Question 1

A nurse is caring for a client who has a closed traumatic brain injury and is experiencing increased intracranial pressure (ICP). This increase in ICP is due to which of the following?

Accepted Answer

Rigid skull containing cranial contents - The nurse should identify that the client's rigid skull prevents expansion. An increase in edema and bleeding from the head injury against the rigid skull results in an increase in ICP

Question 2

A client with a closed head injury who has received mannitol for manifestations of increased ICP. Which of the following findings indicates that the medication is having a therapeutic effect?

Accepted Answer

The client’s serum osmolality is 310 osm/L - Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. A serum osmolarity of 310 mOsm/L is desired. A decrease in cerebral edema should result in a decrease in ICP.

Question 3

A nurse is caring for a client who experienced a traumatic brain injury. Which of the following findings indicates the client is experiencing increased intracranial pressure?

Accepted Answer

Dilated pupils - Dilated pupils can indicate that intracranial pressure is increasing. This finding should be reported to the provider immediately.

Question 4

A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these finding

Accepted Answer

Remove extra blankets and give the patient a cool bath -  It is important to monitor the patient for hyperthermia (a fever). A fever increases ICP and cerebral blood volume, and metabolic needs of the patient. The nurse can administer antipyretics per MD order, remove extra blankets, decrease room temperature, give a cool bath or use a cooling system. Remember it is important to prevent shivering (this also increases metabolic needs and ICP)

Question 5

Which patient below with ICP is experiencing Cushing's Triad? A patient with the following:

Accepted Answer

BP 200/60, HR 50, RR 8 -  These vital signs represent Cushing's triad. There is an increase in the systolic pressure, widening pulse pressure of 140 (200-60=140), bradycardia, and bradypnea.

Question 6

Which is the earliest sign of increasing intracranial pressure?

Accepted Answer

Change in level of consciousness - The earliest sign of increasing intracranial pressure (ICP) is a change in level of consciousness. Other manifestations of increasing ICP are vomiting, headache, and posturing.

Question 7

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?

Accepted Answer

Shrivering - Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption. A capillary refill of 2 seconds, urine output of 100mL/hr, and cool, dry skin are expected findings.

Question 8

Which positions are used to help reduce intracranial pressure (ICP)?

Accepted Answer

Avoiding flexion of the neck with use of a cervical collar - se of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.

Question 9

Which is a late sign of increased intracranial pressure (ICP)?

Accepted Answer

Altered respiratory patterns - Altered respiratory patterns are late signs of increased ICP and may indicate pressure or damage to the brainstem. Headache, irritability, and any change in LOC are early signs of increased ICP. Speech changes, such as slowed speech or slurring, are also early signs of increased ICP

Question 10

A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing? SATA

Accepted Answer

Coughing , Sneezing , Valsalva Maneuver  - *Coughing, sneezing, talking, and valsalva manuver can increase intracranial pressure

Question 11

What nursing intervention should be implemented in the care of a patient who is experiencing increased ICP?

Accepted Answer

Monitor fluid and electrolyte status carefully. - Fluid and electrolyte disturbances can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically administered in the treatment of ICP.

Question 12

A client who sustained a head injury has an intracranial pressure (ICP) monitor reading of 12 mm Hg. Which action should the nurse take?

Accepted Answer

patency of of airway - *Maslow's hierarchy of needs (airway, breathing, and circulation)---hypoxia can increase ICP

Question 13

A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema. What is an appropriate nursing intervention for the patient?

Accepted Answer

Avoid positioning the patient with neck and hip flexion - *Hip and neck flexion stops drainage. Elevate the HOB at least 30-45 degrees to reduce ICP & promote venous drainage

Question 14

A client has a closed head injury with ICP readings ranging from 16-22 mm hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP SATA

Accepted Answer

decrease noise level in client's room , administer stool softener  - *Decreasing the noise level and restriciting the number of people in the client's room can help prevent increases in ICP, administration of stool softener will decrease need to bear down during bowel mcvements (valsalva maneuver) which can increase ICP

Question 15

A nurse in critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessments are indicative of increased ICP?

Accepted Answer

headache, decorticate posturing , dilated pupils  - *headache, decorticate posturing, and dilated pupils are all expected findings of increased ICP

Question 16

A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to

Accepted Answer

Blood pressure 156/60, pulse 55, respirations 12 - Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the intracranial pressure (ICP) has increased

Question 17

While the nurse performs ROM on an unconscious patient with increased ICP, the patient experiences severe decerebrate posturing reflexes. What should the nurse do FIRST?

Accepted Answer

perform the exercises less frequently because posturing can increase ICP - *Perform exercises ess frequently because posturing can increase ICP

Question 18

A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor?

Accepted Answer

hyponatremia

Question 19

A nurse is caring for a client who had just been admitted following surgical evacuation of subdural hematoma. Which of the following is a priority assessment?

Accepted Answer

oxygen saturation  - *Use airway, breathing, circulation priority setting framework. Brain tissue can only survive 3 minutes before permenant damage occurs.

Question 20

Which intervention should the nurse initiate secondary to a change in the level of consciousness​ (LOC) for a client experiencing increased intracranial pressure​ (IICP)?  SATA

Accepted Answer

Assess​ LOC, pupillary​ response, and neurologic status., Maintain the head of the bed at 30 degrees., Implement deep vein thrombosis prophylaxis., Monitor​ ICP/cerebral perfusion pressure​ (CCP) as indicated. - A client with IICP requires an environment with reduced stimulation to help keep the pressure​ lowered; therefore, encouraging family to keep the client engaged in normal activities can worsen the​ client's condition.

Intracranial Pressure Trivia

2) A client with a closed head injury who has received mannitol for manifestations of increased ICP. Which of the following findings indicates that the medication is having a therapeutic effect?

3) A nurse is caring for a client who experienced a traumatic brain injury. Which of the following findings indicates the client is experiencing increased intracranial pressure?

4) A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these finding

5) Which patient below with ICP is experiencing Cushing's Triad? A patient with the following:

6) Which is the earliest sign of increasing intracranial pressure?

7) A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?

8) Which positions are used to help reduce intracranial pressure (ICP)?

9) Which is a late sign of increased intracranial pressure (ICP)?

10) A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing? SATA

11) What nursing intervention should be implemented in the care of a patient who is experiencing increased ICP?

12) A client who sustained a head injury has an intracranial pressure (ICP) monitor reading of 12 mm Hg. Which action should the nurse take?

13) A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema. What is an appropriate nursing intervention for the patient?

14) A client has a closed head injury with ICP readings ranging from 16-22 mm hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP SATA

15) A nurse in critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessments are indicative of increased ICP?

16) A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to

17) While the nurse performs ROM on an unconscious patient with increased ICP, the patient experiences severe decerebrate posturing reflexes. What should the nurse do FIRST?

18) A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor?

19) A nurse is caring for a client who had just been admitted following surgical evacuation of subdural hematoma. Which of the following is a priority assessment?

20) Which intervention should the nurse initiate secondary to a change in the level of consciousness​ (LOC) for a client experiencing increased intracranial pressure​ (IICP)? SATA