RNSG 2432- Exam 3 UPDATED
QUESTIONS AND CORRECT ANSWERS
ICP- Increased Intracranial Pressure - CORRECT ANSWER Force or pressure
measured in brain/CSF compartment
What is an abnormal ICP? - CORRECT ANSWER Sustained ICP >20
What factors affect ICP? - CORRECT ANSWER Changes in temperature,
arterial/venous pressure, intra-abdominal and intra-thoracic pressure, posture.
What causes increased ICP? - CORRECT ANSWER Head injury
Brain Injury
Hematoma
Stroke
Cerebral edema
What does cerebral blood flow regulate? - CORRECT ANSWER Maintains perfusion
pressure within normal limits
What affects cerebral blood flow? - CORRECT ANSWER Systemic blood pressure-
- Increased BP -> Vessel vasoconstriction -> decreased blood flow to brain
Hypoxia- normal PaO2= 80-100
Accumulation of lactic acid
How do you calculate cerebral perfusion pressure (CPP)? - CORRECT
ANSWER CPP= MAP - ICP
Normal = 60-100
<50 associated with ischemia and neuron death
Minimum MAP to maintain CBF= 70
,What do you assess when assessing increased ICP?
ASSESSMENTS - CORRECT ANSWER Respiratory rate & Pattern
Glasgow coma scale
- Lowest score =3
-INTUBATE IF LESS THAN 8
Pupils
Eye mvmt
Extremity strength
Vitals- BP, RR, HR, TEMP
What labs are you trending?
LABS/DIAGNOSTICS - CORRECT ANSWER CT scan- #1 fastest test
ICP- EVD
CBC- WBC (inc. risk of infection), H&H
Coagulation profile (PT/INR)- if patient is clotting too fast then there could be too much
blood in the brain.
Electrolytes- Sodium
Serum Osmolality- blood concentration- check before giving mannitol (PRIORITY)
Serum Creatinine
ABG- acidosis=vasodilation
CSF analysis
What is a normal WBC? - CORRECT ANSWER 4,500-11,00
What is a normal hemoglobin? - CORRECT ANSWER 12-17.5
What is a normal hematocrit? - CORRECT ANSWER 36-50%
, What is a normal PT/INR? - CORRECT ANSWER 11-13.5 seconds/0.8-1.2
What is a normal sodium? - CORRECT ANSWER 135-145 mEq/L
What is a normal serum osmolality? - CORRECT ANSWER 275-295 mOsm/kg
What is a normal serum creatinine? - CORRECT ANSWER Males: 0.74 to 1.35 mg/dL
(61.9 to 114.9 µmol/L)
Females: 0.59 to 1.04 mg/dL (52.2 to 91.9 µmol/L
What are early signs and symptoms of increased ICP? - CORRECT ANSWER Change
in level of consciousness:irritability, restless. Altered mental status.
- These are normally the first sign
Change in motor ability
Unexpected vomiting
Ocular changes
What are late signs and symptoms of increased ICP? - CORRECT ANSWER Body
posturing
Vital sign changes- CUSHINGS TRIAD
- Increased BP
- Bradycardia
- Irregular respirations
The critical care nurse provides care for a client who is admitted for the treatment of head
trauma and prescribed mannitol to reduce intracranial pressure. Which electrolyte is the
priority for the nurse to monitor?
Potassium
Chloride
QUESTIONS AND CORRECT ANSWERS
ICP- Increased Intracranial Pressure - CORRECT ANSWER Force or pressure
measured in brain/CSF compartment
What is an abnormal ICP? - CORRECT ANSWER Sustained ICP >20
What factors affect ICP? - CORRECT ANSWER Changes in temperature,
arterial/venous pressure, intra-abdominal and intra-thoracic pressure, posture.
What causes increased ICP? - CORRECT ANSWER Head injury
Brain Injury
Hematoma
Stroke
Cerebral edema
What does cerebral blood flow regulate? - CORRECT ANSWER Maintains perfusion
pressure within normal limits
What affects cerebral blood flow? - CORRECT ANSWER Systemic blood pressure-
- Increased BP -> Vessel vasoconstriction -> decreased blood flow to brain
Hypoxia- normal PaO2= 80-100
Accumulation of lactic acid
How do you calculate cerebral perfusion pressure (CPP)? - CORRECT
ANSWER CPP= MAP - ICP
Normal = 60-100
<50 associated with ischemia and neuron death
Minimum MAP to maintain CBF= 70
,What do you assess when assessing increased ICP?
ASSESSMENTS - CORRECT ANSWER Respiratory rate & Pattern
Glasgow coma scale
- Lowest score =3
-INTUBATE IF LESS THAN 8
Pupils
Eye mvmt
Extremity strength
Vitals- BP, RR, HR, TEMP
What labs are you trending?
LABS/DIAGNOSTICS - CORRECT ANSWER CT scan- #1 fastest test
ICP- EVD
CBC- WBC (inc. risk of infection), H&H
Coagulation profile (PT/INR)- if patient is clotting too fast then there could be too much
blood in the brain.
Electrolytes- Sodium
Serum Osmolality- blood concentration- check before giving mannitol (PRIORITY)
Serum Creatinine
ABG- acidosis=vasodilation
CSF analysis
What is a normal WBC? - CORRECT ANSWER 4,500-11,00
What is a normal hemoglobin? - CORRECT ANSWER 12-17.5
What is a normal hematocrit? - CORRECT ANSWER 36-50%
, What is a normal PT/INR? - CORRECT ANSWER 11-13.5 seconds/0.8-1.2
What is a normal sodium? - CORRECT ANSWER 135-145 mEq/L
What is a normal serum osmolality? - CORRECT ANSWER 275-295 mOsm/kg
What is a normal serum creatinine? - CORRECT ANSWER Males: 0.74 to 1.35 mg/dL
(61.9 to 114.9 µmol/L)
Females: 0.59 to 1.04 mg/dL (52.2 to 91.9 µmol/L
What are early signs and symptoms of increased ICP? - CORRECT ANSWER Change
in level of consciousness:irritability, restless. Altered mental status.
- These are normally the first sign
Change in motor ability
Unexpected vomiting
Ocular changes
What are late signs and symptoms of increased ICP? - CORRECT ANSWER Body
posturing
Vital sign changes- CUSHINGS TRIAD
- Increased BP
- Bradycardia
- Irregular respirations
The critical care nurse provides care for a client who is admitted for the treatment of head
trauma and prescribed mannitol to reduce intracranial pressure. Which electrolyte is the
priority for the nurse to monitor?
Potassium
Chloride
