Adult Health 2 - Increased ICP NCLEX
Test. Newest 2025-2026. Questions &
Correct Verified Answers. Graded A
A client recovering from a head injury is arousable and participating in care.
The nurse determines that the client understands measures to prevent
elevations in intracranial pressure if the nurse observes the client doing
which of the following activities?
A. blowing the nose
B. isometric exercises
C. coughing vigorously
D. exhaling during repositioning - ANSD. exhaling during repositioning
(activities that increase intra-throacic and intra-abdominal pressures cause
indirect elevation of the ICP. Exhaling during activities such as
repositioning or pulling up in bed opens the glottis, which prevents intra-
thoracic pressure from rising).
A nurse is positioning a client with increased ICP. Which position would the
nurse avoid?
A. head midline
B. head turned to the side
C. neck in neutral position
D. head of bed elevated 30-45 degrees - ANSB. head turned to the side
The head of a client with increased ICP should be positioned so that the
head is in a neutral, midline position. The nurse should avoid flexing or
, extending the neck or turning the head side to side . The head of the bed
should be raised 30-45 degrees . Use of proper position promotes venous
drainage from the cranium to keep ICP down
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 - ANSCorrect 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.
A patient has a nursing diagnosis of risk for ineffective cerebral tissue
perfusion related to cerebral edema. An appropriate nursing intervention for
the patient is
a. avoiding positioning the patient with neck and hip flexion
b. maintaining hyperventilation to a PaCO2 of 15 to 20 mm Hg
c. clustering nursing activities to provide periods of uninterrupted rest
Test. Newest 2025-2026. Questions &
Correct Verified Answers. Graded A
A client recovering from a head injury is arousable and participating in care.
The nurse determines that the client understands measures to prevent
elevations in intracranial pressure if the nurse observes the client doing
which of the following activities?
A. blowing the nose
B. isometric exercises
C. coughing vigorously
D. exhaling during repositioning - ANSD. exhaling during repositioning
(activities that increase intra-throacic and intra-abdominal pressures cause
indirect elevation of the ICP. Exhaling during activities such as
repositioning or pulling up in bed opens the glottis, which prevents intra-
thoracic pressure from rising).
A nurse is positioning a client with increased ICP. Which position would the
nurse avoid?
A. head midline
B. head turned to the side
C. neck in neutral position
D. head of bed elevated 30-45 degrees - ANSB. head turned to the side
The head of a client with increased ICP should be positioned so that the
head is in a neutral, midline position. The nurse should avoid flexing or
, extending the neck or turning the head side to side . The head of the bed
should be raised 30-45 degrees . Use of proper position promotes venous
drainage from the cranium to keep ICP down
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 - ANSCorrect 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.
A patient has a nursing diagnosis of risk for ineffective cerebral tissue
perfusion related to cerebral edema. An appropriate nursing intervention for
the patient is
a. avoiding positioning the patient with neck and hip flexion
b. maintaining hyperventilation to a PaCO2 of 15 to 20 mm Hg
c. clustering nursing activities to provide periods of uninterrupted rest
