ICP NCLEX style Questions with 100% Verified Answers
1. The nurse notes that a patient Correct Answer: C
with a head injury has a clear Rationale: If the drainage is cere-
nasal drainage. The most appropri- brospinal fluid (CSF) leakage from a
ate nursing action for this finding dural tear, glucose will be present. Fluid
is to leaking from the nose will have normal
a. obtain a specimen of the fluid nasal flora, so culture and sensitivity
and send for culture and sensitiv- will not be useful. A dural tear does
ity. increase the risk for infections such as
b. take the patient's temperature to meningitis, but the nurse should first
determine whether a fever is pre- determine whether the clear drainage
sent. is CSF. Blowing the nose is avoided to
c. check the nasal drainage for glu- prevent CSF leakage.
cose with a Dextrostik or Testape.
d. have the patient to blow the nose Cognitive Level: Application Text Refer-
and then check the nares for red- ence: p. 1481
ness. Nursing Process: Implementation
NCLEX: Physiological Integrity
2. A patient admitted with a head in- Correct Answer: C
jury has admission vital signs of Rationale: Systolic hypertension with
temperature 98.6° F (37° C), blood widening pulse pressure, bradycar-
pressure 128/68, pulse 110, and dia, and respiratory changes represent
respirations 26. Which of these vi- Cushing's triad and indicate that the
tal signs, if taken 1 hour after ad- ICP has increased and brain herniation
mission, will be of most concern to may be imminent unless immediate ac-
the nurse? tion is taken to reduce ICP. The other
a. Blood pressure 130/72, pulse 90, vital signs may indicate the need for
respirations 32 changes in treatment, but they are not
b. Blood pressure 148/78, pulse indicative of an immediately life-threat-
112, respirations 28 ening process.
c. Blood pressure 156/60, pulse 60,
respirations 14 Cognitive Level: Application Text Refer-
d. Blood pressure 110/70, pulse ence: p. 1469
120, respirations 30 Nursing Process: Assessment NCLEX:
Physiological Integrity
3. When assessing a patient with a Correct Answer: C
head injury, the nurse recognizes Rationale: LOC is the most sensitive
that the earliest indication of in- indicator of the patient's neurologic sta-
, ICP NCLEX style Questions with 100% Verified Answers
creased intracranial pressure (ICP) tus and possible changes in ICP. Vom-
is iting and sluggish pupil response to
a. vomiting. light are later signs of increased ICP.
b. headache. A headache can be caused by com-
c. change in level of conscious- pression of intracranial structures as
ness (LOC). the brain swells, but it is not unexpected
d. sluggish pupil response to light. after a head injury.
Cognitive Level: Comprehension Text
Reference: p. 1470
Nursing Process: Assessment NCLEX:
Physiological Integrity
4. A patient with a head injury has Correct Answer: C
an arterial blood pressure is 92/50 Rationale: The patient's cerebral perfu-
mm Hg and an intracranial pres- sion pressure is only 46 mm Hg, which
sure of 18 mm Hg. Which action by will rapidly lead to cerebral ischemia
the nurse is appropriate? and neuronal death unless rapid action
a. Document and continue to mon- is taken to reduce ICP and increase
itor the parameters. arterial BP. Documentation and moni-
b. Elevate the head of the patient's toring are inadequate responses to the
bed. patient's problem. Elevating the head
c. Notify the health care provider of the bed will lower the ICP but may
about the assessments. also lower cerebral blood flow and fur-
d. Check the patient's pupillary re- ther decrease CPP. Changes in pupil
sponse to light. response to light are signs of increased
ICP, so the nurse will only take more
time doing this without adding any use-
ful information.
Cognitive Level: Analysis Text Refer-
ence: pp. 1468-1469
Nursing Process: Implementation
NCLEX: Physiological Integrity
5. A patient has a systemic blood Correct Answer: C
pressure (BP) of 120/60 mm Hg and Rationale: The patient's CPP is 56, be-
an intracranial pressure of 24 mm low the normal of 70 to 100 mm Hg and
Hg. The nurse determines that the approaching the level of ischemia and
, ICP NCLEX style Questions with 100% Verified Answers
cerebral perfusion pressure (CPP) neuronal death. The patient has low
of this patient indicates cerebral blood flow/perfusion. Normal
a. high blood flow to the brain. ICP is 0 to 15 mm Hg.
b. normal intracranial pressure
(ICP). Cognitive Level: Application Text Refer-
c. impaired brain blood flow. ence: p. 1468
d. adequate cerebral perfusion. Nursing Process: Assessment NCLEX:
Physiological Integrity
6. When caring for a patient who has Correct Answer: B
had a head injury, which assess- Rationale: The change in level of con-
ment information is of most con- sciousness (LOC) is an indicator of in-
cern to the nurse? creased ICP and suggests that action
a. The blood pressure increases by the nurse is needed to prevent com-
from 120/54 to 136/62. plications. The change in BP should
b. The patient is more difficult to be monitored but is not an indicator of
arouse. a need for immediate nursing action.
c. The patient complains of a Headache is not unusual in a patient
headache at pain level 5 of a after a head injury. A slightly irregular
10-point scale. apical pulse is not unusual.
d. The patient's apical pulse is
slightly irregular. Cognitive Level: Application Text Refer-
ence: p. 1470
Nursing Process: Assessment NCLEX:
Physiological Integrity
7. When the nurse applies a painful Correct Answer: A
stimulus to the nailbeds of an un- Rationale: Internal rotation, adduction,
conscious patient, the patient re- and flexion of the arms in an uncon-
sponds with internal rotation, ad- scious patient is documented as decor-
duction, and flexion of the arms. ticate posturing. Extension of the arms
The nurse documents this as and legs is decerebrate posturing. Be-
a. decorticate posturing. cause the flexion is general, it does not
b. decerebrate posturing. indicate localization of pain or flexion
c. localization of pain. withdrawal.
d. flexion withdrawal.
Cognitive Level: Comprehension Text
Reference: p. 1472
, ICP NCLEX style Questions with 100% Verified Answers
Nursing Process: Assessment NCLEX:
Physiological Integrity
8. A patient with possible cerebral Correct Answer: B
edema has a serum sodium lev- Rationale: The patient's low sodium
el of 115 mEq/L (115 mmol/L), indicates that hyponatremia may be
a decreasing level of conscious- causing the cerebral edema, and the
ness (LOC) and complains of a nurse's first action should be to correct
headache. All of the following or- the low sodium level. Acetaminophen
ders have been received. Which (Tylenol) will have minimal effect on the
one should the nurse accomplish headache because it is caused by cere-
first? bral edema and increased ICP. Drawing
a. Administer acetaminophen ABGs and obtaining a CT scan may
(Tylenol) 650 mg orally. add some useful information, but the
b. Administer 5% hypertonic saline low sodium level may lead to seizures
intravenously. unless it is addressed quickly.
c. Draw blood for arterial blood
gases (ABGs). Cognitive Level: Application Text Refer-
d. Send patient to radiology for ence: p. 1470
computed tomography (CT) of the Nursing Process: Implementation
head. NCLEX: Physiological Integrity
9. Mechanical ventilation with a rate Correct Answer: C
and volume to maintain a mild hy- Rationale: The purpose of hyperventi-
perventilation is used for a patient lation for a patient with a head injury
with a head injury. To evaluate the is reduction of ICP, and ICP should be
effectiveness of the therapy, the monitored to evaluate whether the ther-
nurse should apy is effective. Although oxygen satu-
a. monitor oxygen saturation. ration and ABGs are monitored in pa-
b. check arterial blood gases tient's receiving hyperventilation, they
(ABGs). do not provide data about whether the
c. monitor intracranial pressure therapy is successful in reducing ICP.
(ICP). Breath sounds are assessed, but they
d. assess patient breath sounds. are not helpful in determining whether
the hyperventilation is effective.
Cognitive Level: Application Text Refer-
ence: p. 1475
1. The nurse notes that a patient Correct Answer: C
with a head injury has a clear Rationale: If the drainage is cere-
nasal drainage. The most appropri- brospinal fluid (CSF) leakage from a
ate nursing action for this finding dural tear, glucose will be present. Fluid
is to leaking from the nose will have normal
a. obtain a specimen of the fluid nasal flora, so culture and sensitivity
and send for culture and sensitiv- will not be useful. A dural tear does
ity. increase the risk for infections such as
b. take the patient's temperature to meningitis, but the nurse should first
determine whether a fever is pre- determine whether the clear drainage
sent. is CSF. Blowing the nose is avoided to
c. check the nasal drainage for glu- prevent CSF leakage.
cose with a Dextrostik or Testape.
d. have the patient to blow the nose Cognitive Level: Application Text Refer-
and then check the nares for red- ence: p. 1481
ness. Nursing Process: Implementation
NCLEX: Physiological Integrity
2. A patient admitted with a head in- Correct Answer: C
jury has admission vital signs of Rationale: Systolic hypertension with
temperature 98.6° F (37° C), blood widening pulse pressure, bradycar-
pressure 128/68, pulse 110, and dia, and respiratory changes represent
respirations 26. Which of these vi- Cushing's triad and indicate that the
tal signs, if taken 1 hour after ad- ICP has increased and brain herniation
mission, will be of most concern to may be imminent unless immediate ac-
the nurse? tion is taken to reduce ICP. The other
a. Blood pressure 130/72, pulse 90, vital signs may indicate the need for
respirations 32 changes in treatment, but they are not
b. Blood pressure 148/78, pulse indicative of an immediately life-threat-
112, respirations 28 ening process.
c. Blood pressure 156/60, pulse 60,
respirations 14 Cognitive Level: Application Text Refer-
d. Blood pressure 110/70, pulse ence: p. 1469
120, respirations 30 Nursing Process: Assessment NCLEX:
Physiological Integrity
3. When assessing a patient with a Correct Answer: C
head injury, the nurse recognizes Rationale: LOC is the most sensitive
that the earliest indication of in- indicator of the patient's neurologic sta-
, ICP NCLEX style Questions with 100% Verified Answers
creased intracranial pressure (ICP) tus and possible changes in ICP. Vom-
is iting and sluggish pupil response to
a. vomiting. light are later signs of increased ICP.
b. headache. A headache can be caused by com-
c. change in level of conscious- pression of intracranial structures as
ness (LOC). the brain swells, but it is not unexpected
d. sluggish pupil response to light. after a head injury.
Cognitive Level: Comprehension Text
Reference: p. 1470
Nursing Process: Assessment NCLEX:
Physiological Integrity
4. A patient with a head injury has Correct Answer: C
an arterial blood pressure is 92/50 Rationale: The patient's cerebral perfu-
mm Hg and an intracranial pres- sion pressure is only 46 mm Hg, which
sure of 18 mm Hg. Which action by will rapidly lead to cerebral ischemia
the nurse is appropriate? and neuronal death unless rapid action
a. Document and continue to mon- is taken to reduce ICP and increase
itor the parameters. arterial BP. Documentation and moni-
b. Elevate the head of the patient's toring are inadequate responses to the
bed. patient's problem. Elevating the head
c. Notify the health care provider of the bed will lower the ICP but may
about the assessments. also lower cerebral blood flow and fur-
d. Check the patient's pupillary re- ther decrease CPP. Changes in pupil
sponse to light. response to light are signs of increased
ICP, so the nurse will only take more
time doing this without adding any use-
ful information.
Cognitive Level: Analysis Text Refer-
ence: pp. 1468-1469
Nursing Process: Implementation
NCLEX: Physiological Integrity
5. A patient has a systemic blood Correct Answer: C
pressure (BP) of 120/60 mm Hg and Rationale: The patient's CPP is 56, be-
an intracranial pressure of 24 mm low the normal of 70 to 100 mm Hg and
Hg. The nurse determines that the approaching the level of ischemia and
, ICP NCLEX style Questions with 100% Verified Answers
cerebral perfusion pressure (CPP) neuronal death. The patient has low
of this patient indicates cerebral blood flow/perfusion. Normal
a. high blood flow to the brain. ICP is 0 to 15 mm Hg.
b. normal intracranial pressure
(ICP). Cognitive Level: Application Text Refer-
c. impaired brain blood flow. ence: p. 1468
d. adequate cerebral perfusion. Nursing Process: Assessment NCLEX:
Physiological Integrity
6. When caring for a patient who has Correct Answer: B
had a head injury, which assess- Rationale: The change in level of con-
ment information is of most con- sciousness (LOC) is an indicator of in-
cern to the nurse? creased ICP and suggests that action
a. The blood pressure increases by the nurse is needed to prevent com-
from 120/54 to 136/62. plications. The change in BP should
b. The patient is more difficult to be monitored but is not an indicator of
arouse. a need for immediate nursing action.
c. The patient complains of a Headache is not unusual in a patient
headache at pain level 5 of a after a head injury. A slightly irregular
10-point scale. apical pulse is not unusual.
d. The patient's apical pulse is
slightly irregular. Cognitive Level: Application Text Refer-
ence: p. 1470
Nursing Process: Assessment NCLEX:
Physiological Integrity
7. When the nurse applies a painful Correct Answer: A
stimulus to the nailbeds of an un- Rationale: Internal rotation, adduction,
conscious patient, the patient re- and flexion of the arms in an uncon-
sponds with internal rotation, ad- scious patient is documented as decor-
duction, and flexion of the arms. ticate posturing. Extension of the arms
The nurse documents this as and legs is decerebrate posturing. Be-
a. decorticate posturing. cause the flexion is general, it does not
b. decerebrate posturing. indicate localization of pain or flexion
c. localization of pain. withdrawal.
d. flexion withdrawal.
Cognitive Level: Comprehension Text
Reference: p. 1472
, ICP NCLEX style Questions with 100% Verified Answers
Nursing Process: Assessment NCLEX:
Physiological Integrity
8. A patient with possible cerebral Correct Answer: B
edema has a serum sodium lev- Rationale: The patient's low sodium
el of 115 mEq/L (115 mmol/L), indicates that hyponatremia may be
a decreasing level of conscious- causing the cerebral edema, and the
ness (LOC) and complains of a nurse's first action should be to correct
headache. All of the following or- the low sodium level. Acetaminophen
ders have been received. Which (Tylenol) will have minimal effect on the
one should the nurse accomplish headache because it is caused by cere-
first? bral edema and increased ICP. Drawing
a. Administer acetaminophen ABGs and obtaining a CT scan may
(Tylenol) 650 mg orally. add some useful information, but the
b. Administer 5% hypertonic saline low sodium level may lead to seizures
intravenously. unless it is addressed quickly.
c. Draw blood for arterial blood
gases (ABGs). Cognitive Level: Application Text Refer-
d. Send patient to radiology for ence: p. 1470
computed tomography (CT) of the Nursing Process: Implementation
head. NCLEX: Physiological Integrity
9. Mechanical ventilation with a rate Correct Answer: C
and volume to maintain a mild hy- Rationale: The purpose of hyperventi-
perventilation is used for a patient lation for a patient with a head injury
with a head injury. To evaluate the is reduction of ICP, and ICP should be
effectiveness of the therapy, the monitored to evaluate whether the ther-
nurse should apy is effective. Although oxygen satu-
a. monitor oxygen saturation. ration and ABGs are monitored in pa-
b. check arterial blood gases tient's receiving hyperventilation, they
(ABGs). do not provide data about whether the
c. monitor intracranial pressure therapy is successful in reducing ICP.
(ICP). Breath sounds are assessed, but they
d. assess patient breath sounds. are not helpful in determining whether
the hyperventilation is effective.
Cognitive Level: Application Text Refer-
ence: p. 1475
