NCLEX Intracranial pressure questions

Which of the following symptoms may occur with phenytoin level of 32 mg/dl? a. ataxia and confusion b. tonic-clonic seizure c. urinary incontinence d. sodium depletion

a. ataxia and confusion *A therapeutic phenytoin level is 10-20mg/dl. A level of 32 mg/dl is a toxic level. Symptoms of toxicity include ataxia and confusion. Incontinence may occur during or after a seizure.

An adult client is brought to the emergency department due to a motor vehicle accident. While monitoring the client, the nurse begins to suspect increased intracranial pressure, ICP, when: a. client is orientated when aroused from sleep, and goes back to sleep immediately b. blood pressure is decreased from 160/90 to 110/70 c. client refuses dinner due to anorexia d. pulse is increased from 88 to 96 with occasional skipped beat

a. client is oriented when aroused from sleep and goes back to sleep immediately. **This behavior indicates a decrease in level of consciousness, which is the primary sign of increased ICP.

A nurse in the emergency department is observing a 4 year old child for signs of increased intracranial pressure after a fall from a bicycle which resulted in a head trauma. Which of the following signs or symptoms would be cause for concern? a. repeated vomiting b. bulging anterior fontanel c. inability to read short words from a distance of 18 inches d. signs of sleepiness at 10 pm

a. repeated vomiting *Increased pressure caused by bleeding or swelling within the skull can damage delicate brain tissue and may become life threatening. *Repeated vomiting can be an early sign of pressure stimulating the vomiting center in the medulla. The fontanel is closed in a four year old. Inability to read and signs of sleepiness would be an expected finding for a four year old.

Which of the following signs and symptoms of increased intracranial pressure, ICP, would occur first after a head injury? a. restlessness and confusion b. bradycardia c. large amounts of very dilute urine d. widened pulse pressure

a. restlessness and confusion *The earliest symptom of increased ICP is a change in mental status. **Bradycardia, widened pulse pressure, and bradypnea occur as late symptoms. Voiding large amounts of very dilute urine typically occurs with damage to the posterior pituitary.

The client is having a lumbar puncture (LP) performed. The nurse would plan to place the client in which position? a. side lying, with legs pulled up and head bent down onto the chest. b. side lying with a pillow under the hip c. prone, in a slight Trendelenburg's position d. prone, with a pillow under the abdomen

a. side lying, with legs pulled up and head bent down onto the chest. **This position helps to open the spaces between the vertebrae.

A client with a subdural hematoma (a collection of blood on the brain's surface beneath the skull) becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? a. to promote osmotic diuresis to reduce ICP b. to reduce intraocular pressure c. to prevent acute tubular necrosis d. to draw water into the vascular system to increase blood pressure

a. to promote osmotic diuresis to reduce ICP *Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. **Although Mannitol is used for all the other reasons, the primary reason it is used in the given case is to reduce ICP.

Which of the following types of drugs might be given to regulate increased intracranial pressure, ICP ? a. carbonic anhydrase inhibitors b. barbiturates c. anticholinergics d. histamine receptor blockers

b. barbiturates *Barbiturates may be given to induce a coma in a patient with increased ICP. *This decreases cortical activity and cerebral metabolism, reduces cerebral blood volume, decreases cerebral edema, and reduces the brain's need for glucose and oxygen. **Carbonic anhydrase inhibitors are used to decrease ocular pressure or to decrease serum pH in a client with metabolic alkalosis. **Anticholinergics are used for many things, such as controlling GI spasms. **Histamine receptor blockers are used to decrease stomach acidity.

The nurse is positioning the client with increased intracranial pressure. Which of the following positions would the nurse avoid? a. neck in neutral position b. head turned to the side c. head of bed elevated 30 to 45 degrees d. head midline

b. head turned to the side *The head of the client with increased cranial pressure should be positioned so the head is in a neutral midline position. *The nurse should avoid flexing or extending the clients neck, or turning the head side to side. *The head of the bed should be raised to 30 to 45 degrees. **Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure balanced.

The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain: a. pressure on the orbital rim b. nail bed pressure c. sternal rub d. squeezing the sternocleidomastoid muscle

b. nail bed pressure * motor testing on the unconscious client can be done only by testing response to painful stimuli. *Nail bed pressure tests peripheral response to pain. *Cerebral responses to pain are tested using sternal rub, placing upward pressure on the orbital rim, squeezing the sternocleidomastoid muscle.

Later signs of intracranial pressure (ICP) include which of the following? a. increased pulse rate b. projectile vomiting c. decreased blood pressure d. narrowed pulse pressure

b. projectile vomiting *Projectile vomiting may occur with increased pressure on the reflex center in the medulla.

A client with a head injury is being monitored for increased intracranial pressure, ICP, His blood pressure is 90/60 mm Hg and the ICP is 15 mm Hg; therefore his cerebral perfusion pressure (CPP) is : a. 68 mm Hg b. 88 mm Hg c. 52 mm Hg d. 48 mm Hg

c. 52 mm Hg **Looking for explanation

An adult client with a severe head injury is being monitored by the nurse for increase intracranial pressure, ICP. Which finding would be the most indicative indication of increased ICP? a. intermittent tachycardia b. polydipsia c. increased restlessness d. Tachypnea

c. Increased restlessness **Restlessness indicates a lack of oxygen to the brain stem which impairs the reticular activating system.

A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has: a. a temporal lesion b. brain death c. an intact brain stem d. a cerebral lesion

c. an intact brain stem *Caloric testing provides information about differentiating between cerebellar and brain stem lesions. *After determining patency of the ear canal, cold or warm water is injected in the auditory canal. A normal response that indicates intact function of cranial nerves III, IV and VIII is conjugate eye movements toward the side being irrigated, followed by rapid nystagmus toward the opposite side. **Absence or dysconjugate eye movements indicate brain stem damage.

The nurse is caring for a client with increased intracranial pressure, ICP. The nurse would note which of the following trends in vital signs if the ICP is rising? a. decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure b. decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure c. increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure d. increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure

c. increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure **A change in vital signs may be a late sign of increased ICP. *Trends include increasing temperature and blood pressure, and decreased pulse and respirations. Respiratory irregularities may also arise.

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity ( inability to flex the neck forward due to rigidity of the neck muscles), and projectile vomiting. The nurse knows that lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? a. the client needs mechanical ventilation b. vomiting continues c. intracranial pressure, ICP, is increased d. blood is anticipated in the cerebral spinal fluid (CSF)

c. intracranial pressure is increased **Sudden removal of CSF results in pressures lower in the lumbar region than the brain and favors herniation of the brain; therefore, LP is contraindicated with increased ICP. **Vomiting may be caused by reasons other than ICP, so LP is not strictly contraindicated. **LP may be performed on a client needing mechanical ventilation.**Blood in the CSF is diagnostic for subarachnoid hemorrhage, and was obtained before signs and symptoms of increased ICP.

The female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning? a. phenytoin (Dilantin) b. mannitrol (Osmitrol) c. lidocaine (Xylocaine) d. furosemide (Lasix)

c. lidocaine (Xylocaine) *Administering lidocaine (Xylocaine) via endotracheal tube may minimize elevations in ICP caused by suctioning. Although mannitol and furosemide may be given to reduce ICP, they're administered parenterally, not endotracheally. *Phenytoin does not reduce ICP directly, but may be used to abolish seizures, which can increase ICP. *Phenytoin is not administered endotracheally.

Problems with memory and learning would relate to which of the following lobes? a. Parietal b. Frontal c. Temporal d. Occipital

c. temporal **The temporal lobe functions to regulate memory and learning problems because of the integration of the hippocampus. **The frontal lobe primarily functions to regulate thinking, planning, and judgement. **The occipital lobe functions to regulate vision. **The parietal lobe functions with sensory functions.

Which of the following values is considered normal for ICP? a. 35-45 mm/Hg b. 120/80 mm/Hg c. 25 mm/Hg d. 0-15 mm/Hg

d. 0-15 mm/Hg

A nurse is teaching family members of a client with a concussion about the early signs of increased cranial pressure, ICP. Which of the following would the nurse cite as early signs of ICP? a. decreased systolic blood pressure b. inability to wake the patient with noxious stimuli c. dilated pupils that don't react to light d. headache and vomiting

d. headache and vomiting *Headache and vomiting are early signs of increased ICP. *Decreases systolic blood pressure, inability to wake a patient with noxious stimuli, and dilated pupils that don't react to light are late signs of increased ICP.

Whether Mr. Synder's tumor is benign or malignant, it will eventually cause an increase in intracranial pressure (ICP). Signs and symptoms of increasing ICP include ALL of the following EXCEPT: a. papilledema, dizziness, mental status changes b. headache, nausea, vomiting c. obvious motor deficits d. increased pulse rate, drop in blood pressure

d. increased pulse rate, drop in blood pressure **As ICP increases, pulse rate decreases, and blood pressure increases. **As ICP continues to increase, vital signs vary considerably.

While cooking your client could not feel the temperature of the oven. Which lobe of the brain could be dysfunctional? a. occipital b. temporal c. frontal d. parietal

d. parietal *The parietal lobe controls / regulates sensory function...including the ability to feel hot and cold. *The frontal lobe regulates thinking, planning and judgement. *The occipital lobe is primarily responsible for vision function. *The temporal lobe regulates memory.

For an adult client with a suspected increased intracranial pressure (ICP), a most appropriate respiratory goal would be: a. lower arterial pH b. maintain partial pressure of arterial oxygen, PaO2, above 80 mm/Hg c. prevent respiratory alkalosis d. promote CO2 elimination

d. promote CO2 elimination *The goal of treatment would be to prevent acidemia by eliminating CO2. *That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. *Preventing respiratory alkalosis and lowering arterial pH could raise acid levels. *A minimum 60 mm/hg can oxygenate most clients.

Which of the following signs of increased intracranial pressure (ICP) would appear first after head trauma? a. widened pulse pressure b. large amounts of very dilute urine c. bradycardia d. restlessness and confusion

d. restlessness and confusion *The earliest sign of increased ICP is a change in mental status. *Bradycardia and widened pulse pressure occur later. *The patient may void a lot of very dilute urine if his posterior pituitary is damaged.

A client with a subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? a. Systolic blood pressure remains at 150 mm Hg b. Pupils are 8mm and non reactive c. BUN and creatinine levels return to normal d. urine output increases

d. urine output increases **Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. *Fixed and dilated pupils are symptoms of ICP or cranial nerve damage. **No information is given about BUN and creatinine levels or that mannitol is being given to treat renal dysfunction or blood pressure.