NURS 2400 Exam #2 Questions with Verified Answers
Graded A+
(Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions)
NCLEX Questions) A patient is experiencing hyperventilation and has a PaCO2
Select the main structures below that play a role with altering level of 52. The patient has an ICP of 20 mmHg. As the nurse
intracranial pressure: you know that the PaCO2 level will?
A. Brain A. cause vasoconstriction and decrease the ICP
B. Neurons B. promote diuresis and decrease the ICP
C. Cerebrospinal Fluid C. cause vasodilation and increase the ICP
D. Blood D. cause vasodilation and decrease the ICP - ANSWER -C
E. Periosteum
F. Dura mater - ANSWER -A, C and D (Registered Nurse RN Increased Intracranial Pressure (ICP)
NCLEX Questions)
You're providing education to a group of nursing students about
ICP. You explain that when cerebral perfusion pressure falls too
(Registered Nurse RN Increased Intracranial Pressure (ICP) low the brain is not properly perfused and brain tissue dies. A
NCLEX Questions) student asks, "What is a normal cerebral perfusion pressure
The Monro-Kellie hypothesis explains the compensatory level?" Your response is:
relationship among the structures in the skull that play a role
with intracranial pressure. Which of the following are NOT A. 5-15 mmHg
compensatory mechanisms performed by the body to decrease
intracranial pressure naturally? Select all that apply: B. 60-100 mmHg
A. Shifting cerebrospinal fluid to other areas of the brain and C. 30-45 mmHg
spinal cord
D. >160 mmHg - ANSWER -B
B. Vasodilation of cerebral vessels
C. Decreasing cerebrospinal fluid production
(Registered Nurse RN Increased Intracranial Pressure (ICP)
D. Leaking proteins into the brain barrier - ANSWER -B NCLEX Questions)
and D Which patient below is at MOST risk for increased intracranial
pressure?
A. A patient who is experiencing severe hypotension.
(Registered Nurse RN Increased Intracranial Pressure (ICP)
NCLEX Questions) B. A patient who is admitted with a traumatic brain injury.
A patient is being treated for increased intracranial pressure.
Which activities below should the patient avoid performing? C. A patient who recently experienced a myocardial infarction.
A. Coughing D. A patient post-op from eye surgery. - ANSWER -B
B. Sneezing
C. Talking (Registered Nurse RN Increased Intracranial Pressure (ICP)
NCLEX Questions)
D. Valsalva maneuver A patient with increased ICP has the following vital signs: blood
pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14,
E. Vomiting oxygen saturation of 95%. ICP reading is 21 mmHg. Based on
these findings you would?
F. Keeping the head of the bed between 30- 35 degrees -
ANSWER -A, B, D and E A. Administered PRN dose of a vasopressor
B. Administer 2 L of oxygen
(Registered Nurse RN Increased Intracranial Pressure (ICP) C. Remove extra blankets and give the patient a cool bath
, NURS 2400 Exam #2 Questions with Verified Answers
Graded A+
C. Axillary - ANSWER -A
D. Perform suctioning - ANSWER -C
(Registered Nurse RN Increased Intracranial Pressure (ICP)
(Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions)
NCLEX Questions) A patient who experienced a cerebral hemorrhage is at risk for
A patient has a ventriculostomy. Which finding would you developing increased ICP. Which sign and symptom below is
immediately report to the doctor? the EARLIEST indicator the patient is having this complication?
A. Temperature 98.4 'F A. Bradycardia
B. CPP 70 mmHg B. Decerebrate posturing
C. ICP 24 mmHg C. Restlessness
D. PaCO2 35 - ANSWER -C D. Unequal pupil size - ANSWER -C
(Registered Nurse RN Increased Intracranial Pressure (ICP) (Registered Nurse RN Increased Intracranial Pressure (ICP)
NCLEX Questions) NCLEX Questions)
External ventricular drains monitor ICP and are inserted where? Select all the signs and symptoms that occur with increased
ICP:
A. Subarachnoid space
A. Decorticate posturing
B. Lateral Ventricle
B. Tachycardia
C. Epidural space
C. Decrease in pulse pressure
D. Right Ventricle - ANSWER -B
D. Cheyne-stokes
E. Hemiplegia
(Registered Nurse RN Increased Intracranial Pressure (ICP)
NCLEX Questions) F. Decerebrate posturing - ANSWER -A, D, E and F
Which of the following is contraindicated in a patient with
increased ICP?
A. Lumbar puncture (Registered Nurse RN Increased Intracranial Pressure (ICP)
NCLEX Questions)
B. Midline position of the head You're maintaining an external ventricular drain. The ICP
readings should be?
C. Hyperosmotic diuretics
A. 5 to 15 mmHg
D. Barbiturates medications - ANSWER -A
B. 20 to 35 mmHg
C. 60 to 100 mmHg
(Registered Nurse RN Increased Intracranial Pressure (ICP)
NCLEX Questions) D. 5 to 25 mmHg - ANSWER -A
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?
(Registered Nurse RN Increased Intracranial Pressure (ICP)
A. Rectal NCLEX Questions)
Which patient below with ICP is experiencing Cushing's Triad? A
B. Oral patient with the following:
A. BP 150/112, HR 110, RR 8
, NURS 2400 Exam #2 Questions with Verified Answers
Graded A+
statement is INCORRECT about this medication?
B. BP 90/60, HR 80, RR 22
A. Mannitol will remove water from the brain and place it in the
C. BP 200/60, HR 50, RR 8 blood to be removed from the body.
D. BP 80/40, HR 49, RR 12 - ANSWER -C B. Mannitol will cause water and electrolyte reabsorption in the
renal tubules.
C. When a patient receives Mannitol the nurse must monitor the
(Registered Nurse RN Increased Intracranial Pressure (ICP) patient for both fluid volume overload and depletion.
NCLEX Questions)
During the assessment of a patient with increased ICP, you D. Mannitol is not for patients who are experiencing anuria. -
note that the patient's arms are extended straight out and toes ANSWER -B
pointed downward. You will document this as:
A. Decorticate posturing
(Registered Nurse RN Increased Intracranial Pressure (ICP)
B. Decerebrate posturing NCLEX Questions)
What assessment finding requires immediate intervention if
C. Flaccid posturing - ANSWER -B found while a patient is receiving Mannitol?
A. An ICP of 10 mmHg
(Registered Nurse RN Increased Intracranial Pressure (ICP)
NCLEX Questions) B. Crackles throughout lung fields
While positioning a patient in bed with increased ICP, it
important to avoid? C. BP 110/72
A. Midline positioning of the head D. Patient complains of dry mouth and thirst - ANSWER -B
B. Placing the HOB at 30-35 degrees
C. Preventing flexion of the neck As the nurse monitors the client who has suffered from a car
accident with trauma to the head, they note that Cushing's triad
D. Flexion of the hips - ANSWER -D includes changes in mental status and vital signs. These include
all of the following except:
A. Bradycardia
B. Hypertension
(Registered Nurse RN Increased Intracranial Pressure (ICP) C. Tachycardia
NCLEX Questions) D.Irregular respirations
During the eye assessment of a patient with increased ICP, you
need to assess the oculocephalic reflex. If the patient has brain Here is the link to the rationals *Start at 8:05*
stem damage what response will you find? https://www.youtube.com/watch?v=B0QOW-
HadUk&feature=youtu.be&t=1m28s - ANSWER -C
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 In reviewing the new medication orders of a client w/ cerebral
moved side to side. edema, who is comatose, which of the following medications
should the nurse clarify with the prescribing physician?
C. The eyes will roll back as the head is moved side to side.
A. Mannitol (Osmitrol) 20% 100cc IV q4
D. The eyes will be in a fixed position as the head is moved side
to side. - ANSWER -D B. Bexamethasone (Decadron) 2mg IV bid
C. Phenytoin Na (Dilantin) 100 mg IV PRN
(Registered Nurse RN Increased Intracranial Pressure (ICP) D. meperidine HCL (Demerol) 25 mg IV Q6H prn
NCLEX Questions)
A patient is receiving Mannitol for increased ICP. Which Here is the link to the rationals *Start at 8:50*
Graded A+
(Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions)
NCLEX Questions) A patient is experiencing hyperventilation and has a PaCO2
Select the main structures below that play a role with altering level of 52. The patient has an ICP of 20 mmHg. As the nurse
intracranial pressure: you know that the PaCO2 level will?
A. Brain A. cause vasoconstriction and decrease the ICP
B. Neurons B. promote diuresis and decrease the ICP
C. Cerebrospinal Fluid C. cause vasodilation and increase the ICP
D. Blood D. cause vasodilation and decrease the ICP - ANSWER -C
E. Periosteum
F. Dura mater - ANSWER -A, C and D (Registered Nurse RN Increased Intracranial Pressure (ICP)
NCLEX Questions)
You're providing education to a group of nursing students about
ICP. You explain that when cerebral perfusion pressure falls too
(Registered Nurse RN Increased Intracranial Pressure (ICP) low the brain is not properly perfused and brain tissue dies. A
NCLEX Questions) student asks, "What is a normal cerebral perfusion pressure
The Monro-Kellie hypothesis explains the compensatory level?" Your response is:
relationship among the structures in the skull that play a role
with intracranial pressure. Which of the following are NOT A. 5-15 mmHg
compensatory mechanisms performed by the body to decrease
intracranial pressure naturally? Select all that apply: B. 60-100 mmHg
A. Shifting cerebrospinal fluid to other areas of the brain and C. 30-45 mmHg
spinal cord
D. >160 mmHg - ANSWER -B
B. Vasodilation of cerebral vessels
C. Decreasing cerebrospinal fluid production
(Registered Nurse RN Increased Intracranial Pressure (ICP)
D. Leaking proteins into the brain barrier - ANSWER -B NCLEX Questions)
and D Which patient below is at MOST risk for increased intracranial
pressure?
A. A patient who is experiencing severe hypotension.
(Registered Nurse RN Increased Intracranial Pressure (ICP)
NCLEX Questions) B. A patient who is admitted with a traumatic brain injury.
A patient is being treated for increased intracranial pressure.
Which activities below should the patient avoid performing? C. A patient who recently experienced a myocardial infarction.
A. Coughing D. A patient post-op from eye surgery. - ANSWER -B
B. Sneezing
C. Talking (Registered Nurse RN Increased Intracranial Pressure (ICP)
NCLEX Questions)
D. Valsalva maneuver A patient with increased ICP has the following vital signs: blood
pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14,
E. Vomiting oxygen saturation of 95%. ICP reading is 21 mmHg. Based on
these findings you would?
F. Keeping the head of the bed between 30- 35 degrees -
ANSWER -A, B, D and E A. Administered PRN dose of a vasopressor
B. Administer 2 L of oxygen
(Registered Nurse RN Increased Intracranial Pressure (ICP) C. Remove extra blankets and give the patient a cool bath
, NURS 2400 Exam #2 Questions with Verified Answers
Graded A+
C. Axillary - ANSWER -A
D. Perform suctioning - ANSWER -C
(Registered Nurse RN Increased Intracranial Pressure (ICP)
(Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions)
NCLEX Questions) A patient who experienced a cerebral hemorrhage is at risk for
A patient has a ventriculostomy. Which finding would you developing increased ICP. Which sign and symptom below is
immediately report to the doctor? the EARLIEST indicator the patient is having this complication?
A. Temperature 98.4 'F A. Bradycardia
B. CPP 70 mmHg B. Decerebrate posturing
C. ICP 24 mmHg C. Restlessness
D. PaCO2 35 - ANSWER -C D. Unequal pupil size - ANSWER -C
(Registered Nurse RN Increased Intracranial Pressure (ICP) (Registered Nurse RN Increased Intracranial Pressure (ICP)
NCLEX Questions) NCLEX Questions)
External ventricular drains monitor ICP and are inserted where? Select all the signs and symptoms that occur with increased
ICP:
A. Subarachnoid space
A. Decorticate posturing
B. Lateral Ventricle
B. Tachycardia
C. Epidural space
C. Decrease in pulse pressure
D. Right Ventricle - ANSWER -B
D. Cheyne-stokes
E. Hemiplegia
(Registered Nurse RN Increased Intracranial Pressure (ICP)
NCLEX Questions) F. Decerebrate posturing - ANSWER -A, D, E and F
Which of the following is contraindicated in a patient with
increased ICP?
A. Lumbar puncture (Registered Nurse RN Increased Intracranial Pressure (ICP)
NCLEX Questions)
B. Midline position of the head You're maintaining an external ventricular drain. The ICP
readings should be?
C. Hyperosmotic diuretics
A. 5 to 15 mmHg
D. Barbiturates medications - ANSWER -A
B. 20 to 35 mmHg
C. 60 to 100 mmHg
(Registered Nurse RN Increased Intracranial Pressure (ICP)
NCLEX Questions) D. 5 to 25 mmHg - ANSWER -A
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?
(Registered Nurse RN Increased Intracranial Pressure (ICP)
A. Rectal NCLEX Questions)
Which patient below with ICP is experiencing Cushing's Triad? A
B. Oral patient with the following:
A. BP 150/112, HR 110, RR 8
, NURS 2400 Exam #2 Questions with Verified Answers
Graded A+
statement is INCORRECT about this medication?
B. BP 90/60, HR 80, RR 22
A. Mannitol will remove water from the brain and place it in the
C. BP 200/60, HR 50, RR 8 blood to be removed from the body.
D. BP 80/40, HR 49, RR 12 - ANSWER -C B. Mannitol will cause water and electrolyte reabsorption in the
renal tubules.
C. When a patient receives Mannitol the nurse must monitor the
(Registered Nurse RN Increased Intracranial Pressure (ICP) patient for both fluid volume overload and depletion.
NCLEX Questions)
During the assessment of a patient with increased ICP, you D. Mannitol is not for patients who are experiencing anuria. -
note that the patient's arms are extended straight out and toes ANSWER -B
pointed downward. You will document this as:
A. Decorticate posturing
(Registered Nurse RN Increased Intracranial Pressure (ICP)
B. Decerebrate posturing NCLEX Questions)
What assessment finding requires immediate intervention if
C. Flaccid posturing - ANSWER -B found while a patient is receiving Mannitol?
A. An ICP of 10 mmHg
(Registered Nurse RN Increased Intracranial Pressure (ICP)
NCLEX Questions) B. Crackles throughout lung fields
While positioning a patient in bed with increased ICP, it
important to avoid? C. BP 110/72
A. Midline positioning of the head D. Patient complains of dry mouth and thirst - ANSWER -B
B. Placing the HOB at 30-35 degrees
C. Preventing flexion of the neck As the nurse monitors the client who has suffered from a car
accident with trauma to the head, they note that Cushing's triad
D. Flexion of the hips - ANSWER -D includes changes in mental status and vital signs. These include
all of the following except:
A. Bradycardia
B. Hypertension
(Registered Nurse RN Increased Intracranial Pressure (ICP) C. Tachycardia
NCLEX Questions) D.Irregular respirations
During the eye assessment of a patient with increased ICP, you
need to assess the oculocephalic reflex. If the patient has brain Here is the link to the rationals *Start at 8:05*
stem damage what response will you find? https://www.youtube.com/watch?v=B0QOW-
HadUk&feature=youtu.be&t=1m28s - ANSWER -C
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 In reviewing the new medication orders of a client w/ cerebral
moved side to side. edema, who is comatose, which of the following medications
should the nurse clarify with the prescribing physician?
C. The eyes will roll back as the head is moved side to side.
A. Mannitol (Osmitrol) 20% 100cc IV q4
D. The eyes will be in a fixed position as the head is moved side
to side. - ANSWER -D B. Bexamethasone (Decadron) 2mg IV bid
C. Phenytoin Na (Dilantin) 100 mg IV PRN
(Registered Nurse RN Increased Intracranial Pressure (ICP) D. meperidine HCL (Demerol) 25 mg IV Q6H prn
NCLEX Questions)
A patient is receiving Mannitol for increased ICP. Which Here is the link to the rationals *Start at 8:50*
