Chapter 56, Nursing Management: Acute Intracranial Problems: Increased Intracranial Pressure

The nurse is educating a patient scheduled for a ventriculostomy. What statement by the patient demonstrates an understanding of the procedure? "I will have an internal transducer in my head." "I won't be able to have drugs instilled through this procedure." "It will directly measure the pressure within the ventricles of my brain." "The primary health care provider won't be able to get samples of my cerebrospinal fluid."

"It will directly measure the pressure within the ventricles of my brain."

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. 4 5 6 9 11

4 5 6

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? 5 to 15 mm Hg 25 to 35 mm Hg 45 to 60 mm Hg 80 to 120 mm Hg

5 to 15 mm Hg

The nurse is calculating the cerebral perfusion pressure (CPP) of an unconscious patient. The patient's blood pressure is 162/58 mm Hg and intracranial pressure (ICP) is 35 mm Hg. What is the patient's CPP? Record your answer using a whole number.

58

A patient with meningitis has seizures, cranial nerve (CN) III palsy, and bradycardia. What is the most likely cause for the development of these symptoms? Cerebral abscess Subdural effusion Acute cerebral edema Increased intracranial pressure

Acute cerebral edema

The nurse is caring for a patient with increased intracranial pressure (ICP). What actions should the nurse perform as a part of nutritional therapy? Select all that apply. Keep the patient in a hypovolemic fluid state. Begin parenteral nutrition if oral intake is not adequate. Begin nutritional replacement within three days after injury. Wait for at least seven days to begin nutritional replacement. Evaluate the patient's urine output, fluid loss, and electrolyte balance.

Begin parenteral nutrition if oral intake is not adequate. Begin nutritional replacement within three days after injury. Evaluate the patient's urine output, fluid loss, and electrolyte balance.

A nurse is caring for a patient with a closed head injury and increasing intracranial pressure. Which of the following manifestations does the nurse report to the health care provider that represent Cushing's triad? Select all that apply. Bradycardia Weak pulse Irregular respirations Increasing systolic blood pressure Decreasing systolic blood pressure

Bradycardia Irregular respirations Increasing systolic blood pressure

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? Stroke Epileptic seizure Decorticate posturing Decerebrate posturing

Decorticate posturing

A nurse should assess pupillary response in a patient with a head trauma and suspected intracranial pressure to evaluate the functioning of which cranial nerve? XII X V III

III

After assessing the patient, the nurse declines to administer mannitol to the patient. Which condition supports this nursing intervention? Cerebral edema Cerebral tissue swelling Increased serum osmolality Increased intracranial pressure (ICP)

Increased serum osmolality

A patient has been diagnosed with a right-sided brain tumor resulting in significant increased intracranial pressure (ICP). The nurse can expect to document which assessment findings? Select all that apply. Ipsilateral pupil dilation Ipsilateral hemiparesis Contralateral hemiparesis Contralateral pupil dilation Altered level of consciousness

Ipsilateral pupil dilation Contralateral hemiparesis Altered level of consciousness

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? It reduces blood pressure in the body. It causes fluid replacement effectively. It maintains electrolyte balance effectively. It has a short half-life and rapid onset of action.

It has a short half-life and rapid onset of action.

The nurse is caring for a patient with increased intracranial pressure. Which actions should the nurse perform to promote optimal outcomes for the patient? Select all that apply. Maintain fluid balance and assess osmolality. Maintain intubation and mechanical ventilation. Lower the head of the bed and turn the patient to one side. Wait for the respiration to improve before beginning with ventilation. Elevate the head of the bed to 30 degrees with the head in a neutral position.

Maintain fluid balance and assess osmolality. Maintain intubation and mechanical ventilation. Elevate the head of the bed to 30 degrees with the head in a neutral position.

The nurse is preparing to change the body position of a patient with increased intracranial pressure (ICP). Which factors should the nurse consider prior to changing the position? Select all that apply. Placing the patient in side-lying position Raising the head of bed above 30 degrees Maintaining a head-up position for the patient Taking care to prevent extreme neck flexion of patient Adjusting the patient's body position to decrease intracranial pressure (ICP)

Maintaining a head-up position for the patient Taking care to prevent extreme neck flexion of patient Adjusting the patient's body position to decrease intracranial pressure (ICP)

The nurse is planning the care for a patient with increased intracranial pressure (ICP). What actions should the nurse plan to perform to provide the most comfort for the patient? Select all that apply. Minimize procedures that can produce agitation. Observe the patient for signs of agitation or irritation. Teach the patient's family about increasing stimulation. Make the patient remain in a quiet and calm environment. Allow the patient's family to visit the patient more often.

Minimize procedures that can produce agitation. Observe the patient for signs of agitation or irritation. Make the patient remain in a quiet and calm environment.

Following an assessment of the oculocephalic reflex, the nurse suspects that the patient has an intracranial lesion. Which behavior of the patient supports the nurse's conclusion? Movement of the eye in the opposite direction to the turning head Movement of the eye in the upward direction when the neck is flexed Movement of the eye in the sideward direction when the neck is extended Movement of the eye in the downward direction when the neck is extended

Movement of the eye in the sideward direction when the neck is extended

A patient with meningitis has adhesions that prevent the normal flow of cerebrospinal fluid from the ventricles. Which complication might be observed first? Cerebral abscess Acute cerebral edema Cranial nerve irritation Noncommunicating hydrocephalus

Noncommunicating hydrocephalus

Which finding in the intracranial pressure waveforms supports the nurse's conclusion that a patient's intracranial compliance is compromised? P3 wave is lower than P1 wave P2 wave is higher than P1 wave P2 wave is higher than P3 wave P1, P2, and P3 resemble a staircase

P2 wave is higher than P1 wave

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? Presence of fixed unresponsive pupils Sluggish reaction of pupil in response to light Brisk constriction of pupil in response to light Slight constriction in the opposite pupil in response to light

Presence of fixed unresponsive pupils

The nurse administers mannitol that has been prescribed for a patient with increased intracranial pressure. What outcome does the nurse expect after administration? Increased urine output Decreased blood pressure Reduced intracranial pressure Increased intracranial perfusion

Reduced intracranial pressure

The nurse is positioning a patient who has increased intracranial pressure (ICP). Which is the most appropriate position for this patient? p>The nurse is positioning a patient who has increased intracranial pressure (ICP). Which is the <b>most </b>appropriate position for this patient?</p> Sims' Prone Trendelenburg Semi-Fowler's

Semi-Fowler's

When considering the use of hypertonic saline treatment in a patient with increased intracranial pressure (ICP), which factors should the nurse consider? Select all that apply. The nurse should closely monitor blood sugar levels in the patient. The nurse should frequently monitor the blood pressure and sodium levels. Hypertonic saline treatment works similarly to mannitol in treating increased ICP. Hypertonic saline treatment provides massive movement of water out of swollen brain cells. The nurse should ensure that antacid is given to prevent gastrointestinal complications.

The nurse should frequently monitor the blood pressure and sodium levels. Hypertonic saline treatment works similarly to mannitol in treating increased ICP. Hypertonic saline treatment provides massive movement of water out of swollen brain cells.

The nurse suspects a patient has increased intracranial pressure. Which assessment findings may indicate this condition? Select all that apply. The patient is alert and oriented. The patient is experiencing hemiplegia. The patient has unilateral pupil dilation. The patient has a regular respiratory rate of 14. The patient is vomiting without preceding nausea.

The patient is experiencing hemiplegia. The patient has unilateral pupil dilation. The patient is vomiting without preceding nausea.

A patient underwent cranial surgery. What actions should the nurse perform to prevent increased intracranial pressure (ICP)? Select all that apply. Turn and position the patient appropriately. Assess the patient's weight loss after surgery. Frequently assess the patient's neurologic status. Monitor the patient's serum creatinine and lipid profile. Closely monitor fluid and electrolyte levels and serum osmolality.

Turn and position the patient appropriately. Frequently assess the patient's neurologic status. Closely monitor fluid and electrolyte levels and serum osmolality.

A nurse is caring for a patient with a traumatic brain injury and increased intracranial pressure (ICP). Which symptom would the nurse report to the physician immediately? ICP of 20 mm Hg Urine output of 1000 mL in 1 hr Respiratory rate of 24 Pulse of 100 beats/minute

Urine output of 1000 mL in 1 hr

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? Administer intravenous (IV) mannitol. Use ventilator to hyperoxygenate the patient. Use strict aseptic technique with dressing changes. Be aware of changes in ICP related to leaking cerebrospinal fluid (CSF).

Use strict aseptic technique with dressing changes.

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. Consider the use of light sedation agents. Observe the skin area under the restraints. Use a stimulating environment in the room. Keep family members away from the patient. Use effective restraints in an agitated patient.

Consider the use of light sedation agents. Observe the skin area under the restraints. Use effective restraints in an agitated patient.

A patient was ejected from a car during a motor vehicle crash and has a diagnosis of subdural hematoma. Which type of brain injury does this represent? Anoxia Primary Cerebral Secondary

Primary

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? 20 40 60 80

60

The nurse is assessing the breathing patterns of four patients. Which patient does the nurse suspect may have a lesion in the medulla of brain? A patient with cluster breathing A patient with apneustic breathing A patient with Cheyne-Stokes breathing A patient with central neurogenic hyperventilation

A patient with cluster breathing

The nurse is performing a neurologic assessment for a patient. When performing a palmar drift test, what is the nurse attempting to determine? Eye movements Pupillary reaction Strength of the legs Strength of the hands

Strength of the hands

The novice nurse is assigned a patient who was admitted earlier in the day with a diagnosis of post-head injury concussion. What statement made by the nurse demonstrates an understanding of the care of the patient's injuries? "I can expect the pupils to be unequal in size and sluggish to respond." "I will delegate to the unlicensed assistive personnel (UAP) to keep the patient awake for the next eight hours." "To help with post-head injury headaches, I will ask the health care provider to prescribe morphine intravenously (IV)." "I need to assess the patient's level of consciousness frequently because that is the first indication of complications."

"I need to assess the patient's level of consciousness frequently because that is the first indication of complications."

A dose of dexamethasone 8 mg intravenous (IV) is prescribed. The unit stock medication has a concentration of 20 mg/mL. How many milliliters will the nurse will draw up to administer this dose? Record your answer using one decimal place. Insert a leading zero if applicable.

0.4 mL

The nurse is caring for a patient experiencing increased intracranial pressure (ICP). What is the priority nursing action in the care of this patient? Monitor fluid and electrolyte status carefully. Position the patient in a high Fowler's position. Administer vasoconstrictors to maintain cerebral perfusion. Maintain physical restraints to prevent episodes of agitation.

Monitor fluid and electrolyte status carefully.

A patient with increased intracranial pressure (ICP) is being treated with corticosteroids. What actions should the nurse perform to avoid complications due to corticosteroid treatment? Select all that apply. Monitor fluid intake and sodium levels regularly. Monitor patient's sleep and diet routine regularly. Perform blood glucose monitoring at least every six hours. Avoid taking any antacids along with corticosteroid treatment. Start concurrent treatment with antacids or proton pump inhibitors.

Monitor fluid intake and sodium levels regularly. Perform blood glucose monitoring at least every six hours. Start concurrent treatment with antacids or proton pump inhibitors.

Which outcomes indicate effective treatment in a patient with increased intracranial pressure who underwent a tracheostomy to help maintain adequate ventilation? Select all that apply. PaO 2 of the patient is 80 mm Hg PaO 2 of the patient is 90 mm Hg PaO 2 of the patient is 110 mm Hg PaCO 2 of the patient is 40 mm Hg PaCO 2 of the patient is 30 mm Hg

PaO 2 of the patient is 110 mm Hg PaCO 2 of the patient is 40 mm Hg

When performing a neurologic assessment on a patient, the nurse notes fixed pupils that are unresponsive to a light stimulus. Which causes of fixed pupils should the nurse consider during this assessment? Select all that apply. Previous eye surgery Administration of diuretics Increased intraocular pressure Increased intracranial pressure (ICP) Direct injury to the third cranial nerve (CN III)

Previous eye surgery Increased intracranial pressure (ICP) Direct injury to the third cranial nerve (CN III)

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)? Tachypnea Bradycardia Hypotension Narrowing pulse pressure

Bradycardia

A nurse is caring for a patient with a brain injury as a result of a car accident. On admission, the patient's vital signs are blood pressure (BP), 132/72; pulse 100 beats/minute; and respirations 24. Later, the nurse reassesses the patient's vital signs. Which set of vital signs should the nurse report to the physician immediately? Blood pressure 172/54, pulse 58 beats/minute, respirations 10 Blood pressure 136/84, pulse 88 beats/minute, respirations 26 Blood pressure 112/56, pulse 98 beats/minute, respirations 28 Blood pressure 126/68, pulse 110 beats/minute, respirations 32

Blood pressure 172/54, pulse 58 beats/minute, respirations 10

Which nursing intervention is the priority when caring for a patient who has increased intracranial pressure (ICP)? Continuous ICP monitoring Placing the patient in a supine position Administration of D5W intravenous infusions Withholding opiates to protect respiratory status

Continuous ICP monitoring

The nurse is caring for a patient with increased intracranial pressure (ICP). What seizure precautions should the nurse take to protect the patient? Select all that apply. Keep suction equipment readily available. Provide sufficient stimulation to the patient. Use seizure treatment only after confirming the diagnosis. Use padded side rails and maintain an airway at the bedside. Use prophylactic antiseizure therapy during first seven days after injury.

Keep suction equipment readily available. Use padded side rails and maintain an airway at the bedside. Use prophylactic antiseizure therapy during first seven days after injury.

A nurse is using the Glasgow Coma Scale (GCS) to assess a patient who fell out of a tree and sustained a head injury and developed increased intracranial pressure. Which components will the nurse assess? Swallowing, speaking, and following verbal commands Swallowing, pupillary response, and following verbal commands Speaking, responding to stimuli, and following verbal commands Responding to stimuli, swallowing, and following verbal commands

Speaking, responding to stimuli, and following verbal commands

A nurse is providing a community presentation on causes of brain injury. Which would the nurse include as possible causes for increased intracranial pressure? Sinusitis Cor pulmonale Diabetes insipidus Subdural hematoma

Subdural hematoma

When evaluating level of consciousness on the basis of the Glasgow Coma Scale (GCS), which possible responses could be scored under best motor response? Select all that apply. Flexion withdrawal Localization of pain Obedience of command Disorganized use of words Opening the eyes in response to sound

Flexion withdrawal Localization of pain Obedience of command

What inflammatory condition is the most common cause of acute nonepidemic encephalitis? St. Louis encephalitis Eastern equine encephalitis Western equine encephalitis Herpes simplex virus encephalitis

Herpes simplex virus encephalitis

The nurse is administering mannitol intravenously to a patient with a head injury. Which assessment will help the nurse determine if the medication is having the desired outcome? Increased blood pressure Decrease in body temperature Decreased intracranial pressure Decreased serum blood glucose

Decreased intracranial pressure

A patient with increased intracranial pressure (ICP) is prescribed a high dose of barbiturates. What outcome does the nurse anticipate the patient will have after administration of the medication? Reduces vasogenic edema Decreases cerebral metabolism Causes plasma expansion and osmotic effect Brings massive movement of water out of brain cells

Decreases cerebral metabolism

A patient who sustained a head injury in a motorcycle crash 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? Increased systolic blood pressure, increased pulse, GCS score of 12 Decreased diastolic blood pressure, decreased pulse, and GCS score of 13 Increased systolic and diastolic blood pressure, increased pulse, GCS score of 9 Increased systolic blood pressure, decreased pulse, widening pulse pressure, GCS score of 4

Increased systolic blood pressure, decreased pulse, widening pulse pressure, GCS score of 4

A patient being treated for viral meningitis arrives at the hospital reporting a persistent severe headache. Which nursing intervention is most appropriate for the patient? Telling the patient to use analgesics Informing the patient that headaches can occur after recovery Informing the patient that a headache is not a major complication Informing the patient that a full recovery from viral meningitis is not possible

Informing the patient that headaches can occur after recovery

A nurse is educating a patient's family about intracranial pressure (ICP). The nurse explains that normal ICP is a balance of which three components? Blood pressure, brain tissue, body mass index Glucose level, blood pressure, and brain tissue Blood pressure, brain tissue, and cerebrospinal fluid Blood pressure, brain tissue, and ventricles of the brain

Blood pressure, brain tissue, and cerebrospinal fluid

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. Cough Blurred vision Gaseous distention Headache and vomiting Decreased level of consciousness

Blurred vision Headache and vomiting Decreased level of consciousness

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 deterioration in the patient's condition? The patient does not remember what happened. The patient is sleeping but awakens in response to painful stimuli. Blood pressure is 110/80 mm Hg, pulse is 78 beats/minute, and respirations are 20 breaths/minute. Blood pressure is 160/74 mm Hg, pulse is 53 beats/minute, and respirations are 10 breaths/minute.

Blood pressure is 160/74 mm Hg, pulse is 53 beats/minute, and respirations are 10 breaths/minute.

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? Presence of a gag reflex Urine output of 50 mL during the past hour Blood pressure of 148/58 mm Hg and pulse 48 beats/minute Temperature of 99.8° F (37.6° C) and pulse of 96 beats/minute

Blood pressure of 148/58 mm Hg and pulse 48 beats/minute

The nurse is planning to administer pharmacologic therapy for a patient with increased intracranial pressure (ICP). Which factors should the nurse consider? Select all that apply. Use benzodiazepines as a standalone treatment for sedation. Monitor for hypotension when using opioids to manage anxiety. Monitor for hypotension when using continuous intravenous sedatives. Use nondepolarizing neuromuscular blocking agents alone for better outcomes. Use sedatives or analgesics with nondepolarizing neuromuscular blocking agents.

Monitor for hypotension when using opioids to manage anxiety. Monitor for hypotension when using continuous intravenous sedatives. Use sedatives or analgesics with nondepolarizing neuromuscular blocking agents.