ICP NCLEX UPDATED ACTUAL Exam
Questions and CORRECT Answers
The nurse notes that a patient with a head injury has a clear nasal drainage. The most
appropriate nursing action for this finding is to
a. obtain a specimen of the fluid and send for culture and sensitivity.
b. take the patient's temperature to determine whether a fever is present.
c. check the nasal drainage for glucose with a Dextrostik or Testape.
d. have the patient to blow the nose and then check the nares for redness. - CORRECT
ANSWER- ✔✔Correct Answer: C
Rationale: If the drainage is cerebrospinal fluid (CSF) leakage from a dural tear, glucose will
be present. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity
will not be useful. A dural tear does increase the risk for infections such as meningitis, but the
nurse should first determine whether the clear drainage is CSF. Blowing the nose is avoided
to prevent CSF leakage.
Cognitive Level: Application Text Reference: p. 1481
Nursing Process: Implementation NCLEX: Physiological Integrity
A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37°
C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken
1 hour after admission, will be of most concern to the nurse?
a. Blood pressure 130/72, pulse 90, respirations 32
b. Blood pressure 148/78, pulse 112, respirations 28
c. Blood pressure 156/60, pulse 60, respirations 14
d. Blood pressure 110/70, pulse 120, respirations 30 - CORRECT ANSWER- ✔✔Correct
Answer: C
Rationale: Systolic hypertension with widening pulse pressure, bradycardia, and respiratory
changes represent Cushing's triad and indicate that the ICP has increased and brain herniation
may be imminent unless immediate action is taken to reduce ICP. The other vital signs may
indicate the need for changes in treatment, but they are not indicative of an immediately life-
threatening process.
Cognitive Level: Application Text Reference: p. 1469
Nursing Process: Assessment NCLEX: Physiological Integrity
,When assessing a patient with a head injury, the nurse recognizes that the earliest indication
of increased intracranial pressure (ICP) is
a. vomiting.
b. headache.
c. change in level of consciousness (LOC).
d. sluggish pupil response to light. - CORRECT ANSWER- ✔✔Correct Answer: C
Rationale: LOC is the most sensitive indicator of the patient's neurologic status and possible
changes in ICP. Vomiting and sluggish pupil response to light are later signs of increased ICP.
A headache can be caused by compression of intracranial structures as the brain swells, but it
is not unexpected after a head injury.
Cognitive Level: Comprehension Text Reference: p. 1470
Nursing Process: Assessment NCLEX: Physiological Integrity
A patient with a head injury has an arterial blood pressure is 92/50 mm Hg and an intracranial
pressure of 18 mm Hg. Which action by the nurse is appropriate?
a. Document and continue to monitor the parameters.
b. Elevate the head of the patient's bed.
c. Notify the health care provider about the assessments.
d. Check the patient's pupillary response to light. - CORRECT ANSWER- ✔✔Correct
Answer: C
Rationale: The patient's cerebral perfusion pressure is only 46 mm Hg, which will rapidly
lead to cerebral ischemia and neuronal death unless rapid action is taken to reduce ICP and
increase arterial BP. Documentation and monitoring are inadequate responses to the patient's
problem. Elevating the head of the bed will lower the ICP but may also lower cerebral blood
flow and further decrease CPP. Changes in pupil response to light are signs of increased ICP,
so the nurse will only take more time doing this without adding any useful information.
Cognitive Level: Analysis Text Reference: pp. 1468-1469
Nursing Process: Implementation NCLEX: Physiological Integrity
A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial pressure
of 24 mm Hg. The nurse determines that the cerebral perfusion pressure (CPP) of this patient
indicates
,a. high blood flow to the brain.
b. normal intracranial pressure (ICP).
c. impaired brain blood flow.
d. adequate cerebral perfusion. - CORRECT ANSWER- ✔✔Correct Answer: C
Rationale: The patient's CPP is 56, below the normal of 70 to 100 mm Hg and approaching
the level of ischemia and neuronal death. The patient has low cerebral blood flow/perfusion.
Normal ICP is 0 to 15 mm Hg.
Cognitive Level: Application Text Reference: p. 1468
Nursing Process: Assessment NCLEX: Physiological Integrity
When caring for a patient who has had a head injury, which assessment information is of
most concern to the nurse?
a. The blood pressure increases from 120/54 to 136/62.
b. The patient is more difficult to arouse.
c. The patient complains of a headache at pain level 5 of a 10-point scale.
d. The patient's apical pulse is slightly irregular. - CORRECT ANSWER- ✔✔Correct
Answer: B
Rationale: The change in level of consciousness (LOC) is an indicator of increased ICP and
suggests that action by the nurse is needed to prevent complications. The change in BP should
be monitored but is not an indicator of a need for immediate nursing action. Headache is not
unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual.
Cognitive Level: Application Text Reference: p. 1470
Nursing Process: Assessment NCLEX: Physiological Integrity
When the nurse applies a painful stimulus to the nailbeds of an unconscious patient, the
patient responds with internal rotation, adduction, and flexion of the arms. The nurse
documents this as
a. decorticate posturing.
b. decerebrate posturing.
c. localization of pain.
d. flexion withdrawal. - CORRECT ANSWER- ✔✔Correct Answer: A
, Rationale: Internal rotation, adduction, and flexion of the arms in an unconscious patient is
documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing.
Because the flexion is general, it does not indicate localization of pain or flexion withdrawal.
Cognitive Level: Comprehension Text Reference: p. 1472
Nursing Process: Assessment NCLEX: Physiological Integrity
A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115
mmol/L), a decreasing level of consciousness (LOC) and complains of a headache. All of the
following orders have been received. Which one should the nurse accomplish first?
a. Administer acetaminophen (Tylenol) 650 mg orally.
b. Administer 5% hypertonic saline intravenously.
c. Draw blood for arterial blood gases (ABGs).
d. Send patient to radiology for computed tomography (CT) of the head. - CORRECT
ANSWER- ✔✔Correct Answer: B
Rationale: The patient's low sodium indicates that hyponatremia may be causing the cerebral
edema, and the nurse's first action should be to correct the low sodium level. Acetaminophen
(Tylenol) will have minimal effect on the headache because it is caused by cerebral edema
and increased ICP. Drawing ABGs and obtaining a CT scan may add some useful
information, but the low sodium level may lead to seizures unless it is addressed quickly.
Cognitive Level: Application Text Reference: p. 1470
Nursing Process: Implementation NCLEX: Physiological Integrity
Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for
a patient with a head injury. To evaluate the effectiveness of the therapy, the nurse should
a. monitor oxygen saturation.
b. check arterial blood gases (ABGs).
c. monitor intracranial pressure (ICP).
d. assess patient breath sounds. - CORRECT ANSWER- ✔✔Correct Answer: C
Rationale: The purpose of hyperventilation for a patient with a head injury is reduction of
ICP, and ICP should be monitored to evaluate whether the therapy is effective. Although
oxygen saturation and ABGs are monitored in patient's receiving hyperventilation, they do
not provide data about whether the therapy is successful in reducing ICP. Breath sounds are
assessed, but they are not helpful in determining whether the hyperventilation is effective.
Questions and CORRECT Answers
The nurse notes that a patient with a head injury has a clear nasal drainage. The most
appropriate nursing action for this finding is to
a. obtain a specimen of the fluid and send for culture and sensitivity.
b. take the patient's temperature to determine whether a fever is present.
c. check the nasal drainage for glucose with a Dextrostik or Testape.
d. have the patient to blow the nose and then check the nares for redness. - CORRECT
ANSWER- ✔✔Correct Answer: C
Rationale: If the drainage is cerebrospinal fluid (CSF) leakage from a dural tear, glucose will
be present. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity
will not be useful. A dural tear does increase the risk for infections such as meningitis, but the
nurse should first determine whether the clear drainage is CSF. Blowing the nose is avoided
to prevent CSF leakage.
Cognitive Level: Application Text Reference: p. 1481
Nursing Process: Implementation NCLEX: Physiological Integrity
A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37°
C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken
1 hour after admission, will be of most concern to the nurse?
a. Blood pressure 130/72, pulse 90, respirations 32
b. Blood pressure 148/78, pulse 112, respirations 28
c. Blood pressure 156/60, pulse 60, respirations 14
d. Blood pressure 110/70, pulse 120, respirations 30 - CORRECT ANSWER- ✔✔Correct
Answer: C
Rationale: Systolic hypertension with widening pulse pressure, bradycardia, and respiratory
changes represent Cushing's triad and indicate that the ICP has increased and brain herniation
may be imminent unless immediate action is taken to reduce ICP. The other vital signs may
indicate the need for changes in treatment, but they are not indicative of an immediately life-
threatening process.
Cognitive Level: Application Text Reference: p. 1469
Nursing Process: Assessment NCLEX: Physiological Integrity
,When assessing a patient with a head injury, the nurse recognizes that the earliest indication
of increased intracranial pressure (ICP) is
a. vomiting.
b. headache.
c. change in level of consciousness (LOC).
d. sluggish pupil response to light. - CORRECT ANSWER- ✔✔Correct Answer: C
Rationale: LOC is the most sensitive indicator of the patient's neurologic status and possible
changes in ICP. Vomiting and sluggish pupil response to light are later signs of increased ICP.
A headache can be caused by compression of intracranial structures as the brain swells, but it
is not unexpected after a head injury.
Cognitive Level: Comprehension Text Reference: p. 1470
Nursing Process: Assessment NCLEX: Physiological Integrity
A patient with a head injury has an arterial blood pressure is 92/50 mm Hg and an intracranial
pressure of 18 mm Hg. Which action by the nurse is appropriate?
a. Document and continue to monitor the parameters.
b. Elevate the head of the patient's bed.
c. Notify the health care provider about the assessments.
d. Check the patient's pupillary response to light. - CORRECT ANSWER- ✔✔Correct
Answer: C
Rationale: The patient's cerebral perfusion pressure is only 46 mm Hg, which will rapidly
lead to cerebral ischemia and neuronal death unless rapid action is taken to reduce ICP and
increase arterial BP. Documentation and monitoring are inadequate responses to the patient's
problem. Elevating the head of the bed will lower the ICP but may also lower cerebral blood
flow and further decrease CPP. Changes in pupil response to light are signs of increased ICP,
so the nurse will only take more time doing this without adding any useful information.
Cognitive Level: Analysis Text Reference: pp. 1468-1469
Nursing Process: Implementation NCLEX: Physiological Integrity
A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial pressure
of 24 mm Hg. The nurse determines that the cerebral perfusion pressure (CPP) of this patient
indicates
,a. high blood flow to the brain.
b. normal intracranial pressure (ICP).
c. impaired brain blood flow.
d. adequate cerebral perfusion. - CORRECT ANSWER- ✔✔Correct Answer: C
Rationale: The patient's CPP is 56, below the normal of 70 to 100 mm Hg and approaching
the level of ischemia and neuronal death. The patient has low cerebral blood flow/perfusion.
Normal ICP is 0 to 15 mm Hg.
Cognitive Level: Application Text Reference: p. 1468
Nursing Process: Assessment NCLEX: Physiological Integrity
When caring for a patient who has had a head injury, which assessment information is of
most concern to the nurse?
a. The blood pressure increases from 120/54 to 136/62.
b. The patient is more difficult to arouse.
c. The patient complains of a headache at pain level 5 of a 10-point scale.
d. The patient's apical pulse is slightly irregular. - CORRECT ANSWER- ✔✔Correct
Answer: B
Rationale: The change in level of consciousness (LOC) is an indicator of increased ICP and
suggests that action by the nurse is needed to prevent complications. The change in BP should
be monitored but is not an indicator of a need for immediate nursing action. Headache is not
unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual.
Cognitive Level: Application Text Reference: p. 1470
Nursing Process: Assessment NCLEX: Physiological Integrity
When the nurse applies a painful stimulus to the nailbeds of an unconscious patient, the
patient responds with internal rotation, adduction, and flexion of the arms. The nurse
documents this as
a. decorticate posturing.
b. decerebrate posturing.
c. localization of pain.
d. flexion withdrawal. - CORRECT ANSWER- ✔✔Correct Answer: A
, Rationale: Internal rotation, adduction, and flexion of the arms in an unconscious patient is
documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing.
Because the flexion is general, it does not indicate localization of pain or flexion withdrawal.
Cognitive Level: Comprehension Text Reference: p. 1472
Nursing Process: Assessment NCLEX: Physiological Integrity
A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115
mmol/L), a decreasing level of consciousness (LOC) and complains of a headache. All of the
following orders have been received. Which one should the nurse accomplish first?
a. Administer acetaminophen (Tylenol) 650 mg orally.
b. Administer 5% hypertonic saline intravenously.
c. Draw blood for arterial blood gases (ABGs).
d. Send patient to radiology for computed tomography (CT) of the head. - CORRECT
ANSWER- ✔✔Correct Answer: B
Rationale: The patient's low sodium indicates that hyponatremia may be causing the cerebral
edema, and the nurse's first action should be to correct the low sodium level. Acetaminophen
(Tylenol) will have minimal effect on the headache because it is caused by cerebral edema
and increased ICP. Drawing ABGs and obtaining a CT scan may add some useful
information, but the low sodium level may lead to seizures unless it is addressed quickly.
Cognitive Level: Application Text Reference: p. 1470
Nursing Process: Implementation NCLEX: Physiological Integrity
Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for
a patient with a head injury. To evaluate the effectiveness of the therapy, the nurse should
a. monitor oxygen saturation.
b. check arterial blood gases (ABGs).
c. monitor intracranial pressure (ICP).
d. assess patient breath sounds. - CORRECT ANSWER- ✔✔Correct Answer: C
Rationale: The purpose of hyperventilation for a patient with a head injury is reduction of
ICP, and ICP should be monitored to evaluate whether the therapy is effective. Although
oxygen saturation and ABGs are monitored in patient's receiving hyperventilation, they do
not provide data about whether the therapy is successful in reducing ICP. Breath sounds are
assessed, but they are not helpful in determining whether the hyperventilation is effective.
