NURSING CARE ALTERED
INTRACRANIAL REGULATION
LATEST UPDATE VERIFIED
QUESTIONS & DETAILED
EXPLANATIONS GRADED A+
Professional Academic Assistance Services
Cranial Nerve Assessment
How should the nurse assess the client's cranial nerve V
(trigeminal)?
Ask the client to say "ah" and observe the upward movement of
the soft palate.
Ask the client to open mouth against resistance.
Ask the client to shrug shoulders against resistance.
Ask the client to smile, raise eyebrows, and puff out cheeks. -
Answer: To assess cranial nerve V, ask the client to open mouth
against resistance.
To assess cranial VII, ask the client to smile, raise eyebrows, and
puff out cheeks.
To assess cranial nerve IX, ask the client to say "ah" and observe
the upward movement of the soft palate.
To assess cranial nerve XI, ask the client to shrug shoulders
,against resistance.
Nursing Management
The client is admitted due to altered intracranial regulation. The
client has cranial nerve IX and X dysfunction. What should the
nurse do first?
Assist the client to ambulate in the bedside commode.
Intubate the client immediately and give oxygen.
Withhold oral fluids and food immediately.
Apply antibiotic eye ointment every 4 hours. - Answer: If the
client has cranial nerve IX (glossopharyngeal) and X (vagus)
dysfunction, this means that the gag and swallowing reflexes of
the client is compromised. Therefore, withholding the oral fluids
and food are very important to promote client safety. Applying
antibiotic eye ointment is not applicable based on the case
scenario. Assist the client to ambulate is important to but not
directly related to cranial nerves IX and X. Intubate the client
and giving oxygen are not necessary yet until the client had
trouble of breathing.
Nursing Process
The client had a positive Romberg test. What is the priority
nursing diagnosis?
,Powerlessness
Risk for fall
Impaired breathing pattern
Decreased cardiac output - Answer: Romberg test assesses
balance. Therefore, if a client is positive Romberg test, this
means that the client does not have good balance and is at
higher risk for falls.
Intracranial Pressure and Perfusion - Answer: Definition
Intracranial pressure (ICP) is the pressure inside the skull. It can
be measured by an intracranial pressure monitor and affected
by changes in the brain.
Indications
Intracranial pressure changes whenever brain tissue,
cerebrospinal fluid, or blood volume is increased or decreased
(for example: brain tumor, meningitis, encephalitis, head injury,
and stroke). Any increase in the amount of brain tissue,
cerebrospinal fluid, or blood can increase the intracranial
pressure in the brain.
Because CPP=MAP-ICP, when intracranial pressure (ICP) goes
up, the client's cerebral perfusion pressure (CPP) will decrease
while the overall MAP remains the same.
, Cerebral Perfusion Pressure
What is the cerebral perfusion pressure of a client that has a
blood pressure of 180/90 mm Hg and an intracranial pressure of
35 mm Hg?
85 mm Hg
95 mm Hg
105 mm Hg
110 mm Hg - Answer: o calculate the cerebral perfusion
pressure (CPP), the formula that will be used is mean arterial
pressure (MAP) - intracranial pressure (ICP). The MAP of 180/90
mm Hg needs to be calculated first, and the ICP is 35 mm Hg.
Use the formula: (SBP + 2 x DBP) / 3.
MAP= [180 + 2 x (90)] / 3 mm Hg
MAP= 120 mm Hg
Once, MAP is calculated, then CPP can be calculated next.
CPP=120 mm Hg - 35 mm Hg
CPP= 85 mm Hg
Intracranial Regulation and Risk Factors
Altered intracranial regulation can be related to many causes.
INTRACRANIAL REGULATION
LATEST UPDATE VERIFIED
QUESTIONS & DETAILED
EXPLANATIONS GRADED A+
Professional Academic Assistance Services
Cranial Nerve Assessment
How should the nurse assess the client's cranial nerve V
(trigeminal)?
Ask the client to say "ah" and observe the upward movement of
the soft palate.
Ask the client to open mouth against resistance.
Ask the client to shrug shoulders against resistance.
Ask the client to smile, raise eyebrows, and puff out cheeks. -
Answer: To assess cranial nerve V, ask the client to open mouth
against resistance.
To assess cranial VII, ask the client to smile, raise eyebrows, and
puff out cheeks.
To assess cranial nerve IX, ask the client to say "ah" and observe
the upward movement of the soft palate.
To assess cranial nerve XI, ask the client to shrug shoulders
,against resistance.
Nursing Management
The client is admitted due to altered intracranial regulation. The
client has cranial nerve IX and X dysfunction. What should the
nurse do first?
Assist the client to ambulate in the bedside commode.
Intubate the client immediately and give oxygen.
Withhold oral fluids and food immediately.
Apply antibiotic eye ointment every 4 hours. - Answer: If the
client has cranial nerve IX (glossopharyngeal) and X (vagus)
dysfunction, this means that the gag and swallowing reflexes of
the client is compromised. Therefore, withholding the oral fluids
and food are very important to promote client safety. Applying
antibiotic eye ointment is not applicable based on the case
scenario. Assist the client to ambulate is important to but not
directly related to cranial nerves IX and X. Intubate the client
and giving oxygen are not necessary yet until the client had
trouble of breathing.
Nursing Process
The client had a positive Romberg test. What is the priority
nursing diagnosis?
,Powerlessness
Risk for fall
Impaired breathing pattern
Decreased cardiac output - Answer: Romberg test assesses
balance. Therefore, if a client is positive Romberg test, this
means that the client does not have good balance and is at
higher risk for falls.
Intracranial Pressure and Perfusion - Answer: Definition
Intracranial pressure (ICP) is the pressure inside the skull. It can
be measured by an intracranial pressure monitor and affected
by changes in the brain.
Indications
Intracranial pressure changes whenever brain tissue,
cerebrospinal fluid, or blood volume is increased or decreased
(for example: brain tumor, meningitis, encephalitis, head injury,
and stroke). Any increase in the amount of brain tissue,
cerebrospinal fluid, or blood can increase the intracranial
pressure in the brain.
Because CPP=MAP-ICP, when intracranial pressure (ICP) goes
up, the client's cerebral perfusion pressure (CPP) will decrease
while the overall MAP remains the same.
, Cerebral Perfusion Pressure
What is the cerebral perfusion pressure of a client that has a
blood pressure of 180/90 mm Hg and an intracranial pressure of
35 mm Hg?
85 mm Hg
95 mm Hg
105 mm Hg
110 mm Hg - Answer: o calculate the cerebral perfusion
pressure (CPP), the formula that will be used is mean arterial
pressure (MAP) - intracranial pressure (ICP). The MAP of 180/90
mm Hg needs to be calculated first, and the ICP is 35 mm Hg.
Use the formula: (SBP + 2 x DBP) / 3.
MAP= [180 + 2 x (90)] / 3 mm Hg
MAP= 120 mm Hg
Once, MAP is calculated, then CPP can be calculated next.
CPP=120 mm Hg - 35 mm Hg
CPP= 85 mm Hg
Intracranial Regulation and Risk Factors
Altered intracranial regulation can be related to many causes.
