NSG 2400 SINCLAIR COMMUNITY EXAM 2
ASSESSMENT SCRIPT 2026 VERIFIED
ANSWERS COMPREHENSIVE REVIEW
◉ ICP S/S.
Answer: -HA
-dizziness
-ataxia
-vomiting
-amnesia
-trouble with speech/formulating words & thoughts
-seizures
-changes in LOC leading to unconsciousness
-↓ motor function such as muscle weakness
-dysphagia
-incontinence
-pupillary changes (dilation of pupils that will result in fixed (non-
reactive) dilated pupils)
-posturing
◉ #1 Sign of Increased ICP.
,Answer: -Decrease in LOC!
◉ #1 killer for head injury pts..
Answer: -Increased ICP
◉ Vasodilation increases.
Answer: -Cerebral blood flow to brain = increased ICP!
◉ Decorticate Posturing.
Answer: -Arms are flexed in toward the spine. (toward core)
-Inward motion is individual's last-ditch effort to protect spinal cord
& brain function.
-Decorticate posturing = "Help me now!"
◉ Decerebrate posturing.
Answer: -Arms are extended & pronated out.
-Decerebrate posturing = "Goodbye. I'm close to death."
◉ Late sign of increased ICP.
Answer: Cushing's Triad
◉ Cushing's Triad.
,Answer: -↑ systolic BP (aka widened pulse pressure)
-↓ HR
-↓ RR
◉ Pediatric s/s of increased ICP.
Answer: -Bulging fontanelles
-separation of cranial sutures
-↑ head circumference measurement for infants < 18 months.
-Infants = shrill cry
◉ ICP nursing interventions.
Answer: -monitor neuro status (GCS)
-limit visitors
-quiet, cold dark room
-HoB elevated 30 degrees, don;t raise feet
-Position: neutral body alignment, no pillow under head
-Avoid compression while positioning for cerebral perfusion
pressure monitoring
-Dont cluster care!
-CT scans
-EEG monitoring
-Lumbar puncture
, ◉ If increased ICP pt. has a decline in status,.
Answer: -Perform neuro assessment (GCS)
-Call PROVIDER!
◉ Glasgow Coma Scale (GCS).
Answer: -3 components: eye opening, verbal response, & best motor
response.
-Normal: GCS = 15.
-Adults: GCS < 8 = a coma.
-Children: GCS < 5 = a coma
◉ 5 types of ICP monitors.
Answer: o Epidural
o Intraparenchymal
o Subarachnoid
o Subdural
o Ventricular
◉ Increased ICP: Goal 1.
Answer: -Keep ICP pressure < 20mm Hg!!!
ASSESSMENT SCRIPT 2026 VERIFIED
ANSWERS COMPREHENSIVE REVIEW
◉ ICP S/S.
Answer: -HA
-dizziness
-ataxia
-vomiting
-amnesia
-trouble with speech/formulating words & thoughts
-seizures
-changes in LOC leading to unconsciousness
-↓ motor function such as muscle weakness
-dysphagia
-incontinence
-pupillary changes (dilation of pupils that will result in fixed (non-
reactive) dilated pupils)
-posturing
◉ #1 Sign of Increased ICP.
,Answer: -Decrease in LOC!
◉ #1 killer for head injury pts..
Answer: -Increased ICP
◉ Vasodilation increases.
Answer: -Cerebral blood flow to brain = increased ICP!
◉ Decorticate Posturing.
Answer: -Arms are flexed in toward the spine. (toward core)
-Inward motion is individual's last-ditch effort to protect spinal cord
& brain function.
-Decorticate posturing = "Help me now!"
◉ Decerebrate posturing.
Answer: -Arms are extended & pronated out.
-Decerebrate posturing = "Goodbye. I'm close to death."
◉ Late sign of increased ICP.
Answer: Cushing's Triad
◉ Cushing's Triad.
,Answer: -↑ systolic BP (aka widened pulse pressure)
-↓ HR
-↓ RR
◉ Pediatric s/s of increased ICP.
Answer: -Bulging fontanelles
-separation of cranial sutures
-↑ head circumference measurement for infants < 18 months.
-Infants = shrill cry
◉ ICP nursing interventions.
Answer: -monitor neuro status (GCS)
-limit visitors
-quiet, cold dark room
-HoB elevated 30 degrees, don;t raise feet
-Position: neutral body alignment, no pillow under head
-Avoid compression while positioning for cerebral perfusion
pressure monitoring
-Dont cluster care!
-CT scans
-EEG monitoring
-Lumbar puncture
, ◉ If increased ICP pt. has a decline in status,.
Answer: -Perform neuro assessment (GCS)
-Call PROVIDER!
◉ Glasgow Coma Scale (GCS).
Answer: -3 components: eye opening, verbal response, & best motor
response.
-Normal: GCS = 15.
-Adults: GCS < 8 = a coma.
-Children: GCS < 5 = a coma
◉ 5 types of ICP monitors.
Answer: o Epidural
o Intraparenchymal
o Subarachnoid
o Subdural
o Ventricular
◉ Increased ICP: Goal 1.
Answer: -Keep ICP pressure < 20mm Hg!!!
