EAQ 56 Increased Intracranial Pressure

Which disorder would the nurse associate with a patient who has meningitis with seizures, cranial nerve (CN) III palsy, and bradycardia? A. Cerebral abscess B. Subdural effusion C. Acute cerebral edema D. Increased intracranial pressure

C. Acute cerebral edema Rationale: Acute cerebral edema is a complication of meningitis that causes seizures, CN III palsy, and bradycardia. Cerebral abscess, subdural effusion, and increased intracranial pressure are complications of meningitis, but they do not cause the aforementioned symptoms.

Which assessment would the nurse perform to determine whether the mannitol (Osmitrol) IV treatment had the desired outcome for a patient with a head injury? A. Increased BP B. Decrease in body temperature C. Decreased intracranial pressure D. Decreased serum blood glucose

C. Decreased intracranial pressure Rationale: Administering mannitol decreases intracranial pressure, so measuring this will determine the effectiveness of the drug. Measurements of serum blood glucose, BP, and body temperature occur, but these will not determine the effectiveness of the mannitol.

Which intervention would the nurse implement when providing care for a patient with an increased intracranial pressure (ICP)? A. Place the patient in a supine position. B. Monitor ICP continuously. C. Administer D 5W IV infusions. D. Withhold opiates to protect respiratory status.

B. Monitor ICP continuously. Rationale: Because ICP is a dangerous condition, the nurse must monitor constantly. Patients with ICP need to be in a semi-Fowler's, not supine, position. The administration of D5W IV fluids will decrease serum osmolality and increase, not decrease, ICP. Opiates such as morphine and fentanyl are rapid acting and have little effect on cerebral perfusion; however, there is a need to monitor the patient's respiratory status closely.

For the mechanically ventilated patient, which response would the nurse use when family members inquire as to the benefit of maintaining the propofol (Diprivan) drip? A. Propofol facilitates efficient fluid replacement. B. The treatment reduces the body's BP. C. The drug maintains electrolyte balance effectively. D. The medication has a short half-life and rapid onset of action.

D. The medication has a short half-life and rapid onset of action. Rationale: The IV anesthetic propofol gained popularity in management of anxiety and agitation because of the short half-life, which facilitates faster therapeutic action of the drug in the body. The side effect of propofol is hypotension, which limits the use of propofol in hypotensive patients. Propofol does not have an effect on fluid replacement or electrolyte balance in the body.

When assessing a patient's level of consciousness, which potential Glasgow Coma Scale (GCS) scores indicate the patient is in a comatose state? Select all that apply. 4 5 6 9 11

4 5 6 Rationale: A GCS score of 8 or less generally indicates coma. Scores of 9 or 11 are greater than 8, and do not indicate coma.

Which interventions would the nurse implement to avoid complications associated with the corticosteroid treatment prescribed for a patient with an increased intracranial pressure (ICP)? Select all that apply. A. Monitor fluid intake and sodium levels regularly. B. Monitor patient's sleep and diet routine regularly. C. Perform blood glucose monitoring at least every six hours. D. Avoid taking any antacids along with corticosteroid treatment. E. Initiate concurrent treatment with antacids or proton pump inhibitors.

A. Monitor fluid intake and sodium levels regularly. C. Perform blood glucose monitoring at least every six hours. E. Initiate concurrent treatment with antacids or proton pump inhibitors. Rationale: Regularly monitor patients on corticosteroid treatment for fluid intake and sodium levels. Perform blood glucose monitoring at least every six hours until ruling out hyperglycemia from the steroids. Starting concurrent treatment with antacids or proton pump inhibitors is important to prevent gastrointestinal ulcers and bleeding because complications associated with the use of corticosteroids include hyperglycemia, increased incidence of infections, and gastrointestinal bleeding. Regularly monitoring the patient's sleep and diet routine does not contribute to avoiding complications related to corticosteroid therapy. Administer antacids along with corticosteroids to prevent gastrointestinal complications.

Which data, obtained during the nurse's assessment of the patient, indicates that the patient in the neurologic intensive care unit with an increased intracranial pressure (ICP) is deteriorating? A. Presence of fixed unresponsive pupils B. Sluggish reaction of pupil in response to light C. Brisk constriction of pupil in response to light D. Slight constriction in the opposite pupil in response to light

A. Presence of fixed unresponsive pupils Rationale: 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.

When performing the prescribed intermittent drainage of cerebrospinal fluid (CSF) from a previously inserted ventriculostomy system, in which order would the intensive care unit nurse drain the fluid? 1. Close the stopcock to return the ventriculostomy to a closed system. 2. Open the ventriculostomy system when ICP is greater than the prescribed pressure. 3. Obtain the intracranial pressure (ICP) and determine whether the pressure is above the prescribed level. 4. Allow the CSF to drain for two to three minutes into the collection bag.

1. Obtain the intracranial pressure (ICP) and determine whether the pressure is above the prescribed level. 2. Open the ventriculostomy system when ICP is greater than the prescribed pressure. 3. Allow the CSF to drain for two to three minutes into the collection bag. 4. Close the stopcock to return the ventriculostomy to a closed system.

When explaining neurological pathophysiology to a group of nursing students, the nurse describes the progression of increased intracranial pressure in which chronological order? 1. Tissue edema 2. Decreased oxygen and death of brain cells 3. Decreased cerebral blood flow 4. Increased intracranial pressure 5. Compression of ventricles and blood vessels 6. Compression of the brainstem and respiratory center

1. Tissue edema 2. Increased intracranial pressure 3. Compression of ventricles and blood vessels 4. Decreased cerebral blood flow 5. Decreased oxygen and death of brain cells 6. Compression of the brainstem and respiratory center

Assessment findings of a patient include a mean arterial pressure (MAP) of 64 mm Hg, intracranial pressure (ICP) of 25 mm Hg, and BP of 180/90 mm Hg. The nurse calculates what cerebral perfusion pressure (CPP)? Record answer as a whole number.

39 mm Hg Rationale: The CPP is calculated by subtracting the ICP from the MAP; 64 - 25 = 39. Normal CPP is 60 to 100 mm Hg to ensure blood flow to the brain. As CPP decreases, autoregulation fails and cerebral blood flow is decreased

When assessing a patient's intracranial pressure (ICP) after they sustained a head trauma, which normative value would the nurse utilize to compare the assessment data? 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 Rationale: A normal ICP reading is 5 to 15 mm Hg. Any ICP value greater than 25 mm Hg represents a life-threatening condition requiring immediate intervention

To determine the amount of cerebral spinal fluid to drain from a patient's ventricle catheter, the nurse calculates the cerebral perfusion pressure (CPP) of an unconscious patient whose BP is 162/58 mm Hg and intracranial pressure (ICP) is 35 mm Hg. Identify the patient's CPP. Record your answer using a whole number.

58 mm Hg Rationale The nurse calculates the CPP by subtracting the ICP from the mean arterial pressure (MAP). The MAP is [162 + 2(58)]/3 = 193. The nurse subtracts 35 from 93 to determine that the patient's CPP is 58 mm Hg.

While providing care for a patient with a closed head injury and increasing intracranial pressures, which clinical manifestations represent Cushing's triad and require notifying the health care provider? Select all that apply. A. Bradycardia B. Weak pulse C. Irregular respirations D. Increasing systolic BP E. Decreasing systolic BP

A. Bradycardia C. Irregular respirations D. Increasing systolic BP Rationale: Cushing's triad consists of bradycardia, irregular respiration, and a widening pulse pressure (increasing systolic pressure). The pulse is full and bounding, not weak. The systolic BP increases, not decreases.

Which intervention would the nurse implement when providing care for a patient experiencing an increased intracranial pressure (ICP)? A. Monitor fluid and electrolyte disturbances 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.

A. Monitor fluid and electrolyte disturbances carefully. Rationale: Monitor fluid and electrolyte disturbances vigilantly because they can have an adverse effect on ICP. Keep the head of the patient's bed at 30 degrees in most circumstances. Physical restraints are not applied unless necessary because agitation increases ICP. Do not administer vasoconstrictors, typically, in the treatment of ICP.

After assessing the breathing patterns of four assigned patients, which patient would the nurse suspect of having a lesion in the medulla of the brain? A. The patient with cluster breathing B. The patient with apneustic breathing C. The patient with Cheyne-Stokes breathing D. The patient with central neurogenic hyperventilation

A. The patient with cluster breathing Rationale: Lesions in the medulla may affect the breathing pattern, resulting in clustered breathing with irregular pauses in between. Lesions on mid or lower pons cause apneustic breathing. Bilateral hemispheric disease causes a Cheyne-Stokes pattern of breathing. Lesions on the brainstem between lower midbrain and upper pons cause central neurogenic hyperventilation.

Which intracranial pressure waveform supports the nurse's assessment of a compromise occurring with the patient's intracranial compliance? A. P3 wave is lower than P1 wave B. P2 wave is higher than P1 wave C. P2 wave is higher than P3 wave D. P1, P2, and P3 resemble a staircase

B. P2 wave is higher than P1 wave Rationale: The P2 wave represents the intracranial compliance, and the P2 wave 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.

For the patient admitted for observation after a minor head injury, which assessment findings would support the nurse's suspicion of an increasing intracranial pressure? Select all that apply. A. The patient is alert and oriented. B. The patient is experiencing hemiplegia. C. The patient has unilateral pupil dilation. D. The patient has a regular respiratory rate of 14 breaths/min. E. The patient is vomiting without preceding nausea.

B. The patient is experiencing hemiplegia. C. The patient has unilateral pupil dilation. E. The patient is vomiting without preceding nausea. Rationale: Unilateral pupil dilation, vomiting, and hemiplegia are signs of increased intracranial pressure. A patient with increased intracranial pressure would likely have an impaired level of consciousness rather than being alert and oriented. He or she would also have an irregular, not regular, respiratory rate.

Which outcome would the nurse expect after administration of IV mannitol (Osmitrol) prescribed for a patient experiencing an increased intracranial pressure (ICP)? A. Increased urine output B. Decreased BP C. Reduced ICP D. Increased intracranial perfusion

C. Reduced ICP Rationale: Mannitol is an osmotic diuretic that increases osmotic pressure in the renal tubules to increase the uptake of water and dieresis by the kidneys, which specifically helps to relieve cerebral edema, thereby decreasing ICP. Increased urine output, decreased BP, and increased intracranial perfusion are secondary outcomes of administration of mannitol. Of these, increased intracranial perfusion is most desirable because it reduces ICP. Monitor BPs closely because an extreme decrease in BP may occur, resulting in decreased intracranial perfusion.

For the patient who sustained a head trauma and has an increased intracranial pressure, which cranial nerve (CN) would the nurse assess to determine the patient's papillary response? CN X CN V CN III CNXII

CN III Rationale: CN III controls oculomotor function, so when the nurse assesses pupillary response, he or she is checking the viability of this nerve. CN XII controls tongue movement, CN X is the vagus nerve, and CN V is the trigeminal nerve.

Which inflammatory condition would the nurse associate to the common cause of acute nonepidemic encephalitis? A. St. Louis encephalitis B. Eastern equine encephalitis C. Western equine encephalitis D. Herpes simplex virus encephalitis

D. Herpes simplex virus encephalitis Rationale: Herpes simplex virus encephalitis is the most common cause of acute nonepidemic viral encephalitis. St. Louis encephalitis, eastern equine encephalitis, and western equine cause epidemic encephalitis.

Which clinical manifestations would the nurse monitor to assess the development of increasing intracranial pressures in a patient who sustained a head injury and has a baseline Glasgow Coma Scale (GCS) score of 14? A. Increased systolic BP, increased pulse, GCS score of 12 B. Decreased diastolic BP, decreased pulse, and GCS score of 13 C. Increased systolic and diastolic BP, increased pulse, GCS score of 9 D. Increased systolic BP, decreased pulse, widening pulse pressure, GCS score of 4

D. Increased systolic BP, decreased pulse, widening pulse pressure, GCS score of 4 Rationale: One classic sign of increasing intracranial pressure and neurologic deterioration is an increased systolic BP and decreased diastolic BP (resulting in a widening pulse pressure) accompanied by bradycardia. Cushing's triad includes hypertension (elevated systolic pressure and widening pulse pressure), bradycardia, and bradypnea. Increased systolic BP, increased pulse, and GCS of 12 and decreased diastolic BP, decreased pulse, and GCS of 13 do not indicate deterioration in neurologic status. Increased systolic and diastolic BP, increased pulse, and GCS of 9 indicate that the patient requires continued assessment. Although the BP 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. Any patient scoring less than 8 on the GCS is comatose

For the patient with an increased intracranial pressure, who required a tracheostomy to help to maintain adequate ventilation, which postprocedural outcomes indicate an effective intervention? SATA 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. Rationale: The goal of maintaining adequate ventilation through tracheostomy is to maintain PaO of the patient greater than or equal to 100 mm Hg with PaCO in the range of 35 to 45 mm Hg. Therefore the PaO value of 110 mm Hg and PaCO value of 40 mm Hg indicate effective treatment. A PaO of less than 100 and PaCO of less than 35 mm Hg indicate ineffective treatment.

The nurse suspects that a patient with bacterial meningitis is experiencing cranial nerve II irritation based on which assessment finding? Facial paresis Papilledema and blindness Ptosis, unequal pupils, and diplopia Sensory loss and loss of corneal reflex

Papilledema and blindness Rationale: Irritation of cranial nerve II can cause papilledema and blindness. Facial paresis would result from irritation of cranial nerve VII. Ptosis, unequal pupils, and diplopia can indicate involvement of cranial nerves III, IV, and VI. Sensory loss and loss of corneal reflex can occur with irritation of cranial nerve V.

While utilizing the Glasgow Coma Scale (GCS) to assess a patient's level of consciousness, which potential responses would the nurse document under best motor response? SATA A. Flexion withdrawal B. Localization of pain C. Obedience of command D. Disorganized use of words E. Opening the eyes in response to sound

A. Flexion withdrawal B. Localization of pain C. Obedience of command Rationale: Utilize flexion withdrawal, localization of pain, and obedience of command to record a patient's best motor response. Do not use opening of the eyes in response to stimuli and disorganized use of words under the scale's motor response.

Which interventions would the nurse implement to promote optimal outcomes for the patient with an increased intracranial pressure (ICP)? Select all that apply. A. Maintain fluid balance and assess osmolality. B. Maintain intubation and mechanical ventilation. C. Lower the head of the bed and turn the patient to one side. E. Wait for the respirations to improve before beginning with ventilation. D. Elevate the head of the bed to 30 degrees with the head in a neutral position.

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

Which potential factors would the nurse associate with explaining a patient's pupils becoming fixed and unresponsive to light stimulus? SATA. A. Previous eye surgery B. Administration of diuretics C. Increased intraocular pressure D. Increased intracranial pressure (ICP) E. Direct injury to the third cranial nerve (CN III)

A. Previous eye surgery D. Increased intracranial pressure (ICP) E. Direct injury to the third cranial nerve (CN III) Rationale: A fixed pupil unresponsive to light stimulus usually indicates a previous eye surgery, increased ICP, direct injury to CN III, administration of atropine, and use of mydriatic eyedrops. Administration of diuretics and increased intraocular pressure do not cause fixed pupils.

Which clinical manifestation would the nurse report immediately to the health care provider when providing care for a patient with a traumatic brain injury and an increased intracranial pressure (ICP)? A. ICP of 20 mm Hg B. Urine output of 1000 mL in one hour C. Respiratory rate of 24 breaths/minute D. Pulse of 100 beats/minute

B. Urine output of 1000 mL in one hour Rationale: An increased urine output of 1000 mL in one hour could cause critical fluid and electrolyte imbalance issues and needs prompt attention; this indicates a decline in the patient's condition. An ICP of 20 mm Hg, respiratory rate of 24 breaths/minute, and pulse of 100 beats/minute do not indicate a need for the nurse to call the health care provider.

A patient's systemic BP is 120/60 mm Hg and the intracranial pressure (ICP) is 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), which interpretation would the nurse apply to the results? A. High blood flow to the brain B. Normal ICP C. Impaired blood flow to the brain D. Adequate autoregulation of blood flow

C. Impaired blood flow to the brain Rationale: A normal CPP is 60 to 100 mm Hg. Determine the calculated CPP by subtracting the ICP from the mean arterial pressure (MAP). MAP = (systolic blood pressure [SBP] + 2[diastolic blood pressure (DBP)])/3: (120 mm Hg + 2[60 mm Hg])/3 = 120 mm Hg + 120 mm Hg = 240 mm Hg; 240/3 = 80 mm Hg. MAP-ICP: 80 mm Hg (MAP) - 24 mm Hg (ICP) = a CPP of 56 mm Hg. The decreased CPP (<60 mm Hg) indicates an impaired cerebral blood flow and impaired autoregulation of the CPP. Because the ICP is 24 mm Hg, the pressure is elevated, preventing perfusion of the brain, and requires treatment.

Which term would the nurse use to document a patient who is comatose from a head injury and displays flexion of the arms, wrists, and fingers, as well as adduction of the upper extremities? Stroke Epileptic seizure Decorticate posturing Decerebrate posturing

Decorticate posturing Rationale: Decorticate posturing—described as flexion of the arms, wrists, and fingers—and adduction of the upper extremities indicate damage to the primary motor areas of the sensorimotor cortex, both anterior and posterior. The described assessment findings do not specifically relate to describing a stroke or cerebrovascular accident and are not commonly seen in patients with epileptic seizure disorders. A nurse would describe decerebrate posturing as rigid extension of all four extremities with hyperpronation of the forearms and flexion of the feet. Decerebrate posturing results from disruption of motor fibers in the midbrain and brainstem and indicates serious tissue damage.

After performing a patient's assessment, which condition supports the nurse's intervention to decline IV administration of mannitol (Osmitrol) to the patient? Cerebral edema Cerebral tissue swelling Increased serum osmolality Increased intracranial pressure (ICP)

Increased serum osmolality Rationale: Mannitol increases the osmotic effect and may cause neurologic complications; contraindications include administering to a patient with an increased serum osmolality. Use mannitol to treat cerebral edema, cerebral tissue swelling, and increased ICP because of its diuretic effect.

Which clinical manifestations would the nurse identify when assessing a patient for intracranial pressure (ICP) changes secondary to a malfunctioning ventricular shunt? Select all that apply. A. Cough B. Blurred vision C. Gaseous distention D. Headache and vomiting E. Decreased level of consciousness

B. Blurred vision D. Headache and vomiting E. Decreased level of consciousness Rationale: 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.

For the patient admitted with a subdural hematoma following a motor vehicle accident, which vital sign change would the nurse interpret as a clinical manifestation of an increasing intracranial pressure (ICP)? A. Tachypnea B. Bradycardia C. Hypotension D. Narrowing pulse pressure

B. Bradycardia Rationale: Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with increased ICP. The triad consists 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).

The nurse suspects that a patient with bacterial meningitis is experiencing cranial nerve II irritation based on which assessment finding? A. Facial paresis B. Papilledema and blindness C. Ptosis, unequal pupils, and diplopia D. Sensory loss and loss of corneal reflex

B. Papilledema and blindness Rationale: Irritation of cranial nerve II can cause papilledema and blindness. Facial paresis would result from irritation of cranial nerve VII. Ptosis, unequal pupils, and diplopia can indicate involvement of cranial nerves III, IV, and VI. Sensory loss and loss of corneal reflex can occur with irritation of cranial nerve V.

When explaining normal intracranial pressure (ICP) balance to the patient's family, which three components would the nurse include? A. BP, brain tissue, body mass index B. Glucose level, BP, and brain tissue C. BP, brain tissue, and cerebrospinal fluid D. BP, brain tissue, and ventricles of the brain

C. BP, brain tissue, and cerebrospinal fluid Rationale: Normal ICP involves a balance of BP, brain tissue, and cerebrospinal fluid. The ventricles of the brain, glucose level, and body mass index do not contribute to maintaining normal ICP.

To preserve cerebral perfusion of a patient with an elevated intracranial pressure (ICP), which cerebral perfusion pressure (CPP) would the nurse maintain when suctioning the patient? 20 mm Hg 40 mm Hg 60 mm Hg 80 mm Hg

80 mm Hg Rationale: Patients with elevated ICP are at risk for lower CPP during suctioning. When suctioning, maintain the patient's CPP above 60 mm Hg to preserve cerebral perfusion.

Which components would the nurse assess when using the Glasgow Coma Scale (GCS) to assess a patient who sustained a head injury and subsequently developed an increased intracranial pressure (ICP)? A. Swallowing, speaking, and following verbal commands B. Swallowing, pupillary response, and following verbal commands C. Speaking, responding to stimuli, and following verbal commands D. Responding to stimuli, swallowing, and following verbal commands

C. Speaking, responding to stimuli, and following verbal commands Rationale: The GSC assesses a patient's ability to respond to stimuli, speak, and follow verbal commands. Swallowing and pupillary response are not components of the GSC.

After performing an assessment of the oculocephalic reflex, the nurse suspects that the patient has an intracranial lesion. Which patient behavior supports the nurse's assessment findings? A. When flexing the neck, eye movement is in the upward direction. B. Movement of the eye is in the opposite direction of the turned head. C. When extending the neck, eye movement is in the downward direction. D. Movement of the eye is in the opposite direction of the turned head.

D. Movement of the eye is in the opposite direction of the turned head. Rationale: Test the oculocephalic reflex by having the patient turn his or her head briskly to the left or right while holding the eyelids open. The eye movement should be in the opposite direction and not in the sideward direction if extending the neck. The sideward eye movement indicates an intracranial lesion. Movement of the eye in the opposite direction to the turning head is a normal response. Movement of eye in the upward direction when flexing the neck is normal and does not indicate any abnormality. When extending the neck, movement of the eye in the downward direction indicates a normal finding.

Which position would the nurse utilize when repositioning a patient who has an increased intracranial pressure (ICP)? A. Sims' B. Prone C. Trendelenburg D. Semi-Fowler's

Semi-Fowler's Rationale: Position a patient with an increased ICP with his or her head elevated, as in semi-Fowler's position (typically at 30 degrees). Sims' position is side-lying with one leg flexed, which may elevate intracranial pressure. A prone position is flat with the face down, and the Trendelenburg position is supine with the feet higher than the head. The head is not elevated in these positions, which is dangerous for someone with ICP.

When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/minute, and respirations 24 breaths/minute, which subsequent vital signs would the nurse report immediately to the health care provider? A. BP 172/54 mm Hg, pulse 58 beats/minute, respirations 10 breaths/minute B. BP 136/84 mm Hg, pulse 88 beats/minute, respirations 26 breaths/minute C. BP 112/56 mm Hg, pulse 98 beats/minute, respirations 28 breaths/minute D. BP 126/68 mm Hg, pulse 110 beats/minute, respirations 32 breaths/minute

A. BP 172/54 mm Hg, pulse 58 beats/minute, respirations 10 breaths/minute Rationale: Fluctuations in vital signs are expected. The nurse will report a BP of 172/54 mm Hg, pulse of 58 beats/minute, and respiration rate of 10 breaths/minute because these values may indicate Cushing's triad or systolic hypertension with a widening pulse pressure, bradycardia, and irregular or low respirations. These values are indicative of an increased intracranial pressure. BPs of 136/84, 126/68, and 112/56; pulses of 88, 110, and 98; and respiration rates of 26, 32, and 28 are not values linked to ICP when compared to the patient's initial vital signs.

Which interventions would the nurse implement to promote optimal outcomes for the patient with an increased intracranial pressure (ICP)? Select all that apply. A. Maintain fluid balance and assess osmolality. B. Maintain intubation and mechanical ventilation. C. Lower the head of the bed and turn the patient to one side. D. Wait for the respirations to improve before beginning with ventilation. E. Elevate the head of the bed to 30 degrees with the head in a neutral position.

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

Which outcome would the nurse anticipate after administering a high dose of prescribed barbiturates to the patient with an increased intracranial pressure (ICP)? A. The medication reduces the vasogenic edema. B. Barbiturates decrease the level of cerebral metabolism. C. The drug facilitates plasma expansion and an osmotic effect. D. The therapy promotes massive movement of water out of brain cells.

B. Barbiturates decrease the level of cerebral metabolism. Rationale: High doses of barbiturates decrease cerebral metabolism levels in patients with increased ICP and helps to reduce ICP. Use corticosteroids to reduce vasogenic edema. Mannitol (Osmitrol) 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.

Which clinical manifestations would the nurse identify when assessing a patient for intracranial pressure (ICP) changes secondary to a malfunctioning ventricular shunt? Select all that apply. Cough Blurred vision Gaseous distention Headache and vomiting Decreased level of consci

Blurred vision Headache and vomiting Decreased level of consciousness Rationale: 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.

Which statement by the novice nurse demonstrates understanding of the care required for a patient admitted earlier today with a diagnosis of post-head injury concussion? A. "I can expect the pupils to be unequal in size and sluggish to respond to my pen light." B. "I will delegate keeping the patient awake for the next eight hours to my unlicensed assistive personnel (UAP)." C. "To help with post-head injury headaches, I will contact the health care provider about prescribing morphine IV." D. "I need to assess the patient's level of consciousness frequently because changes are the first indication of complications."

D. "I need to assess the patient's level of consciousness frequently because changes are the first indication of complications." Rationale: 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 are often 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, avoid narcotics for pain management because they can mask the signs of impending complications, particularly alteration in level of consciousness

When providing a community safety presentation, which disorder would the nurse include as a possible cause for a patient's increased intracranial pressure? A. Sinusitis B. Cor pulmonale C. Diabetes insipidus D. Subdural hematoma

D. Subdural hematoma Rationale: A subdural hematoma is a collection of blood between the brain and its covering, which can cause intracranial pressure. Sinusitis is a respiratory disorder, which would not cause increased intracranial pressure. Cor pulmonale is a cardiorespiratory disorder, which would not affect intracranial pressure. Diabetes insipidus is an endocrine disorder affecting glucose regulation, not intracranial pressure.

Which interventions would the nurse implement to prevent injury to the patient with an increased intracranial pressure (ICP) and a decreased level of consciousness in the intensive care unit? SATA A. Consider administering 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.

A. Consider administering light sedation agents. B. Observe the skin area under the restraints. E. Use effective restraints in an agitated patient. Rationale: To prevent injury to the patient, the nurse should consider the use of light sedation agents, as prescribed by the health care provider. Check skin area under the restraints for signs of irritation because the irritation 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. Do not prevent family members from visiting the patient; instead, allow a family member to visit to assist in calming the patient.

Which response would the nurse document when a patient with a brain injury experiences the motor function changes depicted in the image? A. Decorticate posturing B. Decerebrate posturing C. Sinusoidal posturing D. Opisthotonic posturing

A. Decorticate posturing Rationale: Decorticate posture involves internal rotation and adduction of the arms with extension of the elbows, wrists, and fingers, as illustrated in the image. This results from interruption of voluntary motor tracts in the cerebral cortex. The patient may also demonstrate an extension of the legs. A decerebrate posture may indicate more serious damage and results from disruption of motor fibers in the midbrain and brainstem. In this position, the arms are stiffly extended, adducted, and hyperpronated. There is also hyperextension of the legs with plantar extension of the feet. Sinusoidal posturing does not exist. Opisthotonic posturing consists of the head, neck, and spinal column in an arching position.

Which assessment findings would the nurse document regarding a patient diagnosed with a right-sided brain tumor resulting in a significantly increased intracranial pressure (ICP)? SATA A. Ipsilateral pupil dilation B. Ipsilateral hemiparesis C. Contralateral hemiparesis D. Contralateral pupil dilation E. Altered level of consciousness

A. Ipsilateral pupil dilation Rationale: The level of consciousness is the most sensitive and reliable indicator of the patient's neurologic status. Patients experiencing increased intracranial pressure will present with varying degrees of altered levels of consciousness, depending on the degree of pressure. Compression of cranial nerve (CN) II (optic) results in dilation of the pupil on the same side (ipsilateral), not the opposite side (contralateral). As ICP continues to rise, the patient will experience changes in motor response on the opposite side of the lesion (contralateral), not the same side (ipsilateral).

For the patient with an increased intracranial pressure (ICP), which precautions would the nurse implement to protect the patient from potential seizure activity? Select all that apply. A. Keep suction equipment readily available at the patient's bedside. B. Provide sufficient stimulation of the patient to avoid comatose behaviors. C. Implement seizure treatment only after confirming the seizure diagnosis. D. Pad side rails and maintain an airway at the bedside per facility protocol. E. Use prophylactic antiseizure therapy during first seven days after injury.

A. Keep suction equipment readily available at the patient's bedside. D. Pad side rails and maintain an airway at the bedside per facility protocol. E. Use prophylactic antiseizure therapy during first seven days after injury. Rationale: 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. Utilize prophylactic antiseizure therapy during the first seven days after injury to prevent seizures. Providing stimulation to the patient may aggravate the condition; therefore the environment should be quiet. Seizure treatment should be used prophylactically. Implement seizure treatment instead of waiting for the confirmation of diagnosis or the seizures to occur. The nurse should administer antiseizure treatment in this situation.

When planning the care for a patient with an increased intracranial pressure (ICP), which interventions would the nurse integrate to provide the most comfort? Select all that apply. A. Provide the patient a quiet and calm environment. B. Minimize procedures that potentially produce agitation. C. Facilitate an increased number of family visits to the patient. D. Encourage the patient's family to increase patient interactions. E. Observe the patient for signs of agitation or irritation and intervene.

A. Provide the patient a quiet and calm environment. B. Minimize procedures that potentially produce agitation. E. Observe the patient for signs of agitation or irritation and intervene. Rationale: When managing the patient with increased ICP, avoid procedures that can produce agitation. Observe the patient for signs of agitation or irritation. The environment should be quiet and calm to provide minimal stimulation to the patient. Decrease the stimulation levels and instruct patient's family to decrease stimulation and reduce noise, including not visiting too frequently.

Which interventions would the nurse implement as a part of nutritional therapy for the patient with an increased intracranial pressure (ICP)? Select all that apply. A. Keep the patient in a hypovolemic fluid state. B. Begin parenteral nutrition if oral intake is not adequate. C. Initiate nutritional replacement within three days after injury. D. If comatose, wait at least seven days to begin nutritional replacement. E. Evaluate the patient's urine output, fluid loss, and electrolyte balance.

B. Begin parenteral nutrition if oral intake is not adequate. C. Initiate nutritional replacement within three days after injury E. Evaluate the patient's urine output, fluid loss, and electrolyte balance. Rationale: For a patient with increased ICP, begin parenteral nutrition or enteral feedings if oral intake is not adequate. Initiate nutritional replacement within three days after injury. Monitor the patient's urine output, fluid loss, and electrolyte balance to evaluate the effectiveness of nutritional therapy. Do not keep the patient in a hypovolemic fluid state; the patient needs to be in a normovolemic state. Instead of waiting, the desired treatment is to reach full nutritional replacement within seven days after injury. Do not confuse reducing brain edema with mannitol (Osmitrol) with the overall fluid balance in the body.

Which interventions would the nurse implement as a part of nutritional therapy for the patient with an increased intracranial pressure (ICP)? Select all that apply A. Keep the patient in a hypovolemic fluid state. B. Begin parenteral nutrition if oral intake is not adequate. C. Initiate nutritional replacement within three days after injury. D. If comatose, wait at least seven days to begin nutritional replacement. E. Evaluate the patient's urine output, fluid loss, and electrolyte balance.

B. Begin parenteral nutrition if oral intake is not adequate. C. Initiate nutritional replacement within three days after injury. E. Evaluate the patient's urine output, fluid loss, and electrolyte balance. Rationale: For a patient with increased ICP, begin parenteral nutrition or enteral feedings if oral intake is not adequate. Initiate nutritional replacement within three days after injury. Monitor the patient's urine output, fluid loss, and electrolyte balance to evaluate the effectiven ss of nutritional therapy. Do not keep the patient in a hypovolemic fluid state; the patient needs to be in a normovolemic state. Instead of waiting, the desired treatment is to reach full nutritional replacement within seven days after injury. Do not confuse reducing brain Edema with mannitol (Osmitrol) with the overall fluid balance in the body.

The nurse reviews the laboratory results of a patient with a cerebral inflammatory condition and notes that glucose was absent in the patient's cerebrospinal fluid. The nurse recognizes that the finding is consistent with which condition? A. Encephalitis B. Brain abscess C. Viral meningitis D. Bacterial meningitis

B. Brain abscess Rationale: The absence of glucose in cerebrospinal fluid indicates a brain abscess. The glucose would be normal in encephalitis, would be normal or low (>40 mg/dL) in viral meningitis, and would be decreased (5 to 40 mg/dL) in bacterial meningitis.

For the patient recovering from cranial surgery involving a bone flap, which interventions would the nurse implement to prevent an increased intracranial pressure (ICP)? SATA A. Assess the patient's weight loss after surgery. B. Frequently assess the patient's neurologic status. C. Monitor the patient's serum creatinine and lipid profile. D. Do not position the patient's surgical site in a dependent position. E. Closely monitor fluid and electrolyte levels and serum osmolality.

B. Frequently assess the patient's neurologic status. D. Do not position the patient's surgical site in a dependent position. E. Closely monitor fluid and electrolyte levels and serum osmolality. Rationale: 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. Closely monitor fluid and electrolyte levels, and monitor serum osmolality 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.

Which intervention would the nurse implement when a patient, receiving treatment for viral meningitis since last week, arrives at the hospital reporting a persistent severe headache? A. Instruct the patient to use analgesics for the headache. B. Inform the patient that headaches can occur after recovery. C. Teach the patient that a headache is not a major complication. D. Notify the patient that a full recovery from viral meningitis is not possible.

B. Inform the patient that headaches can occur after recovery. Rationale: Inform the patient that headaches might occur postrecovery, even though they are a rare manifestation. Treat the patient symptomatically based on the reason for developing the headache. A complete recovery is expected. A severe headache might be a major complication.

Which factors would the nurse consider when preparing to administer the pharmacologic therapy for a patient with an increased intracranial pressure (ICP)? Select all that apply. A. Use benzodiazepines as a standalone treatment for sedation. B. Monitor for hypotension when using opioids to manage anxiety. C. Monitor for hypotension when using continuous IV sedatives. D. Use nondepolarizing neuromuscular blocking agents alone for better outcomes. E. Use sedatives or analgesics with nondepolarizing neuromuscular blocking agents.

B. Monitor for hypotension when using opioids to manage anxiety. C. Monitor for hypotension when using continuous IV sedatives. E. Use sedatives or analgesics with nondepolarizing neuromuscular blocking agents. Rationale: The appropriate factors to evaluate include monitoring for hypotension when using opioids to manage anxiety and monitoring for hypotension when using continuous IV sedatives because hypotension is a side effect. Using sedatives or analgesics with nondepolarizing neuromuscular blocking agents is important because these agents paralyze muscles without blocking pain or noxious stimuli. Using benzodiazepines as a standalone treatment for sedation is not advisable due to their hypotensive effects and long half-life. Nondepolarizing neuromuscular blocking agents paralyze muscles without blocking pain or noxious stimuli; providers use these agents in combination with sedatives, analgesics, or benzodiazepines.

Which type of brain injury would the nurse associate with the patient who sustained a subdural hematoma from a motor vehicle crash? A. Anoxia B. Primary C. Cerebral D. Secondary

B. Primary Rationale: Primary injuries are those that occur at the time of the injury (e.g., blunt force trauma, car accident); the subdural hematoma is itself an example of this. Secondary injuries are those injuries resulting from the primary injury; for instance, increased intracranial pressure may result from the hematoma. A cerebral injury is damage to the cerebrum, and an anoxia injury results from a lack of oxygen to the brain.

Which factors would the nurse consider prior to repositioning a patient with an increased intracranial pressure (ICP)? SATA A. Raise the head of bed above 30 degrees B. Take care to prevent extreme neck flexion of patient. C. Adjust body position to decrease ICP. D. Rotate the patient to a side-lying position to prevent skin breakdown. E. Follow protocol standards to maintain a head-up position for the patient.

B. Take care to prevent extreme neck flexion of patient. C. Adjust body position to decrease ICP. E. Follow protocol standards to maintain a head-up position for the patient. Rationale: Maintaining a head-up position for the patient is important because elevation of the head of the bed promotes drainage and decreases the vascular congestion that can produce cerebral edema. The nurse should take care to prevent extreme neck flexion of the patient because it can cause venous obstruction and contribute to elevated ICP. Position the patient's body to decrease ICP and improve the cerebral perfusion pressure (CPP). Raising the head of the bed above 30 degrees is not advisable because it may decrease the CPP by lowering systemic BP. Rotating the patient to a side-lying position may further increase the ICP. Special air beds can alternate skin pressures to prevent tissue damage.

Which factors would the nurse associate with the use of hypertonic saline as a treatment for the patient with an increased intracranial pressure (ICP)? Select all that apply. A. The nurse would closely monitor the patient's blood sugar levels. B. The nurse would frequently monitor the BP and sodium levels. C. Hypertonic saline treatment provides massive movement of water out of the swollen brain cells. D. Hypertonic saline treatment works similarly to mannitol (Osmitrol) when treating increased ICP. E. The nurse should ensure administration of an antacid prior to administration to prevent gastrointestinal complications.

B. The nurse would frequently monitor the BP and sodium levels. C. Hypertonic saline treatment provides massive movement of water out of the swollen brain cells. D. Hypertonic saline treatment works similarly to mannitol (Osmitrol) when treating increased ICP. Rationale: Hypertonic saline provides massive movement of water out of swollen brain cells and into blood vessels. When the patient is on this treatment, frequent monitoring of BP and sodium levels is required because intravascular fluid volume excess can occur. Hypertonic saline is as effective as mannitol in treating increased ICP. The treatment does not require monitoring of blood sugar levels and does not require administration of antacids. IV medications may be administered to prevent gastric ulcers, but not because of the use of mannitol.

For the patient admitted with a subdural hematoma following a motor vehicle accident, which vital sign change would the nurse interpret as a clinical manifestation of an increasing intracranial pressure (ICP)? Tachypnea Bradycardia Hypotension Narrowing pulse pressure

Bradycardia Rationale: Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with increased ICP. The triad consists 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).

After receiving preprocedural instructions, which patient statement demonstrates an understanding of a scheduled ventriculostomy? A. "I will have an internal transducer inserted into my head." B. "I won't be able to have drugs instilled through this procedure." C. "It will directly measure the pressure within the ventricles of my brain." D. "The health care provider won't be able to get samples of my cerebrospinal fluid."

C. "It will directly measure the pressure within the ventricles of my brain." Rationale: Ventriculostomy is a gold standard procedure for monitoring the intracranial pressure (ICP). In this procedure, the health care provider positions the catheter to measure the pressure within the ventricles. The ventriculostomy transducer is external and facilitates sampling of cerebrospinal fluid. The procedure permits intraventricular drug administration.

The initial assessment of a patient in the postanesthesia care unit recovering from a brain tumor resection included a temperature of 100°F (37.7°C), BP of 130/76 mm Hg, pulse 64 beats/min, a urinary catheter in place, and oxygen at a rate of 2 L/min by nasal cannula. One hour later, which assessment finding would the nurse immediately report to the surgeon? A. Presence of a gag reflex B. Urine output of 50 mL during the past hour C. BP of 148/58 mm Hg and pulse 48 beats/min D. Temperature of 99.8°F (37.6°C) and pulse of 96 beats/min

C. BP of 148/58 mm Hg and pulse 48 beats/min Rationale: Associate a BP with a widening pulse pressure, bradycardia, and irregular respirations with an increasing intracranial pressure (ICP) known as the Cushing's triad, which 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/min are acceptable assessment findings in a postoperative patient.

When the unlicensed assistive personnel (UAP) reports the vital signs (VS) of a patient with a suspected brain injury as temperature = 101.6° F (38.7° C) orally, heart rate = 58 beats/minute, respiratory rate = 14 breaths/minute, and BP = 162/48 mm Hg, which action would the nurse implement first? A. Ask the UAP to repeat the BP. B. Validate the VS by repeating the measurements. C. Compare the current VS to recorded baseline VS. D. Administer prescribed acetaminophen (Tylenol) for fever.

C. Compare the current VS to recorded baseline VS. Rationale: Increasing pressure on the thalamus, hypothalamus, pons, and medulla changes a patient's VS. 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 BP can change with increased intracranial pressure; therefore asking the UAP to repeat the BP 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 acetaminophen.

Which intervention would the nurse implement as the priority when providing care for a patient with a ventriculostomy to measure increased intracranial pressures (ICP) caused by a brain tumor? A. Administer IV mannitol (Osmitrol). B. Maintain hyperoxygenation through use of a ventilator. C. Use strict aseptic technique with all procedural dressing changes. D. Be aware of changes in ICP related to leaking cerebrospinal fluid (CSF).

C. Use strict aseptic technique with all procedural dressing changes. Rationale: 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. Administer IV mannitol or hypertonic saline as prescribed. Potential ventilator use is to maintain oxygenation, not hyperoxygenation. CSF leaks may cause inaccurate ICP readings, or staff may drain CSF to decrease the patient's ICP, but strict aseptic technique to prevent infection is the nurse's priority of care.

The patient admitted with a closed head injury is awake but lethargic, and the baseline vital signs include a BP of 120/80 mm Hg, pulse of 78 beats/min, and respirations of 20 breaths/min. Which findings indicate deterioration of the patient's condition two hours later? A. The patient is sleeping but awakens in response to painful stimuli. B. The patient does not remember what happened during the six hours prior to the injury. C. BP is 110/80 mm Hg, pulse is 78 beats/min, and respirations are 20 breaths/min. D. BP is 160/74 mm Hg, pulse is 53 beats/min, and respirations are 10 breaths/min.

D. BP is 160/74 mm Hg, pulse is 53 beats/min, and respirations are 10 breaths/min. Rationale: Late signs of increased intracranial pressure include an increased systolic BP and decreasing diastolic BP (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 BP of 110/80 mm Hg, pulse of 78 beats/min, and respirations of 20 breaths/min do not necessarily indicate deterioration in the patient's condition.

For which complication would the nurse monitor potential development while providing care for a patient with meningitis and ventricle adhesions that prevent the normal flow of cerebrospinal fluid? A. Cerebral abscess B. Acute cerebral edema C. Cranial nerve irritation D. Noncommunicating hydrocephalus

D. Noncommunicating hydrocephalus Rationale: Adhesions preventing the normal flow of cerebrospinal fluid lead to an obstruction of the foramen magnum, which causes noncommunicating hydrocephalus. Cerebral abscess is an accumulation of pus within the brain tissue. An acute cerebral edema is an abnormal increase in water content within the extracellular fluid of the brain. The condition occurs due to hydrocephalus. Cranial nerve irritation is caused by neurologic dysfunctions because of increased intracranial pressure.

Which characteristic would the nurse assess when performing a palmar drift (pronator drift) test during a neurologic assessment? A. Eye movements B. Pupillary reaction C. Strength of the legs D. Strength of the hands

D. Strength of the hands Rationale: A palmar or pronator 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. Test the patient's pupillary reactions with a penlight. Test strength by asking the patient to pull the knees up in bed.