N4010 Adult Health 2 Exam 3 Questions with
Verified Correct Answers
What is the normal range for intracranial pressure (ICP)?
The normal ICP range for a healthy adult is 0-10 mmHg.
>20 needs intervention and monitoring
What is the range for mild elevation in intracranial pressure (ICP)?
16-20 mmHg → needs monitoring
What is the range for moderate elevation in intracranial pressure (ICP)?
21-40 mmHg → may require interventions
What is the range for severe elevation in intracranial pressure (ICP)?
>40 mmHg → medical emergency; risk for brain herniation
What are some factors that affect intracranial pressure (ICP)?
body position (supine increases ICP), coughing, straining, sneezing, suctioning, and pain
What are some interventions for increased intracranial pressure (ICP)?
Elevate head of bed 30°, avoid neck flexion, maintain airway, control pain and anxiety, and
administer osmotic diuretics (e.g., mannitol) if ordered.
What are the early signs of increased intracranial pressure (ICP)?
-Change in level of consciousness (LOC): Confusion, restlessness, lethargy
-Headache: Often persistent and worsening
-Nausea and vomiting: Usually not preceded by nausea
,-Visual disturbances: Blurred vision, diplopia
-Pupillary changes: Slight sluggishness or unequal pupils
-Vital sign changes: May be subtle (slightly elevated BP)
-Behavioral changes: Irritability, agitation
What are the late signs of increased intracranial pressure (ICP)?
-Cushing’s triad: Classic late sign
Hypertension with widened pulse pressure Bradycardia (slow, bounding pulse) Irregular
respirations (Cheyne-Stokes, ataxic breathing)
-Severe alteration in LOC: Stupor, coma
-Pupillary changes: Fixed and dilated pupils, non-reactive to light
-Motor changes: Posturing (decerebrate or decorticate)
-Seizures
What is Cushing's Triad?
a set of late signs of increased intracranial pressure (ICP) indicating brainstem compression
and impending herniation
1. Hypertension
2. Bradycardia
3. Irregular or abnormal respirations
Why does Cushing's Triad occur?
1. Hypertension (with widened pulse pressure)
,-Why it occurs: The brain attempts to maintain cerebral perfusion despite rising ICP. The
systemic blood pressure rises to overcome the increased pressure in the skull. Widened pulse
pressure occurs because systolic pressure rises while diastolic remains normal or decreases.
2. Bradycardia (slow heart rate)
-Why it occurs: The parasympathetic nervous system responds to the hypertension via the
baroreceptor reflex, causing a slowing of the heart rate.
3. Irregular or abnormal respirations
-Why it occurs: Pressure on the brainstem affects the respiratory center, leading to patterns
such as Cheyne-Stokes, ataxic, or irregular breathing.
What are nursing interventions for increased ICP?
Nursing interventions for increased intracranial pressure (ICP) focus on reducing ICP,
maintaining cerebral perfusion, preventing secondary brain injury, and monitoring for
changes in neurological status.
Why are nursing interventions for increased ICP important?
1. Elevate the head of the bed to 30 degrees – Promotes venous drainage from the brain
2. Maintain a patent airway and administer oxygen as needed – Hypoxia increases cerebral
blood flow and ICP
3. Monitor neurological status frequently (GCS, pupillary response, motor function)
4. Maintain normovolemia and normal blood pressure – Hypotension reduces cerebral
perfusion pressure (CPP), worsening ischemia. Hypervolemia can worsen edema.
5. Avoid activities that increase ICP - coughing, straining, sneezing, suctioning without
precautions
, 6. Administer medications as prescribed – Mannitol or hypertonic saline may be used to
reduce cerebral edema; sedatives and analgesics can decrease metabolic demand.
7. Control environmental stimuli
8. Monitor and manage fluid and electrolyte balance – Hypernatremia can occur with
hypertonic solutions
9. Provide seizure precautions
10.Maintain body temperature – Hyperthermia increases cerebral metabolism and ICP
What are critical complications to monitor for post-craniotomy?
1. Increased Intracranial Pressure (ICP) – Watch for headache, vomiting, altered level of
consciousness, pupillary changes, or Cushing’s triad (hypertension, bradycardia, irregular
respirations).
2. Bleeding / Hematoma formation
3. Infection (meningitis, surgical site infection, brain abscess) – Assess incision site, CSF
leaks, fever, or neck stiffness.
4. Seizures
5. Cerebral edema – Can cause increased ICP and neurological decline
6. CSF leakage – Clear fluid drainage from the incision or nose may
7. Hydrocephalus – Accumulation of CSF can increase ICP; monitor for headache, vomiting,
confusion, and vision changes.
8. Venous thromboembolism (VTE) – Immobilization post-op increases risk; monitor for leg
swelling, pain, or redness.
Verified Correct Answers
What is the normal range for intracranial pressure (ICP)?
The normal ICP range for a healthy adult is 0-10 mmHg.
>20 needs intervention and monitoring
What is the range for mild elevation in intracranial pressure (ICP)?
16-20 mmHg → needs monitoring
What is the range for moderate elevation in intracranial pressure (ICP)?
21-40 mmHg → may require interventions
What is the range for severe elevation in intracranial pressure (ICP)?
>40 mmHg → medical emergency; risk for brain herniation
What are some factors that affect intracranial pressure (ICP)?
body position (supine increases ICP), coughing, straining, sneezing, suctioning, and pain
What are some interventions for increased intracranial pressure (ICP)?
Elevate head of bed 30°, avoid neck flexion, maintain airway, control pain and anxiety, and
administer osmotic diuretics (e.g., mannitol) if ordered.
What are the early signs of increased intracranial pressure (ICP)?
-Change in level of consciousness (LOC): Confusion, restlessness, lethargy
-Headache: Often persistent and worsening
-Nausea and vomiting: Usually not preceded by nausea
,-Visual disturbances: Blurred vision, diplopia
-Pupillary changes: Slight sluggishness or unequal pupils
-Vital sign changes: May be subtle (slightly elevated BP)
-Behavioral changes: Irritability, agitation
What are the late signs of increased intracranial pressure (ICP)?
-Cushing’s triad: Classic late sign
Hypertension with widened pulse pressure Bradycardia (slow, bounding pulse) Irregular
respirations (Cheyne-Stokes, ataxic breathing)
-Severe alteration in LOC: Stupor, coma
-Pupillary changes: Fixed and dilated pupils, non-reactive to light
-Motor changes: Posturing (decerebrate or decorticate)
-Seizures
What is Cushing's Triad?
a set of late signs of increased intracranial pressure (ICP) indicating brainstem compression
and impending herniation
1. Hypertension
2. Bradycardia
3. Irregular or abnormal respirations
Why does Cushing's Triad occur?
1. Hypertension (with widened pulse pressure)
,-Why it occurs: The brain attempts to maintain cerebral perfusion despite rising ICP. The
systemic blood pressure rises to overcome the increased pressure in the skull. Widened pulse
pressure occurs because systolic pressure rises while diastolic remains normal or decreases.
2. Bradycardia (slow heart rate)
-Why it occurs: The parasympathetic nervous system responds to the hypertension via the
baroreceptor reflex, causing a slowing of the heart rate.
3. Irregular or abnormal respirations
-Why it occurs: Pressure on the brainstem affects the respiratory center, leading to patterns
such as Cheyne-Stokes, ataxic, or irregular breathing.
What are nursing interventions for increased ICP?
Nursing interventions for increased intracranial pressure (ICP) focus on reducing ICP,
maintaining cerebral perfusion, preventing secondary brain injury, and monitoring for
changes in neurological status.
Why are nursing interventions for increased ICP important?
1. Elevate the head of the bed to 30 degrees – Promotes venous drainage from the brain
2. Maintain a patent airway and administer oxygen as needed – Hypoxia increases cerebral
blood flow and ICP
3. Monitor neurological status frequently (GCS, pupillary response, motor function)
4. Maintain normovolemia and normal blood pressure – Hypotension reduces cerebral
perfusion pressure (CPP), worsening ischemia. Hypervolemia can worsen edema.
5. Avoid activities that increase ICP - coughing, straining, sneezing, suctioning without
precautions
, 6. Administer medications as prescribed – Mannitol or hypertonic saline may be used to
reduce cerebral edema; sedatives and analgesics can decrease metabolic demand.
7. Control environmental stimuli
8. Monitor and manage fluid and electrolyte balance – Hypernatremia can occur with
hypertonic solutions
9. Provide seizure precautions
10.Maintain body temperature – Hyperthermia increases cerebral metabolism and ICP
What are critical complications to monitor for post-craniotomy?
1. Increased Intracranial Pressure (ICP) – Watch for headache, vomiting, altered level of
consciousness, pupillary changes, or Cushing’s triad (hypertension, bradycardia, irregular
respirations).
2. Bleeding / Hematoma formation
3. Infection (meningitis, surgical site infection, brain abscess) – Assess incision site, CSF
leaks, fever, or neck stiffness.
4. Seizures
5. Cerebral edema – Can cause increased ICP and neurological decline
6. CSF leakage – Clear fluid drainage from the incision or nose may
7. Hydrocephalus – Accumulation of CSF can increase ICP; monitor for headache, vomiting,
confusion, and vision changes.
8. Venous thromboembolism (VTE) – Immobilization post-op increases risk; monitor for leg
swelling, pain, or redness.
