Esmeralda Espitia
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Adult health 2 test 2 Quiz am Intracranial pressure, erstellt von Esmeralda Espitia am 05/02/2020.

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Intracranial pressure

Frage 1 von 22

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1. Select the main structures below that play a role with altering intracranial pressure:

Wähle eine oder mehr der folgenden:

  • A. Brain

  • B. Neurons

  • C. Cerebrospinal Fluid

  • D. Blood

  • E. Periosteum

  • F. Dura mater

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Frage 2 von 22

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2. The Monro-Kellie hypothesis explains the compensatory relationship among the structures in the skull that play a role with intracranial pressure. Which of the following are NOT compensatory mechanisms performed by the body to decrease intracranial pressure naturally? Select all that apply:

Wähle eine oder mehr der folgenden:

  • A. Shifting cerebrospinal fluid to other areas of the brain and spinal cord

  • B. Vasodilation of cerebral vessels

  • C. Decreasing cerebrospinal fluid production

  • D. Leaking proteins into the brain barrier

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Frage 3 von 22

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

Wähle eine oder mehr der folgenden:

  • A. Coughing

  • B. Sneezing

  • C. Talking

  • D. Valsalva maneuver

  • E. Vomiting

  • F. Keeping the head of the bed between 30- 35 degrees

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Frage 4 von 22

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4. A patient is experiencing hyperventilation and has a PaCO2 level of 52. The patient has an ICP of 20 mmHg. As the nurse you know that the PaCO2 level will?

Wähle eine der folgenden:

  • A. cause vasoconstriction and decrease the ICP

  • B. promote diuresis and decrease the ICP

  • C. cause vasodilation and increase the ICP

  • D. cause vasodilation and decrease the ICP

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Frage 5 von 22

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5. You’re providing education to a group of nursing students about ICP. You explain that when cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies. A student asks, “What is a normal cerebral perfusion pressure level?” Your response is:

Wähle eine der folgenden:

  • A. 5-15 mmHg

  • B. 60-100 mmHg

  • C. 30-45 mmHg

  • D. >160 mmHg

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Frage 6 von 22

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6. Which patient below is at MOST risk for increased intracranial pressure?

Wähle eine der folgenden:

  • A. A patient who is experiencing severe hypotension.

  • B. A patient who is admitted with a traumatic brain injury.

  • C. A patient who recently experienced a myocardial infarction.

  • D. A patient post-op from eye surgery.

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Frage 7 von 22

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7. 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 findings you would?

Wähle eine der folgenden:

  • A. Administered PRN dose of a vasopressor

  • B. Administer 2 L of oxygen

  • C. Remove extra blankets and give the patient a cool bath

  • D. Perform suctioning

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Frage 8 von 22

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8. A patient has a ventriculostomy. Which finding would you immediately report to the doctor?

Wähle eine der folgenden:

  • A. Temperature 98.4 ‘F

  • B. CPP 70 mmHg

  • C. ICP 24 mmHg

  • D. PaCO2 35

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Frage 9 von 22

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9. External ventricular drains monitor ICP and are inserted where?

Wähle eine der folgenden:

  • A. Subarachnoid space

  • B. Lateral Ventricle

  • C. Epidural space

  • D. Right Ventricle

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Frage 10 von 22

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10. Which of the following is contraindicated in a patient with increased ICP?

Wähle eine der folgenden:

  • A. Lumbar puncture

  • B. Midline position of the head

  • C. Hyperosmotic diuretics

  • D. Barbiturates medications

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Frage 11 von 22

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11. You’re collecting vital signs on a patient with ICP. The patient has a Glascoma Scale rating of 4. How will you assess the patient’s temperature?

Wähle eine der folgenden:

  • A. Rectal

  • B. Oral

  • C. Axillary

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Frage 12 von 22

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12. A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication?

Wähle eine der folgenden:

  • A. Bradycardia

  • B. Decerebrate posturing

  • C. Restlessness

  • D. Unequal pupil size

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Frage 13 von 22

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13. Select all the signs and symptoms that occur with increased ICP:

Wähle eine oder mehr der folgenden:

  • A. Decorticate posturing

  • B. Tachycardia

  • C. Decrease in pulse pressure

  • D. Cheyne-stokes

  • E. Hemiplegia

  • F. Decerebrate posturing

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Frage 14 von 22

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14. You’re maintaining an external ventricular drain. The ICP readings should be?

Wähle eine der folgenden:

  • A. 5 to 15 mmHg

  • B. 20 to 35 mmHg

  • C. 60 to 100 mmHg

  • D. 5 to 25 mmHg

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Frage 15 von 22

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15. Which patient below with ICP is experiencing Cushing’s Triad? A patient with the following:

Wähle eine der folgenden:

  • A. BP 150/112, HR 110, RR 8

  • B. BP 90/60, HR 80, RR 22

  • C. BP 200/60, HR 50, RR 8

  • D. BP 80/40, HR 49, RR 12

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Frage 16 von 22

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16. The patient has a blood pressure of 130/88 and ICP reading of 12. What is the patient’s cerebral perfusion pressure, and how do you interpret this as the nurse?

Wähle eine der folgenden:

  • A. 90 mmHg, normal

  • B. 62 mmHg, abnormal

  • C. 36 mmHg, abnormal

  • D. 56 mmHg, normal

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Frage 17 von 22

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17. According to question 16, the patient’s blood pressure is 130/88. What is the patient’s mean arterial pressure (MAP)?

Wähle eine der folgenden:

  • A. 42

  • B. 74

  • C. 102

  • D. 88

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Frage 18 von 22

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18. During the assessment of a patient with increased ICP, you note that the patient’s arms are extended straight out and toes pointed downward. You will document this as:

Wähle eine der folgenden:

  • A. Decorticate posturing

  • B. Decerebrate posturing

  • C. Flaccid posturing

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Frage 19 von 22

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19. While positioning a patient in bed with increased ICP, it important to avoid?

Wähle eine der folgenden:

  • A. Midline positioning of the head

  • B. Placing the HOB at 30-35 degrees

  • C. Preventing flexion of the neck

  • D. Flexion of the hips

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Frage 20 von 22

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20. During the eye assessment of a patient with increased ICP, you need to assess the oculocephalic reflex. If the patient has brain stem damage what response will you find?

Wähle eine der folgenden:

  • A. The eyes will move in the same direction as the head is moved side to side.

  • B. The eyes will move in the opposite direction as the head is moved side to side.

  • C. The eyes will roll back as the head is moved side to side.

  • D. The eyes will be in a fixed position as the head is moved side to side.

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Frage 21 von 22

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21. A patient is receiving Mannitol for increased ICP. Which statement is INCORRECT about this medication?

Wähle eine der folgenden:

  • A. Mannitol will remove water from the brain and place it in the blood to be removed from the body.

  • B. Mannitol will cause water and electrolyte reabsorption in the renal tubules.

  • C. When a patient receives Mannitol the nurse must monitor the patient for both fluid volume overload and depletion.

  • D. Mannitol is not for patients who are experiencing anuria.

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Frage 22 von 22

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22. What assessment finding requires immediate intervention if found while a patient is receiving Mannitol?

Wähle eine der folgenden:

  • A. An ICP of 10 mmHg

  • B. Crackles throughout lung fields

  • C. BP 110/72

  • D. Patient complains of dry mouth and thirst

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