ICP Nclex Questions, ICP NCLEX style Questions, ICP Nclex Questions And Answers

ICP Nclex Questions, ICP NCLEX style
Questions, ICP Nclex Questions And
Answers


The nurse notes that a patient with a head injury has a clear nasal drainage. The most
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



appropriate nursing action for this finding is to
fl fl fl fl fl fl fl fl



a. obtain a specimen of the fluid and send for culture and sensitivity.
fl fl fl fl fl fl fl fl fl fl fl fl



b. take the patient's temperature to determine whether a fever is present.
fl fl fl fl fl fl fl fl fl fl fl



c. check the nasal drainage for glucose with a Dextrostik or Testape.
fl fl fl fl fl fl fl fl fl fl fl



d. have the patient to blow the nose and then check the nares for redness. -
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



Correct Answer: C
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



Rationale: If the drainage is cerebrospinal fluid (CSF) leakage from a dural tear, glucose will
fl fl fl fl fl fl fl fl fl fl fl fl fl fl



be present. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



will not be useful. A dural tear does increase the risk for infections such as meningitis, but the
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



nurse should first determine whether the clear drainage is CSF. Blowing the nose is avoided to
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



prevent CSF leakage.
fl fl fl




Cognitive Level: Application Text Reference: p. 1481 fl fl fl fl fl fl



Nursing Process: Implementation NCLEX: Physiological Integrity
fl fl fl fl fl




A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C),
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



hour after admission, will be of most concern to the nurse?
fl fl fl fl fl fl fl fl fl fl fl



a. Blood pressure 130/72, pulse 90, respirations 32
fl fl fl fl fl fl fl



b. Blood pressure 148/78, pulse 112, respirations 28
fl fl fl fl fl fl fl



c. Blood pressure 156/60, pulse 60, respirations 14
fl fl fl fl fl fl fl



d. Blood pressure 110/70, pulse 120, respirations 30 -
fl fl fl fl fl fl fl fl fl



Correct Answer: C
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



Rationale: Systolic hypertension with widening pulse pressure, bradycardia, and respiratory
fl fl fl fl fl fl fl fl fl



changes represent Cushing's triad and indicate that the ICP has increased and brain herniation
fl fl fl fl fl fl fl fl fl fl fl fl fl fl



may be imminent unless immediate action is taken to reduce ICP. The other vital signs may
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



indicate the need for changes in treatment, but they are not indicative of an immediately life-
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



threatening process. fl




Cognitive Level: Application Text Reference: p. 1469 fl fl fl fl fl fl



Nursing Process: Assessment NCLEX: Physiological Integrityfl fl fl fl fl




When assessing a patient with a head injury, the nurse recognizes that the earliest indication of
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



increased intracranial pressure (ICP) is
fl fl fl fl fl



a. vomiting.
fl



b. headache.
fl



c. change in level of consciousness (LOC).
fl fl fl fl fl fl



d. sluggish pupil response to light. -
fl fl fl fl fl fl fl




1|Pa g e
fl fl

, Correct Answer: C
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



Rationale: LOC is the most sensitive indicator of the patient's neurologic status and possible
fl fl fl fl fl fl fl fl fl fl fl fl fl



changes in ICP. Vomiting and sluggish pupil response to light are later signs of increased ICP.
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



A headache can be caused by compression of intracranial structures as the brain swells, but it
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



is not unexpected after a head injury.
fl fl fl fl fl fl fl




Cognitive Level: Comprehension Text Reference: p. 1470 fl fl fl fl fl fl



Nursing Process: Assessment NCLEX: Physiological Integrity
fl fl fl fl fl




A patient with a head injury has an arterial blood pressure is 92/50 mm Hg and an intracranial
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



pressure of 18 mm Hg. Which action by the nurse is appropriate?
fl fl fl fl fl fl fl fl fl fl fl fl



a. Document and continue to monitor the parameters.
fl fl fl fl fl fl fl



b. Elevate the head of the patient's bed.
fl fl fl fl fl fl fl



c. Notify the health care provider about the assessments.
fl fl fl fl fl fl fl fl



d. Check the patient's pupillary response to light. -
fl fl fl fl fl fl fl fl fl



Correct Answer: C
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



Rationale: The patient's cerebral perfusion pressure is only 46 mm Hg, which will rapidly lead
fl fl fl fl fl fl fl fl fl fl fl fl fl fl



to cerebral ischemia and neuronal death unless rapid action is taken to reduce ICP and
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



increase arterial BP. Documentation and monitoring are inadequate responses to the patient's
fl fl fl fl fl fl fl fl fl fl fl fl



problem. Elevating the head of the bed will lower the ICP but may also lower cerebral blood
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



flow and further decrease CPP. Changes in pupil response to light are signs of increased ICP,
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



so the nurse will only take more time doing this without adding any useful information.
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl




Cognitive Level: Analysis Text Reference: pp. 1468-1469 fl fl fl fl fl fl



Nursing Process: Implementation NCLEX: Physiological Integrity
fl fl fl fl fl




A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial pressure of
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



24 mm Hg. The nurse determines that the cerebral perfusion pressure (CPP) of this patient
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



indicates
fl



a. high blood flow to the brain.
fl fl fl fl fl fl



b. normal intracranial pressure (ICP).
fl fl fl fl



c. impaired brain blood flow.
fl fl fl fl



d. adequate cerebral perfusion. -
fl fl fl fl fl



Correct Answer: C
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



Rationale: The patient's CPP is 56, below the normal of 70 to 100 mm Hg and approaching the
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



level of ischemia and neuronal death. The patient has low cerebral blood flow/perfusion.
fl fl fl fl fl fl fl fl fl fl fl fl fl



Normal ICP is 0 to 15 mm Hg.
fl fl fl fl fl fl fl fl




Cognitive Level: Application Text Reference: p. 1468 fl fl fl fl fl fl



Nursing Process: Assessment NCLEX: Physiological Integrity
fl fl fl fl fl




When caring for a patient who has had a head injury, which assessment information is of most
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



concern to the nurse?
fl fl fl fl



a. The blood pressure increases from 120/54 to 136/62.
fl fl fl fl fl fl fl fl



b. The patient is more difficult to arouse.
fl fl fl fl fl fl fl



c. The patient complains of a headache at pain level 5 of a 10-point scale.
fl fl fl fl fl fl fl fl fl fl fl fl fl fl



d. The patient's apical pulse is slightly irregular. -
fl fl fl fl fl fl fl fl fl



Correct Answer: B
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



Rationale: The change in level of consciousness (LOC) is an indicator of increased ICP and
fl fl fl fl fl fl fl fl fl fl fl fl fl fl



suggests that action by the nurse is needed to prevent complications. The change in BP should
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl




2|Pa g e
fl fl

,fl be monitored but is not an indicator of a need for immediate nursing action. Headache is not
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



fl unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual.
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl




Cognitive Level: Application Text Reference: p. 1470 fl fl fl fl fl fl



Nursing Process: Assessment NCLEX: Physiological Integrity
fl fl fl fl fl




When the nurse applies a painful stimulus to the nailbeds of an unconscious patient, the patient
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



responds with internal rotation, adduction, and flexion of the arms. The nurse documents this
fl fl fl fl fl fl fl fl fl fl fl fl fl fl



as
fl



a. decorticate posturing.
fl fl



b. decerebrate posturing.
fl fl



c. localization of pain.
fl fl fl



d. flexion withdrawal. -
fl fl fl fl



Correct Answer: A
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



Rationale: Internal rotation, adduction, and flexion of the arms in an unconscious patient is
fl fl fl fl fl fl fl fl fl fl fl fl fl



documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing.
fl fl fl fl fl fl fl fl fl fl fl fl fl



Because the flexion is general, it does not indicate localization of pain or flexion withdrawal.
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl




Cognitive Level: Comprehension Text Reference: p. 1472 fl fl fl fl fl fl



Nursing Process: Assessment NCLEX: Physiological Integrity
fl fl fl fl fl




A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L),
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



a decreasing level of consciousness (LOC) and complains of a headache. All of the following
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



orders have been received. Which one should the nurse accomplish first?
fl fl fl fl fl fl fl fl fl fl fl



a. Administer acetaminophen (Tylenol) 650 mg orally.
fl fl fl fl fl fl



b. Administer 5% hypertonic saline intravenously.
fl fl fl fl fl



c. Draw blood for arterial blood gases (ABGs).
fl fl fl fl fl fl fl



d. Send patient to radiology for computed tomography (CT) of the head. -
fl fl fl fl fl fl fl fl fl fl fl fl fl



Correct Answer: B
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



Rationale: The patient's low sodium indicates that hyponatremia may be causing the cerebral
fl fl fl fl fl fl fl fl fl fl fl fl



edema, and the nurse's first action should be to correct the low sodium level. Acetaminophen
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



(Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



increased ICP. Drawing ABGs and obtaining a CT scan may add some useful information, but
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



the low sodium level may lead to seizures unless it is addressed quickly.
fl fl fl fl fl fl fl fl fl fl fl fl fl




Cognitive Level: Application Text Reference: p. 1470 fl fl fl fl fl fl



Nursing Process: Implementation NCLEX: Physiological Integrity
fl fl fl fl fl




Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



patient with a head injury. To evaluate the effectiveness of the therapy, the nurse should
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



a. monitor oxygen saturation.
fl fl fl



b. check arterial blood gases (ABGs).
fl fl fl fl fl



c. monitor intracranial pressure (ICP).
fl fl fl fl



d. assess patient breath sounds. -
fl fl fl fl fl fl



Correct Answer: C
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



Rationale: The purpose of hyperventilation for a patient with a head injury is reduction of ICP,
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



and ICP should be monitored to evaluate whether the therapy is effective. Although oxygen
fl fl fl fl fl fl fl fl fl fl fl fl fl fl



saturation and ABGs are monitored in patient's receiving hyperventilation, they do not
fl fl fl fl fl fl fl fl fl fl fl fl



provide data about whether the therapy is successful in reducing ICP. Breath sounds are
fl fl fl fl fl fl fl fl fl fl fl fl fl fl



assessed, but they are not helpful in determining whether the hyperventilation is effective.
fl fl fl fl fl fl fl fl fl fl fl fl fl




3|Pa g e
fl fl

, Cognitive Level: Application Text Reference: p. 1475 fl fl fl fl fl fl



Nursing Process: Evaluation NCLEX: Physiological Integrity
fl fl fl fl fl




A patient has ICP monitoring with an intraventricular catheter. A priority nursing intervention
fl fl fl fl fl fl fl fl fl fl fl fl



for the patient is
fl fl fl fl



a. aseptic technique to prevent infection
fl fl fl fl fl



b. constant monitoring of ICP waveforms
fl fl fl fl fl



c. removal of CSF to maintain normal ICP
fl fl fl fl fl fl fl



d. sampling CSF to determine abnormalities -
fl fl fl fl fl fl fl



A. Aseptic technique to prevent infection- An intraventricular catheter is a fluid
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



coupled system that can provide direct access for microorganisms to enter the ventricles of the
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



brain, and aseptic technique is a very high nursing priority to decrease the risk for infection.
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



Constant monitoring of ICP waveforms is not usually necessary, and removal of CSF for
fl fl fl fl fl fl fl fl fl fl fl fl fl fl



sampling or to maintain normal ICP is done only when specifically ordered
fl fl fl fl fl fl fl fl fl fl fl fl




Skull radiographs and a computed tomography (CT) scan provide evidence of a depressed
fl fl fl fl fl fl fl fl fl fl fl fl



parietal fracture with a subdural hematoma in a patient admitted to the emergency department
fl fl fl fl fl fl fl fl fl fl fl fl fl fl



following an automobile accident. In planning care for the patient, the nurse anticipates that
fl fl fl fl fl fl fl fl fl fl fl fl fl fl



a. the patient will receive life-support measures until the condition stabilizes
fl fl fl fl fl fl fl fl fl fl



b. immediate burr holes will be made to rapidly decompress the intracranial activity
fl fl fl fl fl fl fl fl fl fl fl fl



c. the patient will be treated conservatively with close monitoring for changes in neurologic
fl fl fl fl fl fl fl fl fl fl fl fl fl



condition
fl



d. the patient will be taken to surgery for a craniotomy for evacuation of blood and
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



decompression of the cranium -
fl fl fl fl fl fl



D. When there is a depressed fracture and fractures with loose fragments, a
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



craniotomy is indicated to elevate the depressed bone and remove free fragments. A
fl fl fl fl fl fl fl fl fl fl fl fl fl



craniotomy is also indicated in cases of acute subdural and epidural hematomas to remove the
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



blood and control the bleeding. Burr holes may be used in an extreme emergency for rapid
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



decompression, but with a depressed fracture, surgery would be the treatment of choice
fl fl fl fl fl fl fl fl fl fl fl fl fl




Metabolic and nutritional needs of the patient with increased ICP are best met with
fl fl fl fl fl fl fl fl fl fl fl fl fl fl



a. enteral feedings that are low in sodium
fl fl fl fl fl fl fl



b. the simple glucose available in D5W IV solutions
fl fl fl fl fl fl fl fl



c. a fluid restriction that promotes a moderate dehydration
fl fl fl fl fl fl fl fl



d. balanced, essential nutrition in a form that the patient can tolerate -
fl fl fl fl fl fl fl fl fl fl fl fl fl



D. Balanced, essential nutrition in a form that the patient can tolerate= A patient with
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



increased ICP is in a hypermetabolic and hypercatabolic state and needs adequate glucose to
fl fl fl fl fl fl fl fl fl fl fl fl fl fl



maintain fuel for the brain and other nutrients to meet metabolic needs. Malnutrition promotes
fl fl fl fl fl fl fl fl fl fl fl fl fl fl



cerebral edema, and if a patient cannot take oral nutrition, other means of providing nutrition
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



should be used, such as tube feedings or parenteral nutrition. Glucose alone is not adequate to
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl



meet nutritional requirements, and 5% dextrose solutions may increase cerebral edema by
fl fl fl fl fl fl fl fl fl fl fl fl



lowering serum osmolarity. Patients should remain in a normovolemic fluid state with close
fl fl fl fl fl fl fl fl fl fl fl fl fl



monitoring of clinical factors such as urine output, fluid intake, serum and urine osmolality,
fl fl fl fl fl fl fl fl fl fl fl fl fl fl



serum electrolytes, and insensible losses.
fl fl fl fl fl




The nurse suspects the presence of an arterial epidural hematoma in the patient who
fl fl fl fl fl fl fl fl fl fl fl fl fl



experiences
fl



a. failure to regain consciousness following a head injury
fl fl fl fl fl fl fl fl



b. a rapid deterioration of neurologic function within 24 to 48 hours following a head injury
fl fl fl fl fl fl fl fl fl fl fl fl fl fl fl




4|Pa g e
fl fl