ICP Actual Questions and Correct Answers
Q1
When assessing a patient with a head injury, the nurse recognizes that the earliest indication of
increased intracranial pressure (ICP) is vomiting. headache. change in level of consciousness
(LOC). sluggish pupil response to light.
Answer: C LOC is the most sensitive indicator of the patient's neurologic status and
possible changes in ICP. Vomiting and sluggish pupil response to light
Q2
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? Document and continue to
monitor the parameters. Elevate the head of the patient's bed. Notify the health care provider
about the assessments. Check the patient's pupillary response to light.
Answer: C The patient's cerebral perfusion pressure is only 46 mm Hg, which will
rapidly lead to
Q3
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 high blood flow to the brain. normal intracranial pressure (ICP). impaired brain blood
flow. adequate cerebral perfusion.
Answer: C The patient's CPP is 56, below the normal of 70 to 100 mm Hg and
approaching the level of
Q4
The patient is more difficult to arouse. The patient complains of a headache at pain level 5 of a
10-point scale.
Answer: The patient complains of a
Q5
The patient's apical pulse is slightly irregular.
Answer: B The change in level of consciousness (LOC) is an indicator of increased ICP
and suggests that action by the nurse is needed to prevent
, Q6
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
decorticate posturing. decerebrate posturing. localization of pain. flexion withdrawal.
Answer: A Internal rotation, adduction, and flexion of the arms in an unconscious
patient is
Q7
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
Answer: Cognitive Level: Application Text Reference: p. 1470 Nursing Process:
Implementation NCLEX:
Q8
Metabolic and nutritional needs of the patient with increased ICP are best met with enteral
feedings that are low in sodium the simple glucose available in D5W IV solutions a fluid
restriction that promotes a moderate dehydration
Answer: the simple glucose available in D5W IV solutions
Q9
When assessing the body function of a patient with increased ICP, the nurse should initially
assess corneal reflex testing extremity strength testing pupillary reaction to light circulatory
and respiratory status
Answer: corneal reflex testing
Q10
When a patient is admitted to the emergency department following a head injury, the nurse's
first priority in management of the patient once a patent airway is confirmed is maintaining
cervical spine precautions determining the presence of increased ICP monitoring for changes in
neurologic status establishing IV access with a large-bore catheter In addition to monitoring for
a patent airway
Answer: maintaining cervical spine precautions
Q1
When assessing a patient with a head injury, the nurse recognizes that the earliest indication of
increased intracranial pressure (ICP) is vomiting. headache. change in level of consciousness
(LOC). sluggish pupil response to light.
Answer: C LOC is the most sensitive indicator of the patient's neurologic status and
possible changes in ICP. Vomiting and sluggish pupil response to light
Q2
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? Document and continue to
monitor the parameters. Elevate the head of the patient's bed. Notify the health care provider
about the assessments. Check the patient's pupillary response to light.
Answer: C The patient's cerebral perfusion pressure is only 46 mm Hg, which will
rapidly lead to
Q3
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 high blood flow to the brain. normal intracranial pressure (ICP). impaired brain blood
flow. adequate cerebral perfusion.
Answer: C The patient's CPP is 56, below the normal of 70 to 100 mm Hg and
approaching the level of
Q4
The patient is more difficult to arouse. The patient complains of a headache at pain level 5 of a
10-point scale.
Answer: The patient complains of a
Q5
The patient's apical pulse is slightly irregular.
Answer: B The change in level of consciousness (LOC) is an indicator of increased ICP
and suggests that action by the nurse is needed to prevent
, Q6
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
decorticate posturing. decerebrate posturing. localization of pain. flexion withdrawal.
Answer: A Internal rotation, adduction, and flexion of the arms in an unconscious
patient is
Q7
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
Answer: Cognitive Level: Application Text Reference: p. 1470 Nursing Process:
Implementation NCLEX:
Q8
Metabolic and nutritional needs of the patient with increased ICP are best met with enteral
feedings that are low in sodium the simple glucose available in D5W IV solutions a fluid
restriction that promotes a moderate dehydration
Answer: the simple glucose available in D5W IV solutions
Q9
When assessing the body function of a patient with increased ICP, the nurse should initially
assess corneal reflex testing extremity strength testing pupillary reaction to light circulatory
and respiratory status
Answer: corneal reflex testing
Q10
When a patient is admitted to the emergency department following a head injury, the nurse's
first priority in management of the patient once a patent airway is confirmed is maintaining
cervical spine precautions determining the presence of increased ICP monitoring for changes in
neurologic status establishing IV access with a large-bore catheter In addition to monitoring for
a patent airway
Answer: maintaining cervical spine precautions
