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NCLEX QS MODULE 9 QUESTIONS AND
ANSWERS
A client admitted to the hospital with a subarachnoid
hemorrhage has complaints of severe headache, nuchal
rigidity, and projectile vomiting. The nurse knows lumbar
puncture (LP) would be contraindicated in this client in which of
the following circumstances?
A. Vomiting continues
B. Intracranial pressure (ICP) is increased
C. The client needs mechanical ventilation
D. Blood is anticipated in the cerebralspinal fluid (CSF) - correct
answer- B.
Sudden removal of CSF results in pressures lower in the
lumbar area than the brain and favors herniation of the brain;
therefore, LP is contraindicated with increased ICP. Vomiting
may be caused by reasons other than increased ICP; therefore,
LP isn't strictly contraindicated. An LP may be preformed on
clients needing mechanical ventilation. Blood in the CSF is
diagnostic for subarachnoid hemorrhage and was obtained
before signs and symptoms of ICP.
A client with a subdural hematoma becomes restless and
confused, with dilation of the ipsilateral pupil. The physician
orders mannitol for which of the following reasons?
A. To reduce intraocular pressure
B. To prevent acute tubular necrosis
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C. To promote osmotic diuresis to decrease ICP
D. To draw water into the vascular system to increase blood
pressure - correct answer- C.
Mannitol promotes osmotic diuresis by increasing the pressure
gradient, drawing fluid from intracellular to intravascular
spaces. Although mannitol is used for all the reasons
described, the reduction of ICP in this client is a concern.
A client with subdural hematoma was given mannitol to
decrease intracranial pressure (ICP). Which of the following
results would best show the mannitol was effective?
A. Urine output increases
B. Pupils are 8 mm and nonreactive
C. Systolic blood pressure remains at 150 mm Hg
D. BUN and creatinine levels return to normal - correct answer-
A.
Mannitol promotes osmotic diuresis by increasing the pressure
gradient in the renal tubes. Fixed and dilated pupils are
symptoms of increased ICP or cranial nerve damage. No
information is given about abnormal BUN and creatinine levels
or that mannitol is being given for renal dysfunction or blood
pressure maintenance.
4) Which of the following values is considered normal for ICP?
A. 0 to 15 mm Hg
B. 25 mm Hg
NCLEX QS MODULE 9 QUESTIONS AND
ANSWERS
A client admitted to the hospital with a subarachnoid
hemorrhage has complaints of severe headache, nuchal
rigidity, and projectile vomiting. The nurse knows lumbar
puncture (LP) would be contraindicated in this client in which of
the following circumstances?
A. Vomiting continues
B. Intracranial pressure (ICP) is increased
C. The client needs mechanical ventilation
D. Blood is anticipated in the cerebralspinal fluid (CSF) - correct
answer- B.
Sudden removal of CSF results in pressures lower in the
lumbar area than the brain and favors herniation of the brain;
therefore, LP is contraindicated with increased ICP. Vomiting
may be caused by reasons other than increased ICP; therefore,
LP isn't strictly contraindicated. An LP may be preformed on
clients needing mechanical ventilation. Blood in the CSF is
diagnostic for subarachnoid hemorrhage and was obtained
before signs and symptoms of ICP.
A client with a subdural hematoma becomes restless and
confused, with dilation of the ipsilateral pupil. The physician
orders mannitol for which of the following reasons?
A. To reduce intraocular pressure
B. To prevent acute tubular necrosis
, 2 | Page
C. To promote osmotic diuresis to decrease ICP
D. To draw water into the vascular system to increase blood
pressure - correct answer- C.
Mannitol promotes osmotic diuresis by increasing the pressure
gradient, drawing fluid from intracellular to intravascular
spaces. Although mannitol is used for all the reasons
described, the reduction of ICP in this client is a concern.
A client with subdural hematoma was given mannitol to
decrease intracranial pressure (ICP). Which of the following
results would best show the mannitol was effective?
A. Urine output increases
B. Pupils are 8 mm and nonreactive
C. Systolic blood pressure remains at 150 mm Hg
D. BUN and creatinine levels return to normal - correct answer-
A.
Mannitol promotes osmotic diuresis by increasing the pressure
gradient in the renal tubes. Fixed and dilated pupils are
symptoms of increased ICP or cranial nerve damage. No
information is given about abnormal BUN and creatinine levels
or that mannitol is being given for renal dysfunction or blood
pressure maintenance.
4) Which of the following values is considered normal for ICP?
A. 0 to 15 mm Hg
B. 25 mm Hg
