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Exam (elaborations)

ICP EXAM 6 Questions With Correct Answers

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ICP EXAM 6 Questions With Correct Answers The nurse describes a concussion as a closed head injury in which 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 - answerc a concussion is a closed head...

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  • October 18, 2024
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sirjoel
©SIRJOEL EXAM SOLUTIONS
12/3/2024 11:27AM



ICP EXAM 6 Questions With Correct
Answers


The nurse describes a concussion as a closed head injury in which

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 in which there is a brief disruption of consciousness,

amnesia, and subsequent headaches that may last for several weeks

the nurse has established a goal to maintain intracranial pressure within the normal range for a

client who had a craniotomy 12 hours ago. what should the nurse doSATA

a. encourage the client to cough to expectorate secretions

b. elevate the head to 15 to 20 degrees

c. contact the HCP if ICP is > 15 mm Hg

, ©SIRJOEL EXAM SOLUTIONS
12/3/2024 11:27AM


d. monitor neurologic status using 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. an unconscious client with multiple injuries to the head and neck arrives in the emergency

department. what should the nurse do first?

a. establish an airway

b. determine the identity of 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

, ©SIRJOEL EXAM SOLUTIONS
12/3/2024 11:27AM


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. what should the nurse do first when a client with a head injury begins to have clear drainage

from the nose?

a. compress the nares

b. tilt the head back

c. collect the drainage


d. administer an antihistamine for postnasal drip - answer✔c




clear drainage must be analyzed to determine whether it is nasal drainage or cerbrospinal fluid

10. which respiratory pattern indictes increasing intracranial pressure in the brain stem

a. slow irregular respirations

, ©SIRJOEL EXAM SOLUTIONS
12/3/2024 11:27AM


b. rapid shallow respirations

c. asymmetric chest excursion


d. nasal flaring - answer✔neural control of respiration takes place in the brain stem. deteroriation

and pressure produce slow and irregular respirations.

11. a client has an increased intracranial pressure of 20 mmHg. The nurse should:

a. give the client a warming blanket

b. administer low dose barbiturates

c. encourage the client to take deep breaths to hyperventilate


d. restrict fluids - answer✔c




normal icp is 15mmHg or less. hyperventilation causes vasoconstriction. which reduces

cerbrospinal fluid and blood volume, two important factors for reducing a sustained ICP of 20

mm Hg

12. the nurse is assessing a client with increasing intracranial pressure. the nurse should notify

the healthcare provider about which early change in the clients condition?

a. widening pulse pressure

b. decrease in the pulse rate

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