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ICP EXAM 6 QUESTIONS AND 100% CORRECT ANSWERS
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ICP EXAM 6 QUESTIONS AND 100% CORRECT ANSWERSA concussion is a closed head injury in which, according to the nurse
a. no brain tissue is bruised
b. no loss of consciousness occurs
c. there is amnesia related to the incident
d. there are no subsequent symptoms - ANSWER c
A concussion is a closed head injury where there is brief disruption of consciousness,
amnesia, and subsequent headaches which may last for several weeks
The nurse has created a plan to maintain the intracranial pressure within the normal
range for a client who had a craniotomy 12 hours earlier. Which of the following would
the nurse implement? SATAA) Encourage the client to cough and eliminate secretionsB)
Elevate the head to 15 to 20 degreesC) Notify the HCP if ICP is > 15 mm HgD) Monitor
neurological status utilizing the Glasgow coma scale
e. stimulate the client with active range of motion exercises - ANSWER b c d
The nurse should elevate the head of the bed between 15 to 20 degrees and monitor
neurologic status. An ICP > 15 indicates ICP. Coughing and range of motion will
increase ICP
6. A unconscious client with multiple injuries to the head and neck is brought to the
emergency department. What is the first action by the nurse?
a. establish an airway
b. identify the client
c, stop bleeding from open wounds
d. check for a neck fracture - ANSWER the highest priority for a client with multiple head
and neck injuries is to establish an open airway for effective ventilation and
oxygenation. Unless the client has a patent airway other measures will he futile.
determining the clients identity, blood loss, and stopping bleeding from open wounds,
and checking for fracture are important but airway should be established first
,8. a client is at risk for increased intracranial pressure. which finding is the priority for
the nurse to monitor
a. unequal pupil size
b. decreasing systolic blood pressure
c. tachycardia
d. decreasing body temperature - ANSWER a
increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve.
increasing ICP causes an increase in the systolic pressure, which reflects the additional
pressure needed to perfuse the brain
9. When a client who has sustained a head injury begins to have clear drainage from the
nose, the nurse should initially do which of the following?
a. Squeeze the nares
b. Tilt the head back
c. Collect the drainage
d. Give an antihistamine for postnasal drip ANSWER c
The clear drainage should be sent to the lab for evaluation to identify whether the
drainage is nasal drainage of cerebrospinal fluid.
10. Which breathing pattern demonstrates increased intracranial pressure in the brain
stem
a. slow irregular respirations
b. tachypnea
c. asynchronous thoracoabdominal movement
d. nasal flaring - ANS neural control of respiration occurs in the brain stem.
Deterioration and pressure produce slow and irregular respirations.
11. A client has an ICP of 20 mm Hg. The nurse should:
a. Provide the client with a warming blanket
b. Administer low dose barbiturates
, c. Instruct the client to take deep breaths to hyperventilate
d. Fluid restriction - ANS c
Normal ICP is 15mmHg or less. Hyperventilation causes vasoconstriction. Which
decreases cerbrospinal fluid and blood volume, two important factors for reducing a
sustained ICP of 20 mm Hg
12. The nurse is evaluating the client with increasing intracranial pressure. The nurse
should notify the health care provider about which early change in the client's
condition?
A. Widening pulse pressure
B. decrease in the pulse rate
C. Dilated fixed pupils
d. decrease in level of consciousness - ANSWER d
An decrease in the clients LOC is an early indicatory of deterioration of the clients
neurologic status. Changes in LOC such as restlessness and irritability may be subtle
13. The client has sustained increased intracranial pressure of 20 mm Hg. Which client
position would be most appropriate?
a. The head of bed elevated to 15-20 degrees
b. Trendelburg's position
c. left sims position
d. the head elevated on two pillows - ANSWER a
the clients ICP is elevated and the client should be positioned to avoid extreme neck
flexion or extension
14. the nurse administers mannitol to the client with increased intracranial pressure.
which parameter requires close monitoring
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