
The nurse should assign a red tag, or a class I label to clients who have
life-threatening injuries but a high possibility of survival once they are stabilized
The nurse should assign a yellow tag, or a class Il label, to clients who have
major injuries that are not yet life-threatening
The nurse should assign a green tag, or a class III label, to clients who have
minor injuries that are not life-threatening and do not need immediate attention
The nurse should check the preschooler's bowel sounds frequently because
peritonitis or an ileus can be postoperative complications
The nurse should position the child with the head of the bed elevated and the child's head in a midline position to assist with
preventing increased intracranial pressure
The nurse should maintain the preschooler in a flat position to avoid
rapid draining of intracranial fluid through the shunt
The nurse should avoid bright lights due the child's risk of increased intracranial pressure.
The nurse should provide an environment with decreased stimulation.
The inability of the shunt to drain due to a blockage will increase intracranial pressure.
This can result in pressure on the oculomotor nerve, which causes dilation of the pupils.
A change in pupils (e.g. dilated or fixed pupils) can indicate increasing intracranial pressure or discrete areas of brain ischemia.
A change in the client's pupils is a later finding that can indicate a change in neurological status; therefore, there is another assessment that is the priority.
A nurse is assessing a school-aged child after a ventriculoperitoneal (VP) shunt replacement. Which of the following findings indicates a complication of this procedure?
Abdominal distention A VP shunt allows excess cerebrospinal fluid from the ventricles to drain into the peritoneal cavity and be reabsorbed. Abdominal distention can indicate the presence of peritonitis due to the draining cerebral spinal fluid or a postoperative ileus.
Posturing is seen when cortical control over motor function is lost.
Abnormal posturing (e.g. decerebrate or decorticate posturing) are later findings that indicate a change in the client's neurological status; therefore; there is another assessment that is the priority.
A nurse is triaging clients during a mass casualty event. Which of the following labels should the nurse assign to a client who has a head injury with fixed, dilated pupils?
Black tag The nurse should assign a black tag, or a class IV label, to clients who are not expected to live and will be allowed to die naturally. Dilated pupils that are fixed or nonreactive to light are a poor prognostic sign and indicate severely increased intracranial pressure. In a mass casualty situation, the overall goal is to provide lifesaving treatment to the greatest number of people possible.
Vital sign changes can indicate increasing intracranial pressure and pressure on the hypothalamus.
Changes in the client's vital signs such as bradycardia and a widening pulse pressure are later findings that indicate a change in neurological status; therefore, there is another assessment that is the priority.
A nurse is caring for a client who experienced a traumatic brain injury. Which of the following findings indicates the client is experiencing increased intracranial pressure?
Dilated pupils Dilated pupils can indicate that intracranial pressure is increasing. This finding should be reported to the provider immediately.
A nurse is assessing a client who has increased intracranial pressure and has received intravenous mannitol. Which of the following findings indicates a therapeutic effect of this medication?
Increased urine output Mannitol is an osmotic diuretic used to reduce intracranial pressure by mobilizing intracranial fluid and inhibiting the reabsorption of water and electrolytes in the kidneys. Increased urine output and decreased intracranial pressure are therapeutic effects of this medication.
Periorbital edema is a result of facial trauma.
It does not indicate increased intracranial pressure.
The leakage of cerebral spinal fluid occurs with a
basilar skull fracture (which is an open traumatic injury rather than a closed traumatic iniury)
Bradycardia is a manifestation of
increased ICP
In the Sims' position, the client is side-lying with flexion of the hip and knee. Flexing the client's hip or neck can cause an increase in intracranial pressure;
therefore, the Sims' position is contraindicated following a craniotomy
In the Trendelenburg position, the entire bed is tilted while the head of the bed points down. This position can cause an increase in intracranial pressure;
therefore, the Trendelenburg position is contraindicated following a craniotomy
A client who has encephalitis is at risk for increased intracranial pressure
therefore, the nurse should maintain the head of the client's bed at 30 to 45 degrees
In the prone position, the client lies flat on the abdomen. This position can cause an increase in intracranial pressure;
therefore, the prone position is contraindicated following a craniotomy
Immediately postoperative following the removal of a brainstem tumor, the nurse should have the child avoid coughing because
this can increase intracranial pressure
Pupils that are not reactive to light do not indicate cataracts.
This finding indicates changes in intracranial pressure and other alterations.
A decrease in cerebral perfusion is a result of increasing ICP, not the cause.
This leads to brain tissue ischemia and edema, which can cause death if untreated.
The nurse should avoid performing nasotracheal suctioning.
This procedure is contraindicated due to the risk of injury to the child's brain if a skull fracture is present.
When caring for a toddler who has manifestations of bacterial meningitis, the nurse should
When caring for a toddler who has manifestations of bacterial meningitis, the nurse should keep the head of the bed slightly elevated to decrease intracranial pressure
A nurse is assessing a client who sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure?
Widened pulse pressure A widening of the pulse pressure (i.e. the difference between the systolic and diastolic pressure) is a manifestation of increased intracranial pressure. Other manifestations include pupil changes, change in the level of consciousness, and nausea and vomiting.
Eating foods that contain tyramine can cause
a hypertensive crisis for clients who take MAOls such as tranylcypromine
Glaucoma, not cataracts, causes
an increase in intraocular pressure
A white circle around the outside border of the iris is an
arcus senilis, not a cataract
When caring for a toddler who has a fever, the nurse should administer acetaminophen rather than aspirin because
aspirin is associated with the development of Reye syndrome
A nurse is assessing an infant who is at risk for increased intracranial pressure (ICP). Which of the following findings should indicate to the nurse that this complication is developing?
High-pitched cry The nurse should identify that an infant's high-pitched cry is an indication of increased ICP. Other indications include a bulging fontanel, a high-pitched cry, and increased sleeping.
The nurse should check the client's pupils for equality and reaction to light to help determine if the client has increased intracranial pressure from a cerebral hemorrhage.
However, another action is the nurse's priority.
A nurse is assessing a client who is unconscious. The client has a rhythmical breathing pattern of rapid deep respirations followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations?
Cheyne-Stokes Cheyne-Stokes respirations is a breathing pattern of deep to shallow breaths followed by periods of apnea. Cheyne-Stokes respirations can be the result of a drug overdose or increased intracranial pressure and can precede death.
The nurse should measure alertness using the Glasgow Coma Scale to determine the client's level of consciousness.
However, another action is the nurse's priority.
The nurse should question the client's coworkers about the mechanism of injury, which can yield information that will aid the treatment of the client's injury.
However, another action is the nurse's priority.
The nurse should provide support for the client's family because the family might feel stressed and overwhelmed while caring for the client.
However, another intervention is the priority.
The nurse should refer the client to an occupational therapist to assist the client in self-care activities and promote independence.
However, another intervention is the priority.
The nurse should take measures to prevent depression in the client such as providing a referral to a support group; a client who has physical or cognitive impairments is at risk for depression.
However, another intervention is the priority.
Monitoring the infant's blood pressure is an essential component of postoperative care.
However, the greatest risk to this client is neurological complications. Therefore, "Monitor the infant's blood pressure" is not the nurse's priority.
Measuring the infant's intake and output is an essential component of postoperative care.
However, the greatest risk to this infant is neurological complications. Therefore, "Measure the infant's intake and output" is not the nurse's priority.
Checking the infant's lower-extremity function is an essential component of postoperative care.
However, the greatest risk to this infant is neurological complications. Therefore, "Check the infant's lower-extremity function" is not the nurse's priority.
A nurse is caring for a client during the first 72 hr following a cerebrovascular accident (CVA). Which of the following actions should the nurse take?
Elevate the head of the bed 25° to 30° with the client in a neutral midline position Elevating the head of the bed 25° to 30° with the client's head in a neutral midline position helps prevent an increase in intracranial pressure. Increased intracranial pressure is a major risk factor for complications in the first 72 hours following the onset of a CVA.
A nurse is caring for a client who has a closed traumatic brain injury and is experiencing increased intracranial pressure (ICP). This increase in ICP is due to which of the following?
Rigid skull containing cranial contents The nurse should identify that the client's rigid skull prevents expansion. An increase in edema and bleeding from the head injury against the rigid skull results in an increase in ICP.
A nurse is caring for a client who is postoperative following a frontal craniotomy. The nurse should place the client in which of the following positions?
Semi-Fowler's To prevent an increase in intracranial pressure, the nurse should position the client with his head midline and the head of the bed elevated 30°. This positioning permits blood flow to the client's brain while allowing venous drainage, thereby decreasing the postoperative risk of increased intracranial pressure.
A nurse is reviewing the medical record of a client who has a new prescription for tranylcypromine. The client still has a current prescription for sertraline. The nurse should notify the provider because taking these medications concurrently increases the risk of which of the following adverse effects?
Serotonin syndrome Serotonin syndrome is a toxic effect that can occur from taking an MAI such as tranylcypromine and an SSRI such as sertraline simultaneously. Manifestations include delirium, abdominal pain, muscle spasms, and irritability, and the condition can worsen to cause cardiovascular shock and death. The nurse should notify the provider immediately of this potential interaction.
A nurse is assessing a child who sustained a head injury. During the assessment, the nurse observes clear drainage leaking from the child's nose. Which of the following actions should the nurse take?
Test the nasal secretions for glucose The nurse should test the nasal secretions for glucose with a reagent strip to determine if the secretions are a leakage of cerebrospinal fluid (CSF). The leakage of CSF is positive for glucose and occurs if the child has a skull fracture.
A nurse is assessing a client with a closed head injury who has received mannitol for manifestations of increased intracranial pressure (ICP). Which of the following findings indicates that the medication is having a therapeutic effect?
The client's serum osmolarity is 310 mOsm/L Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. A serum osmolarity of 310 mOsm/L is desired. A decrease in cerebral edema should result in a decrease in ICP.
Immediately postoperative following the removal of a brainstem tumor, the nurse should not offer the child clear liquids for at least 24 hours following the procedure.
The gag and swallow reflexes are frequently depressed, increasing the risk of aspiration.
West Nile virus is an arbovirus that is transmitted to humans after a person is bitten by an infected organism such as a mosquito.
The nurse should follow STANDARD precautions when caring for a client who has encephalitis due to West Nile virus.
A decrease in blood glucose is NOT a therapeutic effect of mannitol.
The nurse should monitor the client for hyperkalemia and hypokalemia.
A decrease in bronchospasms is NOT a therapeutic effect of mannitol.
The nurse should monitor the client for pulmonary edema.
An increase in temperature is NOT a therapeutic effect of mannitol.
The nurse should monitor the client for renal failure.
A. Turn the client's head to the side with the head of the bed elevated 60° B. Place the head of the bed flat with pillows under the client's neck and feet D. Position the client in a dorsal recumbent position with pillows under the head and knees
These positions are unlikely to be comfortable for a client immediately following a CVA. Additionally, they place the client at risk for increased intracranial pressure.
Tachycardia can be a manifestation of hypovolemia
however, bradycardia is a manifestation of increased intracranial pressure
A decrease in urine output can be a manifestation of hypovolemia
however, it is not a manifestation of increased intracranial pressure
Periorbital edema can occur following eye trauma or a craniotomy
however, it is not a manifestation of increased intracranial pressure
The nurse should assess the client's gag reflex to determine the extent of disability and limit the risk of aspiration due to the stroke;
however, there is another assessment that is the nurse's priority.
The nurse should assess the client's muscle tone to determine the extent of disability and the hemisphere affected by the stroke;
however, there is another assessment that is the nurse's priority.
The nurse should assess the sensory changes the client is experiencing to determine the extent of disability and the hemisphere affected by the stroke;
however, there is another assessment that is the nurse's priority.
Neither tranylcypromine nor sertraline causes acute kidney injury
however, they can cause urinary manifestations such as frequency and hesitancy
Neither tranylcypromine nor sertraline causes increased intracranial pressure
however, they can cause neurological manifestations such as dizziness, insomnia, anxiety, and confusion.
Dilated pupils, pinpoint pupils, and asymmetrical pupils are manifestations of
increased ICP
Restlessness and behavioral changes are manifestations of
increased ICP
The nurse should identify bradycardia as an indication of
increased ICP
The nurse should identify increased sleep time as an indication of
increased ICP
The nurse should identify that a firm and bulging fontanel is an indication of
increased ICP
