Intracranial pressure

Descrição

Adult health 2 test 2 Quiz sobre Intracranial pressure, criado por Esmeralda Espitia em 05-02-2020.
Esmeralda Espitia
Quiz por Esmeralda Espitia, atualizado more than 1 year ago
Esmeralda Espitia
Criado por Esmeralda Espitia quase 5 anos atrás
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Resumo de Recurso

Questão 1

Questão
1. Select the main structures below that play a role with altering intracranial pressure:
Responda
  • A. Brain
  • B. Neurons
  • C. Cerebrospinal Fluid
  • D. Blood
  • E. Periosteum
  • F. Dura mater

Questão 2

Questão
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:
Responda
  • 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

Questão 3

Questão
3. A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing?
Responda
  • A. Coughing
  • B. Sneezing
  • C. Talking
  • D. Valsalva maneuver
  • E. Vomiting
  • F. Keeping the head of the bed between 30- 35 degrees

Questão 4

Questão
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?
Responda
  • 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

Questão 5

Questão
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:
Responda
  • A. 5-15 mmHg
  • B. 60-100 mmHg
  • C. 30-45 mmHg
  • D. >160 mmHg

Questão 6

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

Questão 7

Questão
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?
Responda
  • 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

Questão 8

Questão
8. A patient has a ventriculostomy. Which finding would you immediately report to the doctor?
Responda
  • A. Temperature 98.4 ‘F
  • B. CPP 70 mmHg
  • C. ICP 24 mmHg
  • D. PaCO2 35

Questão 9

Questão
9. External ventricular drains monitor ICP and are inserted where?
Responda
  • A. Subarachnoid space
  • B. Lateral Ventricle
  • C. Epidural space
  • D. Right Ventricle

Questão 10

Questão
10. Which of the following is contraindicated in a patient with increased ICP?
Responda
  • A. Lumbar puncture
  • B. Midline position of the head
  • C. Hyperosmotic diuretics
  • D. Barbiturates medications

Questão 11

Questão
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?
Responda
  • A. Rectal
  • B. Oral
  • C. Axillary

Questão 12

Questão
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?
Responda
  • A. Bradycardia
  • B. Decerebrate posturing
  • C. Restlessness
  • D. Unequal pupil size

Questão 13

Questão
13. Select all the signs and symptoms that occur with increased ICP:
Responda
  • A. Decorticate posturing
  • B. Tachycardia
  • C. Decrease in pulse pressure
  • D. Cheyne-stokes
  • E. Hemiplegia
  • F. Decerebrate posturing

Questão 14

Questão
14. You’re maintaining an external ventricular drain. The ICP readings should be?
Responda
  • A. 5 to 15 mmHg
  • B. 20 to 35 mmHg
  • C. 60 to 100 mmHg
  • D. 5 to 25 mmHg

Questão 15

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

Questão 16

Questão
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?
Responda
  • A. 90 mmHg, normal
  • B. 62 mmHg, abnormal
  • C. 36 mmHg, abnormal
  • D. 56 mmHg, normal

Questão 17

Questão
17. According to question 16, the patient’s blood pressure is 130/88. What is the patient’s mean arterial pressure (MAP)?
Responda
  • A. 42
  • B. 74
  • C. 102
  • D. 88

Questão 18

Questão
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:
Responda
  • A. Decorticate posturing
  • B. Decerebrate posturing
  • C. Flaccid posturing

Questão 19

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

Questão 20

Questão
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?
Responda
  • 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.

Questão 21

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

Questão 22

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