Frage 1
Frage
1. Select the main structures below that play a role with altering intracranial pressure:
Antworten
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A. Brain
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B. Neurons
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C. Cerebrospinal Fluid
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D. Blood
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E. Periosteum
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F. Dura mater
Frage 2
Frage
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:
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A. Shifting cerebrospinal fluid to other areas of the brain and spinal cord
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B. Vasodilation of cerebral vessels
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C. Decreasing cerebrospinal fluid production
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D. Leaking proteins into the brain barrier
Frage 3
Frage
3. A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing?
Frage 4
Frage
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?
Antworten
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A. cause vasoconstriction and decrease the ICP
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B. promote diuresis and decrease the ICP
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C. cause vasodilation and increase the ICP
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D. cause vasodilation and decrease the ICP
Frage 5
Frage
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:
Antworten
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A. 5-15 mmHg
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B. 60-100 mmHg
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C. 30-45 mmHg
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D. >160 mmHg
Frage 6
Frage
6. Which patient below is at MOST risk for increased intracranial pressure?
Antworten
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A. A patient who is experiencing severe hypotension.
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B. A patient who is admitted with a traumatic brain injury.
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C. A patient who recently experienced a myocardial infarction.
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D. A patient post-op from eye surgery.
Frage 7
Frage
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?
Antworten
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A. Administered PRN dose of a vasopressor
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B. Administer 2 L of oxygen
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C. Remove extra blankets and give the patient a cool bath
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D. Perform suctioning
Frage 8
Frage
8. A patient has a ventriculostomy. Which finding would you immediately report to the doctor?
Antworten
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A. Temperature 98.4 ‘F
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B. CPP 70 mmHg
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C. ICP 24 mmHg
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D. PaCO2 35
Frage 9
Frage
9. External ventricular drains monitor ICP and are inserted where?
Antworten
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A. Subarachnoid space
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B. Lateral Ventricle
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C. Epidural space
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D. Right Ventricle
Frage 10
Frage
10. Which of the following is contraindicated in a patient with increased ICP?
Antworten
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A. Lumbar puncture
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B. Midline position of the head
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C. Hyperosmotic diuretics
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D. Barbiturates medications
Frage 11
Frage
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?
Antworten
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A. Rectal
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B. Oral
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C. Axillary
Frage 12
Frage
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?
Antworten
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A. Bradycardia
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B. Decerebrate posturing
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C. Restlessness
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D. Unequal pupil size
Frage 13
Frage
13. Select all the signs and symptoms that occur with increased ICP:
Frage 14
Frage
14. You’re maintaining an external ventricular drain. The ICP readings should be?
Antworten
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A. 5 to 15 mmHg
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B. 20 to 35 mmHg
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C. 60 to 100 mmHg
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D. 5 to 25 mmHg
Frage 15
Frage
15. Which patient below with ICP is experiencing Cushing’s Triad? A patient with the following:
Antworten
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A. BP 150/112, HR 110, RR 8
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B. BP 90/60, HR 80, RR 22
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C. BP 200/60, HR 50, RR 8
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D. BP 80/40, HR 49, RR 12
Frage 16
Frage
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?
Antworten
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A. 90 mmHg, normal
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B. 62 mmHg, abnormal
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C. 36 mmHg, abnormal
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D. 56 mmHg, normal
Frage 17
Frage
17. According to question 16, the patient’s blood pressure is 130/88. What is the patient’s mean arterial pressure (MAP)?
Frage 18
Frage
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:
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A. Decorticate posturing
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B. Decerebrate posturing
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C. Flaccid posturing
Frage 19
Frage
19. While positioning a patient in bed with increased ICP, it important to avoid?
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A. Midline positioning of the head
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B. Placing the HOB at 30-35 degrees
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C. Preventing flexion of the neck
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D. Flexion of the hips
Frage 20
Frage
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?
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A. The eyes will move in the same direction as the head is moved side to side.
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B. The eyes will move in the opposite direction as the head is moved side to side.
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C. The eyes will roll back as the head is moved side to side.
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D. The eyes will be in a fixed position as the head is moved side to side.
Frage 21
Frage
21. A patient is receiving Mannitol for increased ICP. Which statement is INCORRECT about this medication?
Antworten
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A. Mannitol will remove water from the brain and place it in the blood to be removed from the body.
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B. Mannitol will cause water and electrolyte reabsorption in the renal tubules.
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C. When a patient receives Mannitol the nurse must monitor the patient for both fluid volume overload and depletion.
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D. Mannitol is not for patients who are experiencing anuria.
Frage 22
Frage
22. What assessment finding requires immediate intervention if found while a patient is receiving Mannitol?