Ch 61: ICP Flashcards

Question

When measuring ICP in a patient, which location allows for the most accurate and direct reading? A. Subdural space B. Subarachnoid space C. Ventricular space D. Epidural space

Answer 1

C. Ventricular space Rationale: The ventricular system provides the most direct and accurate measurement of ICP and allows for therapeutic CSF drainage, making it the gold standard for monitoring.

Answer 2

B. Elevate the head of the bed to 30 degrees Rationale: Elevating the HOB promotes venous drainage and decreases ICP. It is a noninvasive first-line intervention. Bearing down increases intrathoracic pressure and would worsen ICP.

Answer 3

The hydrostatic force measured in the brain CSF compartment

Answer 4

C. Displacement of CSF into spinal subarachnoid space Rationale: One of the body’s first compensatory responses to increased intracranial volume is to reduce CSF volume by displacing it into the spinal subarachnoid space, or altering its production and absorption.

Answer 5

B. Compression of brain tissue Rationale: In later stages of compensation, brain tissue volume adapts through distention of the dura and compression of brain tissue to maintain normal ICP, though this is limited and eventually leads to ischemia.

Answer 6

A. Cerebral venous vasoconstriction Rationale: The second category of compensatory mechanisms involves changes in intracranial blood volume, including regional vasoconstriction or dilation and venous outflow alterations.

Answer 7

D. Decompensation is occurring, leading to ischemia Rationale: When compensatory mechanisms are exhausted, ICP rises uncontrollably, leading to tissue compression and cerebral ischemia—a dangerous, decompensated state.

Answer 8

A. Collapse of cerebral veins D. Compression of brain tissue E. Displacement of CSF to the spinal subarachnoid space Rationale: Collapse of cerebral veins, compression of brain tissue, and CSF displacement are normal compensatory mechanisms. Increased CSF production and arterial vasodilation increase ICP rather than reduce it.

Answer 9

B. Stable neurologic exam Rationale: A stable neurologic exam suggests cerebral perfusion is maintained, indicating that compensatory mechanisms (such as CSF displacement or venous outflow changes) are effectively managing the volume shift.

Answer 10

B. “Venous outflow can adapt to help manage increased volume.” Rationale: One of the second-line compensatory mechanisms includes adjusting venous outflow to reduce cerebral blood volume and help maintain ICP.

Answer 11

A. Rapid increase in ICP and signs of herniation Rationale: Once compensatory mechanisms are overwhelmed, ICP rises rapidly. This can lead to brain tissue compression and potentially fatal herniation syndromes.

Answer 12

C. The brain depends on a constant supply of oxygen and glucose due to high metabolic demand. Rationale: The brain uses 20% of the body’s oxygen and 25% of its glucose, making continuous blood flow essential to prevent hypoxia and ischemia.

Answer 13

D. Decreased CBF has led to cerebral hypoxia and altered function Rationale: The brain requires consistent blood flow to receive oxygen and glucose. A drop in cerebral perfusion compromises brain function, leading to symptoms like confusion and altered mental status.

Answer 14

A. Even brief interruptions in CBF can cause permanent brain damage. Rationale: The brain has minimal ability to store oxygen or glucose, so interruptions in CBF—even for a short time—can cause irreversible damage.

Answer 15

A. The global CBF is approximately 50 mL/min/100 g of brain tissue. C. Adequate CBF is essential for delivering glucose to the brain. E. Maintaining CBF is critical due to the brain’s high metabolic demands. Rationale: Global CBF is about 50 mL/min/100 g of tissue. The brain uses 25% of the body’s glucose and 20% of its oxygen, making options A, C, and E correct. The brain cannot survive long without blood flow.

Answer 16

B. Bradycardia with a MAP of 52 mm Hg Rationale: Cerebral perfusion is pressure-dependent. A MAP less than 60 mm Hg can critically reduce cerebral blood flow, leading to symptoms of cerebral hypoperfusion such as confusion and dizziness.

Answer 17

The automatic adjustment in the diameter of the cerebral blood vessels by the brain to maintain a constant blood flow with changes in arterial blood pressure

Answer 18

the pressure needed to ensure blood flow to the brain

Answer 19

B. The MAP is below the lower limit of autoregulation, decreasing CBF. Rationale: A MAP <70 mm Hg is below the threshold of effective autoregulation, causing a drop in cerebral blood flow and symptoms of ischemia like blurred vision.

Answer 20

C. CPP is 65 mm Hg, which may not be sufficient in localized swelling. Rationale: CPP = MAP − ICP → 90 − 25 = 65 mm Hg. While this is technically within normal limits (60–100), in patients with localized injury or stroke, a higher CPP may be required to ensure adequate perfusion to damaged areas.

Answer 21

B. It ensures consistent cerebral blood flow by adjusting vessel diameter. Rationale: Autoregulation maintains consistent cerebral blood flow (CBF) despite changes in systemic pressure by adjusting cerebral vessel diameter.

Answer 22

A. CPP = MAP − ICP B. Normal CPP is 60–100 mm Hg C. CPP < 50 mm Hg may cause ischemia Rationale: Options A–C are correct based on standard definitions. Option D is false—CPP <30 mm Hg is incompatible with life. Option E is false because CPP may not reflect local perfusion due to swelling or compression.

Answer 23

A. Prepare for emergency CSF drainage. Rationale: CPP = 80 − 30 = 50 mm Hg, indicating risk for cerebral ischemia. Immediate interventions to lower ICP (e.g., draining CSF) are priority to prevent neuron death.

Answer 24

C. 150 mm Hg Rationale: The upper limit of autoregulation is a MAP of 150 mm Hg. Beyond this, vessels can no longer constrict to protect brain tissue, increasing risk of hyperperfusion and damage.

Answer 25

A. To enhance CPP and perfusion to affected brain tissue Rationale: In localized injury like stroke, raising MAP helps elevate CPP in areas of compromised perfusion and prevent further ischemic injury.

Answer 26

D. CPP is 50 mm Hg, which may lead to ischemia Rationale: CPP = 95 − 35 = 60 mm Hg, which is borderline low. In a patient with brain trauma, local swelling may mean even 60 mm Hg is insufficient, putting them at risk for ischemia.

Answer 27

B. MAP of 160 mm Hg with normal ICP Rationale: A MAP >150 mm Hg exceeds the upper limit of autoregulation. Beyond this, vessels are maximally constricted, losing their ability to regulate CBF.

Answer 28

A. Cerebral blood flow becomes pressure-dependent B. CPP falls to dangerous levels D. Local ischemia may occur Rationale: When autoregulation fails, CBF varies directly with MAP (A), CPP can fall dangerously (B), and local ischemia (D) can result. Options C and E are false—vessels can no longer adjust, and brain metabolic needs remain high.

Answer 29

B. Lower head of bed to reduce ICP Rationale: Lowering the head of bed can reduce ICP, which increases CPP when MAP remains constant (CPP = MAP − ICP). Maintaining a CPP >70 mm Hg ensures adequate perfusion.

Answer 30

C. CPP is 55 mm Hg, which is below the threshold for adequate perfusion. Rationale: CPP = 65 − 10 = 55 mm Hg. This is below the normal limit (60 mm Hg), indicating cerebral hypoperfusion and ischemic symptoms.

Answer 31

A. Increased resistance impairs brain perfusion. Rationale: As cerebrovascular resistance increases (due to arteriolar constriction or swelling), blood flow is reduced even if CPP appears normal.

Answer 32

C. To support CPP and maintain oxygen delivery Rationale: Maintaining MAP ensures adequate CPP when ICP is elevated, supporting cerebral oxygenation and perfusion.

Answer 33

D. Administer vasopressors to increase MAP Rationale: CPP = 70 − 22 = 48 mm Hg. Vasopressors will raise MAP, which increases CPP and improves perfusion. Other options either reduce MAP or are not clinically appropriate for increasing CPP.

Answer 34

B. Vasodilation leading to increased CBF Rationale: An elevated PaCO₂ causes cerebral vasodilation, decreasing cerebrovascular resistance and increasing CBF.

Answer 35

A. 30 mm Hg Rationale: A PaCO₂ of 30 mm Hg is below the normal range, leading to cerebral vasoconstriction, increased resistance, and decreased CBF.

Answer 36

A. Elevated PaCO₂ B. Decreased PaO₂ below 50 mm Hg D. Acidosis Rationale: Elevated PaCO₂ and decreased PaO₂ below 50 mm Hg cause vasodilation, increasing CBF. Acidosis (increased hydrogen ion concentration) also leads to vasodilation. Alkalosis and hyperventilation (which lowers PaCO₂) cause vasoconstriction, decreasing CBF.

Answer 37

C. Vasodilation to increase CBF Rationale: A PaO₂ below 50 mm Hg triggers cerebral vasodilation to increase CBF and improve oxygen delivery.

Answer 38

A. Vasodilation to increase CBF Rationale: Acidosis leads to vasodilation in cerebral vessels, decreasing resistance and increasing CBF to meet metabolic demands.

Answer 39

B. Hyperventilation-induced hypocapnia Rationale: Hypocapnia from hyperventilation causes cerebral vasoconstriction, which can impair autoregulation and decrease CBF.

Answer 40

B. Decrease cerebral blood flow Rationale: Hyperventilation lowers PaCO₂, causing cerebral vasoconstriction, which decreases CBF and subsequently lowers intracranial pressure.

Answer 41

B. PaCO₂ 50 mm Hg, PaO₂ 60 mm Hg, pH 7.35 Rationale: Elevated PaCO₂ and lower PaO₂ levels promote cerebral vasodilation to increase CBF.

Answer 42

A. Severe hypoxia B. Traumatic brain injury C. Hypercapnia E. Systemic infections Rationale: Severe hypoxia, traumatic brain injury, hypercapnia, and systemic infections can disrupt the mechanisms of cerebral autoregulation. Hypocapnia typically causes vasoconstriction but does not directly lead to loss of autoregulation.

Answer 43

B. Increases due to vasodilation Rationale: Metabolic acidosis increases hydrogen ion concentration, leading to cerebral vasodilation and increased CBF.

Answer 44

D. Decreases due to loss of perfusion pressure Rationale: Cardiac arrest leads to a cessation of effective circulation, resulting in decreased cerebral perfusion pressure and CBF.

Answer 45

D. Causes vasodilation, increasing CBF Rationale: Hypercapnia (elevated PaCO₂) causes cerebral vasodilation, increasing CBF and potentially raising intracranial pressure.

Answer 46

A. Administer mannitol to decrease intracranial pressure Rationale: Mannitol is an osmotic diuretic used to reduce intracranial pressure by drawing fluid from the brain tissue into the vascular space. A lumbar puncture is contraindicated in increased ICP due to risk of brain herniation. Plasmapheresis is not indicated here. Cushing’s triad indicates late signs of brain herniation, so waiting for this would delay care.

Answer 47

D. Unilateral fixed and dilated pupil Rationale: A unilateral fixed and dilated pupil indicates increased ICP with possible herniation, which is a neurologic emergency. Other values are concerning but not immediately life-threatening.

Answer 48

A. Brain abscess B. Cerebral edema D. Brain tumor Rationale: Brain abscess, cerebral edema, and brain tumors are all known causes of increased ICP. Liver failure and hypokalemia are not direct causes.

Answer 49

C. Cerebral acidosis impairs autoregulation and increases cerebral edema Rationale: Cerebral acidosis leads to impaired autoregulation and worsens cerebral edema, contributing to sustained ICP elevation. Hypocapnia causes vasoconstriction, not vasodilation.

Answer 50

C. Elevate the head of the bed to 30 degrees Rationale: Elevating the HOB to 30 degrees promotes venous drainage and decreases ICP. Supine position can worsen ICP. Surgery and opioids may be appropriate later but are not the first nursing priority.

Answer 51

D. It results in compression of the medulla and cessation of respiratory function Rationale: Brain herniation compresses the medulla, which contains the respiratory center. If unrelieved, this can result in respiratory arrest and death.

Answer 52

A. Bradycardia, widened pulse pressure, and irregular respirations Rationale: This describes Cushing’s triad, a classic late sign of increased ICP and impending herniation.

Answer 53

A. Loss of gag reflex Rationale: The gag reflex is controlled by cranial nerves IX and X, which emerge from the brainstem. Loss of this reflex may indicate brainstem dysfunction or herniation.

Answer 54

C. Cerebral edema and hypercapnia cause further acidosis and vasodilation Rationale: Hypercapnia and lactic acid both contribute to acidosis, leading to vasodilation and further increasing ICP.

Answer 55

D. Hyperoxygenate and prepare for mechanical ventilation Rationale: Hyperoxygenation can reduce ICP by preventing hypoxia. Mechanical ventilation may be necessary if respiratory effort is compromised. Trendelenburg increases ICP and should be avoided.

Answer 56

D. Brainstem compression Rationale: Cheyne-Stokes respirations and pupillary changes are classic signs of brainstem involvement, suggesting worsening herniation and increased ICP.

Answer 57

A. Elevate HOB to 30 degrees B. Keep neck in a neutral position D. Cluster care to minimize disturbances Rationale: Elevating HOB and neutral neck positioning promote venous drainage. Clustering care reduces stimulation. Vigorous suctioning and rapid fluids can raise ICP.

Answer 58

A. Respiratory arrest Rationale: The respiratory center is in the medulla. Compression leads to respiratory failure and death if not reversed quickly.

Answer 59

increased accumulation of fluid in the extravascualr spaces of brain tissue

Answer 60

B. Disruption of the blood-brain barrier allowing fluid to shift into extracellular space Rationale: Vasogenic edema is caused by a breakdown in the blood-brain barrier, typically due to tumors or trauma, allowing plasma proteins and fluid to leak into the extracellular space, increasing brain volume and ICP.

Answer 61

A. Cytotoxic edema Rationale: Cytotoxic edema is common after ischemia or hypoxia. It results from failure of the sodium-potassium pump in brain cells, leading to intracellular swelling and increased brain volume.

Answer 62

C. Obstructive hydrocephalus causing CSF leakage into brain parenchyma Rationale: Interstitial edema occurs primarily with hydrocephalus, where CSF flows across the ependymal lining into surrounding brain tissue, increasing brain volume and ICP.

Answer 63

D. Vomiting without nausea Rationale: Vomiting without nausea (projectile vomiting) is a classic sign of increased ICP, commonly associated with worsening cerebral edema.

Answer 64

A. Brain tumor B. Head trauma E. Meningitis Rationale: Vasogenic edema is caused by BBB disruption, commonly seen with tumors, trauma, and infections like meningitis. Stroke and hypoxia more often result in cytotoxic edema.

Answer 65

D. Administering hypertonic saline solution Rationale: Hypertonic saline draws fluid from swollen brain cells into the intravascular space, reducing cerebral edema and ICP. Flat positioning and increased fluids can worsen ICP; deep suctioning may increase ICP due to stimulation.

Answer 66

B. Disruption of the blood-brain barrier Rationale: Vasogenic cerebral edema is caused by the disruption of the blood-brain barrier, which allows large molecules (like proteins and blood products) to enter brain tissue, leading to edema.

Answer 67

C. Blood-brain barrier disruption allows blood products and proteins to enter the brain Rationale: In vasogenic cerebral edema, the disruption of the blood-brain barrier allows large molecules, including proteins and blood products, to enter the brain, resulting in swelling and increased ICP.

Answer 68

C. A change in mental status, from confusion to coma Rationale: A rapid decline in mental status, including confusion progressing to coma, is indicative of worsening cerebral edema and increased ICP.

Answer 69

A. Systemic blood pressure and the site of the brain injury Rationale: Systemic blood pressure and the site of the brain injury influence the extent of vasogenic edema because the blood-brain barrier’s disruption can vary based on these factors.

Answer 70

B. Osmotic changes leading to fluid accumulation in brain tissue Rationale: In vasogenic cerebral edema, osmotic changes occur as large molecules enter brain tissue, creating an osmotic gradient that draws fluid into the extracellular space, leading to increased ICP.

Answer 71

C. Sudden onset of severe headache with altered mental status Rationale: A sudden onset of severe headache combined with altered mental status, such as confusion, is indicative of worsening cerebral edema and requires immediate attention.

Answer 72

D. Neurologic status, including level of consciousness Rationale: Changes in neurologic status, including level of consciousness, are critical to monitor in patients with vasogenic cerebral edema as it can rapidly progress from confusion to coma and death.

Answer 73

D. “Vasogenic edema occurs mainly in the gray matter of the brain.” Rationale: Vasogenic edema occurs primarily in the white matter, not the gray matter. This reflects a misunderstanding that needs correction.

Answer 74

A. Administering corticosteroids to reduce inflammation Rationale: Corticosteroids are commonly used to reduce cerebral edema by decreasing inflammation and stabilizing the blood-brain barrier, which helps reduce ICP.

Answer 75

B) Fluid and protein shifts into the cells Rationale: Cytotoxic cerebral edema results from the disruption of cell membranes in brain tissue, causing fluid and protein to shift from the extracellular space into the cells, leading to cellular swelling. The blood-brain barrier remains intact in this type of edema, differentiating it from vasogenic edema.

Answer 76

B) Impaired cellular function due to swelling and fluid shift into the cells Rationale: Cytotoxic cerebral edema occurs due to fluid and protein shifts into the brain cells, resulting in cellular swelling. This swelling impairs cellular function and causes tissue damage, unlike vasogenic edema, which involves the leakage of large molecules due to blood-brain barrier disruption.

Answer 77

D) Sudden onset of confusion and a change in mental status Rationale: Cytotoxic cerebral edema causes swelling of brain cells, which may lead to a gradual or sudden decline in neurological function. Symptoms often include confusion, changes in mental status, and possibly loss of consciousness as the swelling increases. Severe cases may progress to coma or death, but subtle changes in mental status are an early sign.

Answer 78

A) Monitoring the patient’s oxygenation and ensuring adequate ventilation Rationale: Oxygenation is critical in managing cytotoxic cerebral edema, as hypoxia or anoxia exacerbates brain injury. Ensuring adequate oxygenation helps prevent further cellular damage and reduces the risk of worsening edema. Hyperventilation or elevated CO2 levels could worsen edema, so managing oxygenation is crucial.

Answer 79

A) Decreased serum sodium levels Rationale: Cytotoxic cerebral edema can occur in the setting of hypoxia and anoxia. A common result is the syndrome of inappropriate antidiuretic hormone (SIADH) secretion, which leads to water retention and dilutional hyponatremia (decreased serum sodium levels). This electrolyte imbalance occurs due to the kidneys’ retention of water in response to elevated ADH levels.

Answer 80

C) Hypertonic saline to decrease intracranial pressure Rationale: Hypertonic saline is commonly used to reduce intracranial pressure in patients with cerebral edema by drawing fluid out of brain cells into the bloodstream. Corticosteroids are more effective for vasogenic edema, not cytotoxic edema. Dehydration therapy is not an appropriate method for managing cerebral edema and could lead to further complications.

Answer 81

a buildup of fluid in the brain

Answer 82

B) Ventricular enlargement Rationale: Interstitial cerebral edema occurs due to the buildup of cerebrospinal fluid (CSF) in the brain, commonly seen in hydrocephalus. This condition leads to ventricular enlargement, which is a hallmark sign of hydrocephalus. It is caused by an excess production of CSF, obstruction in its flow, or an inability to reabsorb it.

Answer 83

C) Obstruction of CSF flow, leading to fluid buildup Rationale: Interstitial cerebral edema is often caused by hydrocephalus, which results from either an overproduction of CSF, obstruction of CSF flow, or an impaired ability to reabsorb CSF. The obstruction leads to a buildup of CSF in the ventricles, causing ventricular enlargement and increased pressure on brain tissue.

Answer 84

A) Increased intracranial pressure (ICP) Rationale: As hydrocephalus leads to a buildup of cerebrospinal fluid (CSF) and enlargement of the ventricles, it causes an increase in intracranial pressure (ICP). This pressure can compress brain tissue, leading to interstitial cerebral edema and associated neurological symptoms such as decreased consciousness and possible focal deficits.

Answer 85

B) Shunt placement to drain excess cerebrospinal fluid (CSF) Rationale: In hydrocephalus, the most appropriate intervention to manage interstitial cerebral edema is to address the buildup of cerebrospinal fluid (CSF) by placing a shunt. The shunt diverts excess CSF away from the ventricles and into other areas of the body, helping to reduce ventricular enlargement and intracranial pressure.

Answer 86

A) Perform a neurological assessment, including cranial nerve reflexes Rationale: Any patient who becomes acutely unconscious should be suspected of having increased ICP. The first priority is to perform a thorough neurological assessment, including checking cranial nerve reflexes, as this will help determine the severity of brain involvement and guide further actions, including the need for imaging studies like CT scans.

Answer 87

B) Decreased level of consciousness Rationale: Decreased level of consciousness (LOC) is one of the most important clinical manifestations of increased ICP. As ICP increases, it can compress the brainstem, leading to a decreased LOC. Early recognition of this change can lead to prompt intervention and prevent further brain injury.

Answer 88

C) Pupillary changes and abnormal eye movements Rationale: Pupillary changes and abnormal eye movements are significant clinical manifestations of increased ICP. These changes may indicate brainstem involvement or pressure on the cranial nerves, which can rapidly worsen if not addressed. Immediate intervention is necessary to assess the degree of brain dysfunction.

Answer 89

D) Pressure on brain tissue from a mass effect, edema, or hemorrhage Rationale: Increased ICP is most commonly caused by pressure on brain tissue due to factors such as a mass (e.g., tumor, hematoma), edema, or hemorrhage. These conditions cause brain tissue compression, which increases ICP and can lead to acute unconsciousness, a key clinical manifestation of increased ICP.

Answer 90

an abnormal state of complete or partial awareness of self or environment

Answer 91

A. Change in level of consciousness Rationale: The most sensitive and earliest indicator of neurologic deterioration or increased ICP is a change in LOC. This occurs due to decreased cerebral perfusion and impaired function of the cerebral cortex or RAS. Pupillary changes, bradycardia, and vomiting are later signs of increased ICP.

Answer 92

B. Notify the provider immediately and prepare for potential intubation Rationale: A declining LOC with reduced response to painful stimuli indicates potential progression toward coma. Airway protection becomes a priority as the patient may lose gag and swallow reflexes. While monitoring urine and administering mannitol may be appropriate later, airway is the immediate concern.

Answer 93

C. Reticular activating system Rationale: The RAS, located in the brainstem, is crucial for maintaining arousal and wakefulness. Impairment of the RAS leads to varying degrees of unconsciousness, depending on the extent of damage.

Answer 94

C. Loss of pupillary reflex Rationale: Loss of pupillary reflexes may indicate brainstem involvement and impending herniation, which is a neurological emergency. Other symptoms indicate progression of increased ICP but are not as immediately life-threatening as brainstem dysfunction.

Answer 95

A. Decreased level of attention B. Flattened affect D. Disorientation to time Rationale: Subtle signs of declining LOC include changes in affect, orientation, and attention. Sudden hemiplegia and inability to cough are more advanced neurologic signs seen in late or severe brain injury.

Answer 96

A. Absent corneal reflex Rationale: In deep coma, the patient loses reflexes such as the corneal and pupillary reflexes. The absence of the corneal reflex is a grave sign indicating severe dysfunction of the brainstem.

Answer 97

D. Elevate the head of the bed to 30 degrees Rationale: A change in LOC following a head injury suggests rising ICP. Elevating the head promotes venous drainage and reduces ICP. A lumbar puncture is contraindicated if ICP is suspected to be elevated due to risk of herniation.

Answer 98

C. Suppressed or absent neuronal activity Rationale: In coma, EEG typically shows suppressed or absent activity, indicating minimal or absent cortical brain function. This confirms severe neurological impairment.

Answer 99

C. These may be early indicators of increased ICP Rationale: Flat affect and decreased orientation are subtle yet important signs of increasing ICP. Prompt recognition and intervention are essential to prevent further neurologic deterioration.

Answer 100

A. Unresponsive to verbal and painful stimuli C. Absent corneal and pupillary reflexes E. Suppressed EEG activity Rationale: In coma, the patient does not respond to pain, has absent brainstem reflexes (corneal, pupillary), and shows severely reduced neuronal activity on EEG. They are typically incontinent and have no protective reflexes like swallowing or gagging.

Answer 101

systolic hypertension with a widening pulse pressure, bradycardia with a full and bounding pulse, irregular respirations

Answer 102

C. The client is showing signs of Cushing triad Rationale: Cushing triad is a classic, late sign of increased ICP and indicates brainstem compression and impending death. It is characterized by systolic hypertension with widening pulse pressure, bradycardia with a full bounding pulse, and irregular respirations. These are compensatory responses triggered by the brainstem in response to increased ICP. Shock would typically present with hypotension and tachycardia. This is a medical emergency requiring immediate intervention.

Answer 103

B. Direct hypothalamic dysfunction due to pressure Rationale: The hypothalamus regulates temperature. When ICP increases and compresses the hypothalamus, it can disrupt temperature regulation, causing hyperthermia. While infection could also cause fever, a sudden high temperature in the absence of infection in a neurologic client suggests central (neurogenic) fever due to hypothalamic involvement.

Answer 104

A. BP 200/100 with pulse pressure of 100 mm Hg B. HR 48 bpm and bounding C. Irregular respiratory pattern E. Apnea followed by deep, rapid breathing Rationale: * A: Wide pulse pressure is part of Cushing triad. * B: Bradycardia with a bounding pulse is classic. * C: Irregular respirations occur due to brainstem involvement. * E: Cheyne-Stokes respirations or other irregular patterns often appear. * D: A low temperature is not commonly associated unless hypothalamus is involved in a different way. * F: Tachycardia and thready pulse are more typical of shock, not increased ICP.

Answer 105

D. Medulla oblongata Rationale: The medulla is the primary respiratory control center. As ICP increases and pressure is exerted on the brainstem, particularly the medulla, respiratory rate and rhythm become irregular, signaling a dangerous progression of ICP.

Answer 106

C. Notify the HCP immediately Rationale: These signs indicate Cushing triad, a medical emergency signaling brainstem compression and the possibility of herniation. While preparing for intubation may be needed soon, the first priority is rapid notification of the provider so life-saving interventions to reduce ICP can be implemented.

Answer 107

D. Compensation to maintain cerebral perfusion pressure Rationale: As ICP increases, the body attempts to maintain cerebral perfusion by increasing systolic blood pressure, while the diastolic may remain the same or drop slightly, resulting in a widening pulse pressure. This is part of Cushing’s triad and is a compensatory mechanism to maintain adequate CPP (MAP - ICP).

Answer 108

A. The patient is experiencing increased ICP with possible brainstem compression Rationale: These vital sign changes are hallmarks of Cushing triad, which suggests a severe increase in ICP. This scenario is an urgent, life-threatening neurologic event that requires immediate intervention to prevent herniation and death. This is not consistent with stroke alone or hypovolemia.

Answer 109

B. Fixed and dilated pupil on the right side Rationale: A fixed, unilateral, dilated pupil is a neurologic emergency indicating uncal herniation with CN III compression. It signifies brain herniation, requiring immediate intervention. Options A, C, and D may suggest increased ICP but are not as immediately life-threatening as a unilateral fixed and dilated pupil.

Answer 110

B. Cranial Nerve III Rationale: Compression of CN III (oculomotor nerve) causes ipsilateral pupil dilation, ptosis (drooping eyelid), and an inability to move the eye upward. CN II is responsible for vision, CN IV controls downward movement, and CN VI affects lateral movement.

Answer 111

D. Compression of the oculomotor nerve Rationale: Unilateral ptosis and unequal pupil size (anisocoria) are hallmark signs of CN III compression, often due to shifting brain tissue from a mass effect like a tumor. This is a serious finding that indicates increased ICP and possible herniation.

Answer 112

A. Unilateral dilated pupil Rationale: Uncal herniation compresses CN III on one side, leading to a unilateral dilated, nonreactive pupil. Central herniation typically results in bilateral sluggish pupils, and pinpoint pupils are more consistent with pontine damage.

Answer 113

A. Notify the provider immediately Rationale: A fixed, dilated pupil is a neurological emergency indicating potential brain herniation. Immediate action is required to prevent irreversible brain damage or death. This finding is not one to simply monitor or assess further before notifying the provider.

Answer 114

A. Blurred vision B. Ptosis D. Diplopia Rationale: Blurred vision, ptosis, and diplopia are all associated with compression of CNs II, III, IV, or VI. Pinpoint pupils are not characteristic of CN compression from increased ICP, and nystagmus is not mentioned as a typical manifestation in this context.

Answer 115

D. It is a nonspecific sign of sustained increased ICP Rationale: Papilledema, or optic disc swelling, is a nonspecific indicator of persistent elevated ICP. It doesn’t necessarily indicate acute herniation or damage but supports the need for further investigation of ICP status.

Answer 116

A. Central herniation Rationale: Central herniation may present with bilateral sluggish pupil responses due to symmetric pressure on the brainstem. In contrast, uncal herniation typically presents with unilateral dilation.

Answer 117

D. Report to the healthcare provider immediately Rationale: Sudden visual changes such as blurred vision and diplopia suggest worsening ICP with possible cranial nerve involvement. These are early neurologic changes that could progress to herniation, and they require prompt medical evaluation.

Answer 118

an edematous optic disc seen on retinal examination

Answer 119

opposite side

Answer 120

C. It indicates disruption of motor fibers in the midbrain and brainstem Rationale: Decerebrate posturing is a sign of more serious brain injury and results from disruption of motor pathways in the midbrain and brainstem. It is a worse sign than decorticate posturing, which originates from cortical damage.

Answer 121

B. Flexion of arms with internal rotation, legs extended Rationale: Decorticate posturing is characterized by arm flexion, internal rotation, and leg extension. It suggests damage to the corticospinal tract above the brainstem, specifically within the cerebral cortex.

Answer 122

A. Progression of brain injury indicating brainstem involvement Rationale: The described posture is decerebrate, which is associated with more severe injury and involvement of the brainstem. It is not normal and indicates worsening neurologic status.

Answer 123

A. Hyperextension of the legs C. Arms stiffly extended E. Plantar flexion of the feet F. Hyperpronation of the arms Rationale: Decerebrate posture involves rigid extension of the arms (C), hyperextension of the legs (A), plantar flexion of the feet (E), and hyperpronation of the arms (F). Internal rotation and flexion of the arms (B and D) describe decorticate posturing, not decerebrate.

Answer 124

B. Left cerebral hemisphere Rationale: Motor deficits are typically contralateral to the lesion. So, right-sided hemiplegia indicates a lesion in the left cerebral hemisphere. The cerebellum primarily controls coordination, and brainstem involvement would likely cause more global or bilateral deficits.

Answer 125

A. Withdrawal from the stimulus Rationale: Withdrawal to pain suggests higher-level motor control and some degree of cortical integrity. Decorticate and decerebrate posturing indicate progressively worse neurologic function, with decerebrate being more severe. No response is the most concerning.

Answer 126

B. Withdraws to pain Rationale: Pulling away from painful stimulus is a withdrawal response, indicating that the spinal cord and some cortical pathways are intact. Localization would involve purposeful movement toward the source of pain, not just pulling away.

Answer 127

D. Notify the provider immediately Rationale: Transition from decorticate to decerebrate posturing indicates neurological deterioration and brainstem involvement, which is life-threatening. Immediate notification is necessary to initiate urgent interventions.

Answer 128

D. Arm flexion in decorticate, arm extension in decerebrate Rationale: The key difference is in arm positioning: decorticate posture involves arm flexion, while decerebrate posture involves arm extension and pronation. Decerebrate posturing is a sign of more severe brain injury.

Answer 129

C. It may be a sign of increased intracranial pressure Rationale: Morning or nocturnal headaches that worsen with activities like coughing or straining are classic signs of increased ICP, potentially from a mass or obstructed CSF flow. The brain tissue doesn’t feel pain, but compression of surrounding structures (e.g., blood vessels or cranial nerves) can lead to this type of headache.

Answer 130

D. Notify the provider; findings suggest a possible increase in ICP Rationale: This headache presentation—worse in the morning, aggravated by Valsalva-like maneuvers (e.g., sneezing, bending)—is concerning for increased ICP, possibly from a mass or lesion. Early identification and neuroimaging are crucial to prevent further complications.

Answer 131

A. “My headache wakes me up at night and is worst when I first get out of bed.” Rationale: A headache that occurs at night or early morning is a red flag for increased ICP, especially when it disrupts sleep and worsens with postural changes. This may indicate a space-occupying lesion or other ICP-related pathology.

Answer 132

A. Coughing B. Straining during bowel movement C. Morning time D. Agitation or movement Rationale: Headaches associated with increased ICP are worsened by activities that raise intrathoracic pressure, like coughing (A) and straining (B). These increase cerebral venous pressure and ICP. Morning time (C) is often when ICP is highest due to recumbent positioning overnight. Agitation or movement (D) may also exacerbate symptoms. Quiet rest (E) may relieve, not worsen, the headache.

Answer 133

vomiting, not preceded by nausea

Answer 134

C. Projectile vomiting not preceded by nausea Rationale: Projectile vomiting without preceding nausea is a classic and nonspecific indicator of increased ICP. It occurs due to direct stimulation of the vomiting center in the brainstem from elevated pressure. This is a neurologic emergency, especially when paired with other signs like headache or altered LOC.

Answer 135

D. Notify the provider of possible increased ICP Rationale: Projectile vomiting without nausea, particularly in the setting of head trauma and headache, raises a strong concern for elevated intracranial pressure. This symptom must be reported immediately to allow for urgent evaluation (e.g., neuroimaging, ICP monitoring). Anti-nausea meds won’t treat the underlying cause.

Answer 136

A. Vomiting without warning or nausea B. Projectile vomiting Rationale: Unexpected (A) and projectile vomiting (B) are both hallmark, nonspecific indicators of increased ICP. These symptoms result from pressure on the vomiting center in the medulla and are not related to GI illness or food intake. Options C, D, and E are more suggestive of gastrointestinal or situational causes.

Answer 137

C. Increased ICP is likely stimulating the vomiting center Rationale: In patients with space-occupying lesions, such as tumors, the development of sudden vomiting without nausea is strongly linked to increased ICP, which affects the brainstem vomiting center directly. This symptom must not be dismissed or attributed solely to chemotherapy or GI causes.

Answer 138

A. “I woke up and threw up suddenly—no nausea at all before it.” Rationale: Vomiting without prior nausea—especially if sudden or projectile—is a neurologic red flag suggestive of increased intracranial pressure. This finding is especially important when evaluating for conditions like tumors, hydrocephalus, or hemorrhages.

Answer 139

D) Elevated serum ammonia Rationale: Elevated serum ammonia is a hallmark of hepatic encephalopathy and contributes to cerebral edema by increasing astrocyte swelling due to ammonia’s neurotoxic effects.

Answer 140

A) Vasogenic edema Rationale: Vasogenic edema, resulting from the breakdown of the blood-brain barrier, is commonly associated with TBI, leading to fluid accumulation in the extracellular space.

Answer 141

A) Cytotoxic edema Rationale: Lead poisoning can cause cytotoxic edema due to direct neuronal injury and disruption of cellular metabolism, leading to intracellular fluid accumulation.

Answer 142

B) Vasogenic edema Rationale: Infections like brain abscesses often lead to vasogenic edema due to increased permeability of the blood-brain barrier, allowing fluid to leak into the extracellular space.

Answer 143

C) Vasogenic edema from increased capillary permeability Rationale: HACE is primarily caused by vasogenic edema resulting from increased capillary permeability at high altitudes, leading to fluid leakage into the brain’s extracellular space.

Answer 144

A) Accumulation of neurotoxins like ammonia Rationale: In acute liver failure, the accumulation of neurotoxins, particularly ammonia, leads to astrocyte swelling and cerebral edema.

Answer 145

B) Vasogenic edema Rationale: Meningitis can disrupt the blood-brain barrier, leading to vasogenic edema characterized by fluid leakage into the extracellular space.

Answer 146

B) Cytotoxic edema Rationale: In the early stages of ischemic stroke, cytotoxic edema occurs due to energy failure and subsequent intracellular fluid accumulation.

Answer 147

D) Disruption of the blood-brain barrier Rationale: Subdural hematomas can disrupt the blood-brain barrier, leading to vasogenic edema from fluid leakage into the extracellular space.

Answer 148

A) Cytotoxic edema due to toxin accumulation Rationale: Uremia leads to the accumulation of toxins that can cause direct neuronal injury, resulting in cytotoxic edema.

Answer 149

B) Vasogenic edema Rationale: Cerebral venous sinus thrombosis can lead to increased venous pressure and disruption of the blood-brain barrier, resulting in vasogenic edema.

Answer 150

D. Cerebral herniation Rationale: Cerebral herniation is a life-threatening complication of uncontrolled ICP and represents a shift of brain tissue from its normal location. This can cause compression of vital structures, especially the brainstem, and often results in irreversible damage or death.

Answer 151

a tent-like cover over the cerebellum

Answer 152

C. Tentorium cerebelli Rationale: The tentorium cerebelli is a fold of dura mater that forms a tent-like separation between the cerebrum and cerebellum. It’s clinically important because it creates compartments within the skull, and herniation through this structure (e.g., uncal or central herniation) can compress the brainstem and be fatal.

Answer 153

D. Cerebral tissue is displaced downward through the foramen magnum Rationale: Central (tentorial) herniation involves downward movement of cerebral structures through the tentorial notch, compressing the brainstem. This is a critical emergency because the brainstem houses vital autonomic centers, including respiratory and cardiovascular regulation.

Answer 154

A. Cingulate herniation occurs under the falx cerebri C. Uncal herniation involves downward movement of the temporal lobe D. Central herniation is associated with compression of the brainstem E. Cerebral herniation can impair cerebral perfusion Rationale: * A: Cingulate herniation involves tissue shifting under the falx cerebri. * C: Uncal herniation occurs laterally and downward, pushing the medial temporal lobe. * D: Central herniation is also known as tentorial herniation and compresses the brainstem. * E: All forms of herniation compromise cerebral blood flow and lead to hypoxia or ischemia. B is incorrect—tentorial herniation compresses brainstem structures, not the cerebellum directly.

Answer 155

B. Lateral shift of cerebral tissue seen on imaging Rationale: Cingulate herniation occurs when brain tissue is pushed laterally under the falx cerebri. This can often be seen as a midline shift on CT or MRI and may initially present without profound clinical signs. As it progresses, neurological deterioration can occur.

Answer 156

A. Fixed and dilated pupil on the ipsilateral side Rationale: In uncal herniation, the medial temporal lobe compresses CN III, leading to ipsilateral pupil dilation that becomes fixed. This is a classic early sign and a neurologic emergency indicating brainstem involvement.

Answer 157

A. Respiratory arrest B. Bradycardia C. Brainstem compression E. Irreversible coma Rationale: Cerebral herniation can cause brainstem compression, leading to loss of autonomic function (A, B), and often progresses to irreversible coma or death (E). D is incorrect—spinal reflexes may diminish or be lost depending on the location of compression.

Answer 158

C. Falx cerebri Rationale: The falx cerebri is a vertical fold of dura mater between the right and left cerebral hemispheres. In cingulate herniation, brain tissue is pushed beneath this midline structure, which may disrupt perfusion and worsen ICP.

Answer 159

B. CN III (Oculomotor) Rationale: The oculomotor nerve (CN III) is often compressed during uncal herniation, leading to a fixed, dilated pupil on the same side of the lesion. This occurs as the medial temporal lobe presses downward on the brainstem, impinging CN III fibers.

Answer 160

D. The patient is restless, agitated, and confused Rationale: Early signs of impaired cerebral perfusion include subtle changes in behavior, restlessness, or altered mental status, as the brain becomes hypoxic. This is an early clue to decreased perfusion due to rising ICP and precedes more severe signs like herniation or coma.

Answer 161

C. Lumbar puncture Rationale: A lumbar puncture is contraindicated in patients with suspected increased ICP because it can cause a sudden release of pressure below the skull, increasing the risk of brain herniation through the foramen magnum—a fatal complication.

Answer 162

A. CT scan B. EEG C. Infrascanner E. Positron emission tomography (PET) Rationale: * CT scan (A): Standard imaging to evaluate structural causes of increased ICP. * EEG (B): Useful for evaluating cerebral function or detecting seizure activity. * Infrascanner (C): Handheld device to identify life-threatening intracranial bleeding. * PET scan (E): Detects metabolic changes in the brain and blood flow. D (serum sodium) is not a direct diagnostic tool for ICP, though important in management.

Answer 163

B. Infrascanner Rationale: The Infrascanner uses near-infrared light to detect intracranial bleeding by identifying areas where light absorption is altered by pooled blood from a hematoma.

Answer 164

A. Transcranial Doppler Rationale: Transcranial Doppler ultrasonography is used to monitor cerebral blood flow velocity and resistance, which is particularly useful in patients with traumatic brain injury or stroke.

Answer 165

D. LICOX catheter Rationale: The LICOX catheter directly measures brain tissue oxygenation (PbtO2) and temperature. It’s an invasive monitoring tool used in ICU settings for patients at risk for brain hypoxia due to increased ICP.

Answer 166

B. Infrascanner detection of abnormal light absorption C. MRI revealing mass effect and midline shift D. LICOX catheter revealing PbtO2 of 12 mm Hg E. Transcranial Doppler revealing reduced cerebral blood flow velocity Rationale: * B: Infrascanner detects light absorption changes from bleeding. * C: MRI can show midline shift and mass lesions, which are ICP indicators. * D: Low PbtO2 (<20 mm Hg) suggests inadequate brain oxygenation. * E: Decreased CBF velocity on Doppler = elevated ICP or poor perfusion. A (PET scan hypermetabolism in brainstem) is nonspecific and less useful here.

Answer 167

B. EEG Rationale: An electroencephalogram (EEG) records brain electrical activity and is useful for detecting seizure activity, especially in patients with altered consciousness or unexplained changes in neurologic status.

Answer 168

A. PET scan Rationale: A PET scan provides functional imaging, including glucose metabolism and blood flow, helping clinicians assess areas of hypometabolism or ischemia in patients with neurologic concerns.

Answer 169

C. Cerebral angiography Rationale: Cerebral angiography is the gold standard to visualize intracranial vessels, detect aneurysms, AV malformations, or assess vascular occlusion in stroke or trauma.

Answer 170

B. Transcranial Doppler is non-invasive C. Infrascanner is useful in pre-hospital or field triage E. LICOX catheter monitors oxygen and temperature in brain tissue Rationale: * B: Transcranial Doppler is non-invasive and monitors blood flow velocity. * C: The Infrascanner is portable and useful in field trauma settings. * E: LICOX catheter gives continuous oxygenation (PbtO2) and temperature readings. A is incorrect—LP is contraindicated with increased ICP. D is incorrect—PET shows function, not just anatomy.

Answer 171

B. Decreased cerebral blood flow velocity Rationale: Decreased velocity suggests increased cerebrovascular resistance, a hallmark of elevated ICP and impending perfusion impairment, requiring urgent intervention.

Answer 172

D. “A lumbar puncture is safe to perform to confirm elevated ICP.” Rationale: This is incorrect and dangerous. A lumbar puncture is contraindicated in patients with increased ICP due to the risk of cerebral herniation following a sudden drop in pressure below the skull.

Answer 173

D. Initiate intracranial pressure monitoring Rationale: ICP monitoring is indicated for patients with a GCS score ≤8 and abnormal CT/MRI findings (e.g., bleeding or edema). This combination suggests a high risk for increased ICP and the need for direct pressure monitoring to guide treatment.

Answer 174

A. A patient with a GCS score of 7 and an MRI showing a contusion C. A patient with bacterial meningitis and a fluctuating LOC E. A patient with a brain tumor and signs of increased ICP Rationale: * A: GCS ≤8 and contusion = classic indication. * C: Meningitis with LOC changes = risk for increased ICP; monitoring helps guide care. * E: Brain tumors can cause mass effect and increased ICP. B is stable and does not meet ICP monitoring criteria. D might be monitored depending on risk factors, but normal CT reduces the urgency.

Answer 175

C. To guide therapy and reduce risk of secondary brain injury Rationale: The main goal of ICP monitoring is to track pressure trends and guide treatment decisions, such as adjusting fluids, osmotic therapy, or sedation, to optimize cerebral perfusion and prevent secondary injury.

Answer 176

A. Prepare for intracranial pressure monitoring Rationale: This patient has both a low GCS and significant cerebral edema, meeting criteria for ICP monitoring. It helps detect and manage dangerous pressure elevations before irreversible brain damage occurs.

Answer 177

B. A patient with a mild concussion and GCS 15 Rationale: ICP monitoring is not indicated in patients with mild neurologic injuries (GCS >13) and no structural brain abnormalities. This patient is stable and does not show signs of increased ICP or deterioration.

Answer 178

B. “Patients with traumatic brain injury and cerebral contusions are high-risk.” C. “ICP monitoring is often needed if CT imaging shows cerebral edema.” E. “A sudden change in LOC can indicate the need for ICP monitoring.” Rationale: * B: TBI with contusion = high risk. * C: Cerebral edema on imaging is a red flag for ICP. * E: Sudden LOC changes suggest brain swelling or bleeding—triggers for monitoring. A is incorrect—a GCS ≤8, not 9+, is the usual cutoff. D is false—stroke patients, especially those with hemorrhagic stroke, often require monitoring.

Answer 179

a specialized catheter is inserted into the lateral ventricle and coupled to an external transducer

Answer 180

an air-filled pouch to measure ICP

Answer 181

C. Ventriculostomy Rationale: The ventriculostomy is the gold standard for ICP monitoring. It provides direct measurement of pressure and allows for CSF sampling and drug administration.

Answer 182

A. Leveling the transducer with the tragus of the ear Rationale: The transducer must be level with the foramen of Monro, which is referenced using the tragus of the ear. This ensures that the ICP measurement is accurate and consistent, regardless of the patient’s positioning.

Answer 183

A. Infection at the insertion site Rationale: Infection is a serious complication associated with ICP monitoring, especially with ventriculostomy, which can result in meningitis or other systemic infections. It is critical to monitor the insertion site and use aseptic technique.

Answer 184

A. CSF leaks around the monitoring device B. Kinks in the ICP tubing C. Incorrect height of the drainage system relative to the reference point Rationale: * A: CSF leaks compromise the pressure readings and the system’s integrity. * B: Kinks in the tubing block or distort the pressure waveforms. * C: The height of the drainage system must be correctly positioned to the reference point (foramen of Monro). D and E are not direct causes of inaccurate readings, though prone positioning may affect the positioning of the catheter or transducer. Fiberoptic catheters have their own characteristics but do not cause inaccurate readings due to positioning.

Answer 185

B. Report the abnormal waveform and monitor the patient for signs of deterioration Rationale: A P2 elevation above P1 indicates poor ventricular compliance, which suggests increased ICP. This requires immediate attention, and the nurse should report the abnormal waveform to the healthcare provider and carefully monitor the patient for signs of deterioration.

Answer 186

B. Closing the CSF drain for at least 6 minutes before taking a reading Rationale: To obtain accurate ICP readings, the CSF drain should be closed for at least 6 minutes to ensure that there is no influence from draining before taking the pressure reading.

Answer 187

B. It provides direct measurement of brain pressure without needing a transducer Rationale: The fiberoptic catheter uses a sensor transducer located at the catheter tip to directly measure brain pressure. Unlike the ventriculostomy, it does not require a separate external transducer.

Answer 188

A. Air bubbles in the tubing Rationale: Air bubbles in the ICP monitoring system can dampen the waveform, leading to false readings. It is crucial to check the system for air bubbles and remove them to ensure accurate readings.

Answer 189

A. 5-10 mm Hg Rationale: Normal ICP typically ranges between 5-10 mm Hg. Values above this range indicate increased ICP, which can lead to poor cerebral perfusion and other complications.

Answer 190

D. Report the findings to the healthcare provider and prepare for intervention Rationale: A sudden increase in ICP with an abnormal waveform requires immediate notification to the healthcare provider, as this indicates deteriorating neurological status and may require urgent intervention.

Answer 191

A. Meningitis B. CSF leak E. Catheter obstruction Rationale: * A: Infection (e.g., meningitis) is a common complication of ICP monitoring. * B: CSF leaks can lead to inaccurate readings or infections. * E: Catheter obstruction from clots or tissue can distort readings. C and D are not typical complications directly associated with ICP monitoring.

Answer 192

B. Use aseptic technique when handling the insertion site Rationale: The nurse should use aseptic technique to avoid introducing infection. Regular dressing changes and careful handling reduce the risk of meningitis or other complications. Flushing and antibiotics are not routine practices unless infection is suspected.

Answer 193

A. The CSF drainage device must be closed for at least 6 minutes before taking a reading Rationale: Closing the drainage device for at least 6 minutes ensures that the measurement reflects true ICP without the influence of draining CSF.

Answer 194

A. Fiberoptic catheter B. Ventriculostomy D. Pneumatic air pouch system

Answer 195

C. Use aseptic technique during the insertion and maintenance of the device Rationale: Using aseptic technique during both insertion and maintenance of the ICP device significantly reduces the risk of infection. Proper hand hygiene, sterile dressings, and avoiding unnecessary manipulation of the device are essential.

Answer 196

C. Notify the healthcare provider for further assessment and management Rationale: A CSF leak could result in inaccurate ICP readings and increased infection risk. It’s essential to notify the healthcare provider to evaluate the situation and determine whether the device needs to be adjusted or replaced.

Answer 197

C. Report the abnormal reading to the healthcare provider immediately Rationale: Abnormal ICP waveforms with P2 rising above P1 indicate that the patient is experiencing increased ICP and may be at risk for neurological deterioration. This requires immediate reporting to the healthcare provider for possible intervention.

Answer 198

D. Keep the insertion site covered with a sterile dressing and monitor for redness or drainage Rationale: To prevent infection, the insertion site should be covered with a sterile dressing. The nurse should monitor for signs of infection such as redness, drainage, or increased warmth around the site. Changing the dressing should occur every 24 hours, not every 72 hours, to ensure proper hygiene.

Answer 199

A. Open the drainage system and allow CSF to drain for 2 to 3 minutes, then close it Rationale: Intermittent drainage requires the nurse to open the system for 2 to 3 minutes to allow CSF to drain, then close the system to maintain the integrity of ICP monitoring. Continuous drainage would require monitoring the volume of CSF drained.

Answer 200

B. Monitor the volume of CSF drainage to avoid excessive removal Rationale: When using continuous CSF drainage, it is essential to monitor the volume of CSF removed to prevent over-drainage, which could lead to complications like ventricular collapse or herniation. Normal CSF production is around 20 to 30 mL/hr, so it is important to keep this in mind.

Answer 201

A. Cerebral herniation or subdural hematoma formation Rationale: Rapid decompression of ICP can cause cerebral herniation or subdural hematoma formation, both of which are serious complications. Proper monitoring and controlled drainage are critical to avoid these risks.

Answer 202

C. Ensure that the system is intact and leveled at the foramen of Monro Rationale: For accurate ICP readings, it is essential to level the system at the foramen of Monro (the reference point) and ensure the system remains intact to prevent errors in ICP measurements.

Answer 203

A. Close the stopcock immediately and monitor for any changes in ICP Rationale: The stopcock should be closed after intermittent drainage to maintain the integrity of the ICP monitoring system. The nurse should monitor the ICP for any changes to ensure proper pressure management.

Answer 204

B. Report the issue to the healthcare provider for assessment and possible intervention Rationale: CSF leakage around the insertion site should be reported immediately to the healthcare provider. This could indicate a problem with the catheter or the insertion site that may need adjustment or further intervention to prevent complications.

Answer 205

A. Ventricular collapse Rationale: Removing too much CSF can cause ventricular collapse, as the brain can lose the cushioning effect provided by the CSF. This can lead to further neurological complications and increased ICP if not corrected.

Answer 206

A. Ensure the drainage system is level with the tragus of the ear Rationale: The system must be leveled at the tragus of the ear (the reference point) to ensure accurate ICP readings when repositioning the patient. Proper positioning is essential to prevent changes in ICP measurements.

Answer 207

B. Use aseptic technique to prevent infection Rationale: Using aseptic technique during dressing changes is critical to prevent infection. Infection is a significant complication with ICP monitoring and should always be carefully avoided through proper technique.

Answer 208

B. Notify the healthcare provider for further instructions and assessment Rationale: The nurse should notify the healthcare provider immediately when there is excessive CSF drainage. This could indicate a problem with the system or a need for a change in treatment, such as stopping or adjusting drainage.

Answer 209

C. Maintain a controlled and safe amount of CSF drainage Rationale: To avoid ventricular collapse, it is crucial to maintain controlled and safe amounts of CSF drainage. The nurse should monitor and adjust the drainage system as needed to prevent excessive CSF loss, which can lead to complications.

Answer 210

B. Perform routine sterile dressing changes to prevent infection Rationale: Routine sterile dressing changes are essential to prevent infection at the insertion site of the ventriculostomy. Keeping the system intact and sterile is critical

Answer 211

A. Increase the patient’s oxygen supply and notify the healthcare provider Rationale: A PbtO2 reading of 15 mm Hg is below the normal range (20–40 mm Hg), indicating ischemia or regional tissue hypoxia. The nurse should increase oxygen supply and notify the healthcare provider for further intervention.

Answer 212

A. Normal brain oxygenation Rationale: The normal range for PbtO2 is 20–40 mm Hg. A reading of 35 mm Hg falls within the normal range, indicating adequate brain oxygenation.

Answer 213

B. Hypoxia and inadequate cerebral oxygenation Rationale: The normal SjvO2 range is 60% to 75%. A value of 48% indicates impaired cerebral oxygenation and potential hypoxia in the brain.

Answer 214

B. Administer high-flow oxygen and notify the healthcare provider Rationale: A PbtO2 value of 18 mm Hg is lower than the normal range (20–40 mm Hg), indicating ischemia or hypoxia. The nurse should administer high-flow oxygen and notify the healthcare provider to address the issue.

Answer 215

C. 60% to 75% Rationale: The normal SjvO2 range is 60% to 75%, which indicates adequate cerebral oxygenation and proper oxygen extraction by the brain.

Answer 216

B. The brain temperature is within the normal range for optimal outcomes Rationale: A brain temperature of 35°C (96.8°F) is generally considered optimal for improving outcomes in patients with brain injuries or intracranial pressure issues.

Answer 217

D. Increase the patient’s oxygen levels and notify the healthcare provider Rationale: An SjvO2 value of 45% is below the normal range of 60% to 75%, indicating that cerebral oxygenation is impaired. The nurse should increase oxygen levels and notify the healthcare provider.

Answer 218

D. Hyperoxia, which could lead to oxygen toxicity Rationale: A PbtO2 value above the normal range (20–40 mm Hg) could indicate hyperoxia. If the oxygen supply is too high, it can cause oxygen toxicity, which may damage brain tissue.

Answer 219

A. Adequate cerebral oxygenation Rationale: A PbtO2 of 30 mm Hg is within the normal range (20–40 mm Hg) for brain oxygenation, indicating adequate oxygenation of the brain tissue.

Answer 220

C. Assess for potential hyperoxia and notify the healthcare provider Rationale: A SjvO2 of 80% is above the normal range of 60% to 75%, which could suggest hyperoxia. The nurse should assess for signs of oxygen toxicity and notify the healthcare provider for further evaluation.

Answer 221

B. To measure the concentration of small molecules in brain tissue Rationale: Brain microdialysis is used to measure small molecules such as glucose and lactate in brain tissue, which helps assess metabolic changes and brain injury.

Answer 222

C. Mild ischemia and potential tissue hypoxia Rationale: A PbtO2 of 22 mm Hg is below the normal range (20–40 mm Hg) and indicates mild ischemia or hypoxia. This requires monitoring and possible adjustment of oxygenation therapy.

Answer 223

B. To prevent herniation and reduce ICP by removing a part of the skull Rationale: A craniectomy is performed to reduce ICP and prevent herniation by removing a portion of the skull, which helps provide space for the brain to expand and reduce pressure.

Answer 224

A. Increase the O2 delivery to maintain PaO2 of 100 mm Hg or greater Rationale: The PaO2 is slightly below the goal of 100 mm Hg or greater, so the nurse should increase oxygen delivery to improve oxygenation. The PaCO2 is slightly elevated, but the focus is on improving oxygenation.

Answer 225

C. Shunt placement to divert excess CSF Rationale: Hydrocephalus (excess CSF) can be treated with a shunt to divert the CSF away from the brain, helping to reduce ICP.

Answer 226

A. Increase oxygen delivery and notify the healthcare provider about the elevated PaCO2 Rationale: The PaO2 is slightly below the target of 100 mm Hg, and the PaCO2 is elevated, which could contribute to increased ICP. The nurse should increase oxygen delivery and notify the healthcare provider for further evaluation and possible intervention to manage PaCO2.

Answer 227

A. Support brain function and maintain adequate oxygenation Rationale: The priority goal in managing increased ICP is to support brain function by ensuring adequate oxygenation and treating the underlying cause, preventing further injury to the brain.

Answer 228

B. To monitor the patient’s neurological status and manage ventilation Rationale: The nurse plays a critical role in monitoring the patient’s neurological status, ensuring adequate ventilation and oxygenation, and collaborating with the healthcare team to manage ICP.

Answer 229

C. Reducing intracranial pressure and preventing herniation during the procedure Rationale: Reducing ICP and preventing herniation are the primary concerns during a craniectomy, as the surgery aims to relieve pressure and prevent further brain injury.

Answer 230

C. Hyperventilate the patient to lower PaCO2 Rationale: Hyperventilation can help lower PaCO2, which in turn can decrease cerebral blood volume and help reduce ICP. However, it should be done carefully to avoid other complications.

Answer 231

D. To prevent hypoxia and maintain PaCO2 within the normal range of 35-45 mm Hg Rationale: The goal of mechanical ventilation in increased ICP is to prevent hypoxia and ensure adequate oxygenation while keeping PaCO2 within the normal range, as elevated CO2 can increase ICP.

Answer 232

A. Surgical removal of the tumor Rationale: Surgical removal of the brain tumor is the most effective treatment for increased ICP caused by a mass. It directly addresses the cause of the pressure and relieves the associated symptoms.

Answer 233

B. Elevating the head of bed to 30 degrees with the head in a neutral position Rationale: Elevating the head of the bed to 30 degrees with the head in a neutral position promotes venous drainage from the brain, reducing intracranial pressure. Other positions can impede venous outflow or increase ICP.

Answer 234

C. To prevent cerebral hypoxia and secondary brain injury Rationale: Maintaining a PaO2 of ≥100 mm Hg ensures adequate oxygenation to brain tissue and minimizes the risk of secondary injury due to hypoxia.

Answer 235

B. Hyponatremia Rationale: Hyponatremia can cause cerebral edema and increased ICP due to the osmotic shift of water into brain cells. This must be corrected promptly.

Answer 236

D. Creates an osmotic gradient drawing fluid from brain tissue Rationale: Mannitol is an osmotic diuretic that reduces ICP by creating an osmotic gradient, drawing water from brain cells into the intravascular space for excretion.

Answer 237

C. Lumbar puncture Rationale: A lumbar puncture is contraindicated in patients with increased ICP due to the risk of sudden pressure shifts that can result in brain herniation.

Answer 238

C. Dexamethasone Rationale: Corticosteroids like dexamethasone are used to reduce inflammation and edema in patients with brain tumors or bacterial meningitis, helping to lower ICP.

Answer 239

D. Brain tissue oxygen monitoring catheter Rationale: Brain tissue oxygen monitoring catheters provide direct PbtO2 measurements, which help guide interventions to improve oxygen delivery to the brain.

Answer 240

A. Notify the provider and prepare for vasopressor administration Rationale: Hypotension is a serious side effect of high-dose barbiturates and can reduce CPP. The nurse must notify the provider and support blood pressure with vasopressors if needed.

Answer 241

B. Phenytoin level Rationale: Phenytoin has a narrow therapeutic range, and serum levels must be monitored closely to avoid toxicity or subtherapeutic levels that could increase seizure risk.

Answer 242

B. Decrease the risk of GI bleeding from stress ulcers Rationale: Proton pump inhibitors like pantoprazole are used prophylactically to prevent stress-related mucosal damage and GI bleeding, which are common in critically ill patients.

Answer 243

D. Administering IV fluids or vasopressors Rationale: A CPP below 60 mm Hg indicates inadequate cerebral perfusion. Increasing MAP through fluids or vasopressors can raise CPP and improve perfusion.

Answer 244

C. Increase the ventilator rate Rationale: A PaCO2 of 52 mm Hg is elevated and can cause cerebral vasodilation, increasing ICP. Increasing the respiratory rate can reduce CO2 and ICP.

Answer 245

C. Transcranial Doppler Rationale: Transcranial Doppler ultrasound provides a noninvasive way to monitor cerebral blood flow velocity, which is useful in patients at risk for increased ICP.

Answer 246

C. Sodium level 118 mEq/L Rationale: A sodium level of 118 mEq/L indicates severe hyponatremia, which can lead to cerebral edema, increased ICP, and seizures. This requires immediate intervention.

Answer 247

D. Evaluate renal function Rationale: Cerebral angiography involves iodinated contrast, so renal function must be assessed to ensure safe clearance of the dye and prevent contrast-induced nephropathy.

Answer 248

b. Monitor fluid and electrolyte status Rationale: Mannitol can cause a shift of fluids from the tissues into the blood vessels, which can result in electrolyte imbalances. The nurse must carefully monitor fluid and electrolyte levels to avoid complications like hypovolemia or hyponatremia.

Answer 249

a. Serum sodium levels Rationale: Hypertonic saline causes fluid to shift from swollen brain cells into the bloodstream, which can lead to increased sodium levels. Monitoring serum sodium is crucial to avoid complications like hypernatremia.

Answer 250

a. Renal disease Rationale: Mannitol is contraindicated in patients with renal disease because it can worsen renal function and may not be effectively eliminated, leading to fluid overload and further complications.

Answer 251

b. Hyperglycemia Rationale: Corticosteroids like dexamethasone can increase blood glucose levels, leading to hyperglycemia, which is a common complication during corticosteroid therapy.

Answer 252

a. Administer a proton pump inhibitor (PPI) Rationale: Corticosteroids increase the risk of GI bleeding. Administering a proton pump inhibitor or H2-receptor blocker helps protect the stomach lining and prevent ulcers and bleeding.

Answer 253

c. 0.9% sodium chloride Rationale: 0.9% sodium chloride is the preferred solution for administering secondary medications because other solutions, like 0.45% sodium chloride or 5% dextrose, may lower serum osmolality and increase cerebral edema.

Answer 254

b. 98.6°F (37°C) Rationale: Maintaining the patient’s temperature between 96.8°F to 98.6°F (36°C to 37°C) helps avoid increasing metabolic demands on the brain, which can worsen ICP.

Answer 255

d. Administer sedatives Rationale: Shivering increases the metabolic workload on the brain, which can worsen ICP. Sedatives can help prevent or control shivering, thereby reducing the brain’s metabolic demands.

Answer 256

c. Monitoring EEG activity Rationale: Pentobarbital suppresses cerebral activity and is dosed to achieve brain wave suppression on the EEG. Monitoring EEG activity ensures the desired therapeutic effect and helps assess the level of brain wave suppression.

Answer 257

d. EEG for burst suppression Rationale: Pentobarbital therapy is aimed at achieving burst suppression on the EEG, which indicates that the treatment is effectively reducing cerebral metabolism and controlling ICP.

Answer 258

b. Lower intracranial pressure (ICP) Rationale: The primary goal of drug therapy in the management of increased ICP is to reduce ICP, which can be achieved through osmotic diuretics, hypertonic saline, corticosteroids, and other treatments.

Answer 259

d. Increased serum sodium levels Rationale: Hypertonic saline can lead to an increase in serum sodium levels. It’s important to monitor for signs of hypernatremia and adjust treatment accordingly to avoid complications.

Answer 260

c. Serum sodium of 160 mEq/L Rationale: A sodium level of 160 mEq/L indicates severe hypernatremia and places the patient at risk for neurological complications. Hypertonic saline can cause dangerous fluid shifts if not carefully monitored.

Answer 261

a. Glucose of 180 mg/dL Rationale: Corticosteroids like dexamethasone can cause hyperglycemia. Glucose levels >180 mg/dL increase the risk of infection and impair healing, especially in neuro patients.

Answer 262

a. Urine output increases from 40 mL/hr to 80 mL/hr Rationale: Mannitol creates an osmotic diuresis. An increase in urine output suggests the drug is reducing cerebral edema and pulling fluid into the vascular space.

Answer 263

b. Administer acetaminophen and start a cooling blanket Rationale: Fever increases cerebral metabolism and ICP. The nurse should act quickly to bring the temperature down using antipyretics and cooling measures.

Answer 264

a. Ibuprofen Rationale: Corticosteroids increase GI ulcer risk. H2-receptor blockers like cimetidine or PPIs are given prophylactically to prevent gastric bleeding.

Answer 265

a. Monitoring respiratory effort Rationale: Barbiturates depress the CNS, including respiratory centers. Monitoring for respiratory depression is essential to prevent hypoxia and further brain injury.

Answer 266

b. 5% dextrose in water Rationale: D5W decreases serum osmolality and can worsen cerebral edema. It is contraindicated in patients with increased ICP.

Answer 267

c. Crackles auscultated in bilateral lung bases Rationale: Crackles suggest fluid overload, a potential complication of concurrent osmotic and hypertonic therapy. This requires immediate intervention to prevent pulmonary edema.

Answer 268

d. No electrical brain activity appears on EEG Rationale: Total burst suppression refers to a flatline or near-complete suppression of EEG activity. This indicates maximal reduction in cerebral metabolism.

Answer 269

a. Stabilization of the cell membrane c. Inhibition of prostaglandin synthesis d. Restoration of cerebral autoregulation Rationale: Corticosteroids stabilize cell membranes, inhibit prostaglandin synthesis (reducing inflammation), and help restore cerebral autoregulation. They do not reduce CSF or directly suppress seizures.

Answer 270

d. Call the provider for sedative orders Rationale: Shivering increases metabolic demand and ICP. The nurse must address the shivering promptly—usually by requesting a sedative or adjusting the cooling method.

Answer 271

c. Avoiding hypotonic IV solutions like D5W Rationale: Hypotonic fluids lower serum osmolality and worsen cerebral edema. Isotonic fluids like 0.9% NS are preferred.

Answer 272

d. Serum osmolality increases to 330 mOsm/kg Rationale: An elevated serum osmolality (>320) may indicate overuse of mannitol and risk of renal damage or rebound ICP. It should be monitored closely.

Answer 273

c. Initiate enteral feedings by day 5 if oral intake remains inadequate Rationale: Nutritional replacement should meet caloric needs by at least day 5 post-injury. Early nutrition supports healing and reduces cerebral edema risk. Enteral feedings are preferred over parenteral when the gut is functional.

Answer 274

b. Serum osmolality of 355 mOsm/kg Rationale: An elevated serum osmolality (>300 mOsm/kg) suggests fluid volume deficit or hyperosmolar state, which can worsen cerebral edema or perfusion issues.

Answer 275

b. “Glucose is the main fuel source for the injured brain and must be provided.” Rationale: The hypermetabolic and hypercatabolic state of brain injury increases glucose demands. Early and adequate glucose provision supports neuronal healing and metabolism.

Answer 276

b. Balanced intake/output with stable electrolytes Rationale: A euvolemic state means fluid balance is maintained. Stable intake/output and normal labs are signs the patient is neither fluid overloaded nor volume depleted.

Answer 277

a. Provide high-protein, high-calorie enteral nutrition Rationale: The body breaks down protein rapidly after brain injury. High-protein, high-calorie support meets hypermetabolic needs and helps prevent further breakdown and cerebral edema.

Answer 278

c. Hyperglycemia Rationale: Parenteral nutrition often contains dextrose. Brain-injured patients are already glucose-sensitive; hyperglycemia can worsen cerebral edema and impair recovery.

Answer 279

b. Urine specific gravity of 1.030 Rationale: A high urine specific gravity indicates dehydration or fluid imbalance, which can trigger compensatory fluid retention and worsen cerebral edema if not corrected.

Answer 280

a. Serum and urine osmolality b. Daily weight d. Blood glucose Rationale: Serum/urine osmolality helps assess fluid status. Daily weight is a key indicator of fluid retention or loss. Blood glucose monitoring ensures adequate energy supply without causing hyperglycemia. Respiratory rate and hematocrit are less specific to nutritional or fluid monitoring in this case.

Answer 281

d. Documenting changes in level of consciousness (LOC) Rationale: LOC is the most sensitive and earliest indicator of increased ICP. Subtle changes such as restlessness, confusion, or lethargy may be the first signs of neurologic decline, and early recognition is essential.

Answer 282

b. A report from the family that the patient “isn’t acting like themselves” Rationale: Subjective data from caregivers familiar with the patient’s baseline behavior is critical. Subtle changes in personality, behavior, or alertness may reflect early changes in LOC due to increased ICP and must be acted on promptly.

Answer 283

a quick, practical, and standard system for assessing the LOC

Answer 284

C. Note “untestable” for eye opening and explain why Rationale: When a feature such as eye opening is physically obstructed (e.g., due to edema), it should be documented as “untestable” with the reason noted rather than scored inaccurately.

Answer 285

C. 15 Rationale: The highest possible GCS score is 15, which indicates a fully alert and oriented individual.

Answer 286

A. Best verbal response B. Brainstem reflexes D. Best motor response Rationale: The GCS includes eye opening, best verbal response, and best motor response. Brainstem reflexes and pupillary response are assessed separately.

Answer 287

C. Notify the HCP immediately

Answer 288

D. To identify trends in neurologic function Rationale: Graphing GCS scores helps in identifying whether the patient’s condition is improving, stable, or deteriorating.

Answer 289

A. NIH Stroke Scale Rationale: For patients with strokes and increased ICP, the NIH Stroke Scale is a validated tool to assess stroke severity and neurologic deficits.

Answer 290

C. Standardized tool used by multiple providers Rationale: The GCS allows for consistent communication and interpretation of LOC across the healthcare team.

Answer 291

D. All of the above Rationale: GCS has limitations in sedated, intubated, or physically impaired patients. Notations should reflect untestable components.

Answer 292

B. Cranial nerve III (Oculomotor) Rationale: The oculomotor nerve (CN III) is responsible for pupil constriction. Compression of CN III causes an ipsilateral dilated pupil that does not react to light—a key sign of increased ICP.

Answer 293

B. This is an expected consensual response. Rationale: A consensual response is normal and expected. It means both pupils constrict simultaneously when light is shone in one eye, showing intact neural pathways.

Answer 294

C. Sluggish pupillary reaction to light Rationale: A sluggish pupillary response is an early sign of increased pressure on CN III, which controls pupil constriction.

Answer 295

D. Absent doll’s eye reflex; brainstem function is impaired Rationale: The absence of eye movement with head turning (doll’s eyes) indicates impaired brainstem function, a critical sign of severe neurologic compromise.

Answer 296

C. Severe neurologic damage or brain death Rationale: The absence of eye movement in response to cold caloric stimulation suggests significant brainstem dysfunction, often used as part of brain death evaluation.

Answer 297

A. Ruptured tympanic membrane Rationale: The oculovestibular test requires intact tympanic membranes; damage to these structures contraindicates the procedure.

Answer 298

D. A reliable indicator of motor function Rationale: Resistance to passive ROM can indicate intact motor pathways and is a valid assessment of motor strength in unresponsive patients.

Answer 299

D. Consider the squeeze a reflex and not reliable Rationale: Hand squeezing may be a reflex rather than a true motor response in an unconscious patient. It should not be solely relied upon to assess motor status.

Answer 300

A. Bradycardia, hypertension, and irregular respirations Rationale: Cushing’s triad—bradycardia, hypertension (widening pulse pressure), and irregular respirations—is a late and ominous sign of increased ICP.

Answer 301

C. Removing subjectivity in pupil size and reactivity measurements Rationale: The pupillometer offers an objective and consistent measurement of pupil size and reactivity, which improves accuracy in neurologic assessment.

Answer 302

B. Ipsilateral compression of CN III Rationale: A fixed, dilated pupil on one side (ipsilateral) suggests compression of CN III, often due to increased ICP pressing on the brainstem.

Answer 303

C. Fixed pupils unresponsive to light Rationale: Fixed pupils that do not respond to light suggest herniation or severe brain damage and require urgent evaluation.

Answer 304

A. Eyes should move opposite the direction of head movement C. Absence of the reflex suggests brainstem dysfunction D. It is part of the neurologic exam in suspected brain death Rationale: Normally, eyes move in the opposite direction of the head turn. If absent, it suggests brainstem damage. It is used during brain death evaluations.

Answer 305

D. Asking the patient to squeeze your hand Rationale: Hand squeezing in unresponsive patients can be a reflexive action and should not be used alone to assess purposeful movement.

Answer 306

C. Extraocular movements Rationale: CN III, IV, and VI control eye movements, so tracking with the eyes is used to evaluate their function.

Answer 307

A. Notify the provider; this may indicate brain death Rationale: Absence of response in a properly performed cold caloric test with intact tympanic membranes may indicate brainstem death.

Answer 308

B. Compare findings to baseline Rationale: Comparing with baseline data helps determine whether this is a new change, progression, or stable finding.

Answer 309

B. Increased tone or possible spasticity Rationale: Resistance during passive movement may indicate increased tone, spasticity, or partial motor pathway integrity.

Answer 310

A. Brainstem herniation Rationale: This is classic Cushing’s triad—bradycardia, widened pulse pressure, and irregular respirations—suggesting imminent brain herniation from increased ICP.

Answer 311

C. It enhances consistency in pupil size/reactivity assessment Rationale: The pupillometer reduces human subjectivity and increases consistency in documenting changes in pupil size and response.

Answer 312

D. Patient has unequal pupils, one fixed and dilated Rationale: A fixed, dilated pupil is an emergency and may indicate uncal herniation or rapid ICP elevation—call the provider immediately.

Answer 313

B. CN III, IV, and VI Rationale: CN III (oculomotor), IV (trochlear), and VI (abducens) coordinate eye movements and are assessed by following a target with the eyes.

Answer 314

C. Mark the eye component as “NT” (not testable) Rationale: When an area of the GCS is untestable (like eye-opening due to swelling), it should be documented as “NT,” and the limitation noted.

Answer 315

A. Bradycardia B. Cheyne-Stokes respirations C. Hypertension with wide pulse pressure E. Decerebrate posturing Rationale: Signs of severe ICP include bradycardia, Cheyne-Stokes respirations, hypertension with widened pulse pressure, and posturing. Pinpoint pupils suggest pontine damage, not necessarily increased ICP.

Answer 316

D. Notify the neurologist STAT Rationale: These are signs of rising ICP and possible brain herniation. The provider should be notified immediately for urgent intervention.

Answer 317

C. Inadequate cerebral tissue perfusion Rationale: Inadequate cerebral tissue perfusion is a critical and priority diagnosis in patients with increased ICP because impaired perfusion can lead to secondary brain injury, ischemia, or herniation. While other diagnoses may apply, preserving brain oxygenation and perfusion is the most immediate concern.

Answer 318

A. Maintain bed in low position with side rails up and call light within reach Rationale: A patient with increased ICP is at high risk for seizures, falls, or altered mental status. Keeping the bed low, side rails up, and ensuring call light accessibility provides safety without increasing ICP. High Fowler’s position can decrease cerebral perfusion and increase fall risk.

Answer 319

C. The patient maintains a patent airway Rationale: Maintaining a patent airway is the highest priority in any neurologic patient, especially those with altered LOC and increased ICP. Without an adequate airway, oxygenation and perfusion to the brain can be compromised, worsening cerebral edema and neurologic outcomes.

Answer 320

B. Perform passive range of motion exercises every 2 hours Rationale: Preventing complications from immobility includes addressing risk for contractures, venous thromboembolism, and skin breakdown. Passive ROM exercises maintain joint flexibility and circulation, which directly supports this goal. While rest is important, complete immobility increases risk of complications.

Answer 321

D. Blood glucose level of 120 mg/dL and serum sodium 140 mEq/L Rationale: Normal blood glucose and serum sodium levels suggest stable electrolyte and nutritional status. Monitoring lab values is essential in patients receiving osmotic diuretics and nutritional support, since these interventions can cause significant shifts in fluid and electrolytes.

Answer 322

A. Maintain ICP within normal range C. Maintain normal fluid and electrolyte levels E. Prevent complications related to decreased level of consciousness F. Maintain oxygen saturation greater than 95% Rationale: Key goals in managing increased ICP include maintaining normal ICP, normal fluid/electrolyte balance, preventing complications of altered LOC, and ensuring adequate oxygenation. Bedrest is appropriate but not complete immobility, and coughing increases intrathoracic pressure, which can elevate ICP.

Answer 323

C. Prepare for intubation and mechanical ventilation Rationale: A GCS score of 8 or less indicates the patient cannot maintain a patent airway. Immediate intubation and mechanical ventilation are required to prevent hypoxia and further increases in ICP.

Answer 324

A. Insert an oral airway in a comatose patient C. Limit suctioning to less than 10 seconds per pass D. Preoxygenate with 100% oxygen before suctioning Rationale: Oral airways prevent tongue obstruction. Suctioning must be brief to prevent hypoxia and ICP spikes. Preoxygenation prevents PaO2 drops. Routine 30-minute suctioning and flat supine positioning are not appropriate in this context.

Answer 325

B. Preoxygenate with 100% oxygen and limit suctioning to two passes Rationale: Suctioning can increase ICP. Preoxygenating and limiting passes reduces hypoxia and secondary injury. Prolonged suctioning and too many passes increase ICP and decrease PaO2.

Answer 326

D. Insert an orogastric tube for decompression Rationale: NG tubes are contraindicated in facial/skull fractures due to risk of brain insertion. An orogastric tube is a safer method for decompression and aspiration prevention.

Answer 327

C. Airway obstruction from the tongue Rationale: Decreased LOC causes the tongue to fall back and occlude the airway, especially in supine positions. This is a major threat to airway patency

Answer 328

A. This indicates hypercapnia; notify the provider for ventilator adjustment Rationale: A PaCO₂ >45 mmHg indicates hypercapnia, which can lead to cerebral vasodilation and increased ICP. Ventilation adjustments are necessary to maintain appropriate CO₂ levels.

Answer 329

A. Visible oral secretions B. Rhonchi on auscultation D. Gurgling sounds from the airway E. Increased respiratory rate with use of accessory muscles Rationale: Audible secretions, abnormal breath sounds, and increased work of breathing all signal the need for suctioning. An SpO₂ of 100% alone does not.

Answer 330

C. PaCO₂ 52 mmHg Rationale: A PaCO₂ of 52 mmHg indicates hypercapnia, leading to cerebral vasodilation and further increasing ICP. This requires ventilatory adjustment.

Answer 331

D. It interferes with respiratory function and increases ICP Rationale: Abdominal distention impairs diaphragm movement, reduces ventilation efficiency, and can contribute to hypoxia and rising ICP.

Answer 332

B. Remove the suction catheter and administer 100% oxygen Rationale: Gagging and coughing increase ICP. The nurse should immediately stop, administer oxygen to prevent hypoxia, and allow the patient to recover before trying again.

Answer 333

D. To prevent suction-induced hypoxia and secondary brain injury Rationale: Suctioning can cause a temporary drop in oxygenation, which worsens brain injury. Pre- and post-oxygenation prevents this complication and protects cerebral tissue.

Answer 334

A. Rapid onset and short half-life, allowing for quick neurologic assessment Rationale: Propofol is used for rapid sedation with a short half-life, allowing for more accurate neurologic assessments after discontinuation.

Answer 335

B. Bradycardia C. Hypotension Rationale: Dexmedetomidine can cause bradycardia and hypotension, which can lower CPP, making it important to monitor these effects closely in patients with increased ICP.

Answer 336

A. Monitor for signs of pain and distress, and provide adequate analgesia Rationale: Nondepolarizing neuromuscular blocking agents like vecuronium paralyze muscles without blocking pain, so it is essential to provide adequate analgesia and sedation to prevent distress.

Answer 337

B. Monitor the patient’s respiratory rate closely, as opioids can depress ventilation Rationale: Opioids like morphine and fentanyl are commonly used for pain management but can depress respiratory function. Monitoring respiratory rate and maintaining adequate ventilation is crucial in patients with increased ICP.

Answer 338

B. These medications can mask true neurologic changes, making assessment difficult Rationale: Sedatives and paralytics can mask neurologic changes, making it challenging to accurately assess the patient’s neurologic state and determine the appropriate course of treatment.

Answer 339

A. Benzodiazepines should be used cautiously due to their hypotensive effect D. Hypotension from benzodiazepines can reduce CPP Rationale: Benzodiazepines can cause hypotension, which can reduce CPP, so they should be used with caution in patients with increased ICP.

Answer 340

A. Wait 30 minutes after the sedative infusion has stopped to assess neurologic changes Rationale: Once the sedative infusion is stopped, a more accurate neurologic assessment can be conducted after 30 minutes, allowing for the effects of the medication to wear off.

Answer 341

C. Respiratory rate and oxygen saturation Rationale: Opioids like fentanyl can depress respiratory function, so it is crucial to monitor respiratory rate and oxygen saturation to prevent hypoxia and further increases in ICP.

Answer 342

B. The choice of medications should be tailored based on the patient’s neurologic state and history Rationale: The choice of sedatives, analgesics, and paralytics must be individualized to the patient’s condition and history. These medications can affect the neurologic state, so monitoring and adjustment are essential.

Answer 343

A. Monitor vital signs regularly, including blood pressure and heart rate B. Assess for any signs of agitation or frustration regularly D. Minimize interruptions and noise in the patient’s environment Rationale: Monitoring vital signs, assessing for signs of agitation, and maintaining a quiet environment are critical for managing increased ICP and ensuring patient comfort.

Answer 344

C. Inadequate pain control Rationale: Neuromuscular blocking agents paralyze muscles without affecting pain perception. Therefore, they must be used in combination with appropriate sedatives and analgesics to ensure adequate pain control.

Answer 345

D. Perform a neurologic assessment immediately after the infusion is stopped Rationale: Propofol has a short half-life, so neurologic assessments can be performed soon after the infusion is stopped.

Answer 346

C. Notify the healthcare provider about the hypotension Rationale: Hypotension from dexmedetomidine can lower CPP, so it is critical to notify the healthcare provider for further assessment and management.

Answer 347

A. Monitor for changes in neurologic status B. Administer analgesics as needed for pain management C. Assess for respiratory depression and hypoxia Rationale: Analgesics should be administered as needed for pain relief, but monitoring neurologic status and respiratory function is essential to prevent complications.

Answer 348

A. Propofol affects cerebral blood flow and may obscure neurologic changes Rationale: Propofol can affect cerebral blood flow and mask true neurologic changes, so it is crucial to stop the medication before assessing the neurologic status.

Answer 349

B. Diabetes insipidus Rationale: Diabetes insipidus, caused by a decrease in antidiuretic hormone (ADH), leads to increased urine output and hypernatremia due to the inability to concentrate urine.

Answer 350

A. Closely monitor IV fluid administration using an accurate infusion control device C. Assess intake and output, accounting for insensible losses D. Monitor daily weights to assess fluid balance Rationale: Accurate monitoring of IV fluids, intake and output, and daily weights are essential to managing fluid balance in patients with increased ICP. These measures help assess whether the body is retaining or losing fluid and electrolytes.

Answer 351

D. Sodium 130 mEq/L Rationale: Sodium levels of 130 mEq/L indicate hyponatremia, which is a concern in patients with increased ICP, as it may lead to cerebral edema, changes in LOC, and seizures.

Answer 352

C. Inappropriate secretion of antidiuretic hormone Rationale: SIADH results from excess ADH secretion, leading to decreased urine output and dilutional hyponatremia, which can cause cerebral edema, LOC changes, and seizures.

Answer 353

A. Vasopressin or desmopressin acetate (DDAVP) Rationale: Diabetes insipidus is treated with fluid replacement and medications such as vasopressin or desmopressin acetate (DDAVP), which help concentrate the urine and correct the hypernatremia.

Answer 354

A. Seizures C. Dilutional hyponatremia E. Cerebral edema Rationale: SIADH leads to dilutional hyponatremia, cerebral edema, and changes in LOC, which can trigger seizures. Increased urine output is not typically seen in SIADH; rather, the hallmark is decreased urine output.

Answer 355

A. Restrict fluids and administer hypertonic saline Rationale: In SIADH, fluid restriction and the administration of hypertonic saline help raise sodium levels and prevent complications like cerebral edema and seizures.

Answer 356

A. Administer fluids to prevent severe dehydration Rationale: The primary goal in treating diabetes insipidus is fluid replacement to prevent dehydration due to increased urine output, and vasopressin or DDAVP may also be used to replace ADH.

Answer 357

B. Restrict fluid intake and administer hypertonic saline Rationale: In SIADH, restricting fluid intake and administering hypertonic saline is essential to correct dilutional hyponatremia and prevent further complications like cerebral edema.

Answer 358

C. Arousal from sleep Rationale: Arousal from sleep can increase ICP due to the sudden increase in cerebral metabolism and blood flow. Other factors like suctioning, hypoxemia, or sudden movements can also raise ICP.

Answer 359

B. Administer analgesics as prescribed to minimize pain and discomfort C. Assist the patient in avoiding the Valsalva maneuver D. Monitor for signs of hypoxemia and provide oxygen therapy as needed Rationale: Administering analgesics, avoiding the Valsalva maneuver, and monitoring for hypoxemia are critical steps in minimizing ICP elevation. Coughing, straining, or remaining in a fully upright position unnecessarily increases pressure in the intracranial space.

Answer 360

B. Place the patient in a position that facilitates venous return Rationale: Positioning the patient to facilitate venous return can help reduce ICP. The Valsalva maneuver (coughing) increases ICP, so the nurse should minimize such actions and manage the situation by ensuring proper body positioning.

Answer 361

D. Intracranial pressure (ICP) readings Rationale: ICP readings are the most direct and reliable way to assess the effectiveness of treatment and the patient’s status when managing increased ICP. Other parameters like blood pressure and ABGs are important but secondary.

Answer 362

A. Avoiding the Valsalva maneuver B. Restricting the patient from coughing or sneezing C. Encouraging deep breathing exercises to improve oxygenation Rationale: The Valsalva maneuver, coughing, and sneezing can increase ICP. Deep breathing exercises can help with oxygenation, which is important for managing ICP. Reducing physical activity may not be necessary unless it involves strain or is otherwise indicated. Proper rest is essential, but deep breathing exercises are a better intervention to manage ICP.

Answer 363

B. Keep the head in a midline position with the head of the bed elevated at 30 degrees Rationale: The head should be elevated at 30 degrees to promote drainage and reduce vascular congestion, while maintaining the head in a midline position to avoid obstruction of venous return, which could increase ICP.

Answer 364

A. Keeping the head in a neutral, midline position C. Avoiding extreme neck flexion D. Turning the patient with slow, gentle movements Rationale: Keeping the head in a neutral, midline position, avoiding neck flexion, and turning the patient with slow, gentle movements help minimize ICP. Elevating the head of the bed too high or flexing the hips can increase ICP by compromising venous return and intraabdominal pressure.

Answer 365

A. Turn the patient slowly and gently to minimize discomfort Rationale: Turning the patient slowly and gently helps minimize discomfort and the risk of increasing ICP. Rapid movements can increase ICP. Flexing the hips or elevating the head too high may compromise venous return and increase ICP.

Answer 366

C. Keep the head in a neutral, midline position with the bed at 30 degrees Rationale: Keeping the head in a neutral, midline position with the bed at 30 degrees promotes venous return and drainage while avoiding increased ICP due to flexion of the neck or excessive head elevation.

Answer 367

A. Turn the patient at least every 2 hours B. Administer pain medication before turning the patient D. Provide passive range of motion exercises regularly Rationale: Turning the patient at least every 2 hours and providing passive range of motion help prevent complications of immobility, such as atelectasis and contractures. Administering pain medication before turning will minimize discomfort. Avoiding repositioning and encouraging sitting up may not be feasible with increased ICP.

Answer 368

D. It can obstruct venous return and contribute to increased ICP Rationale: Extreme neck flexion can obstruct venous return from the brain, leading to an increase in ICP. Maintaining a neutral head position avoids this complication.

Answer 369

C. Decrease the head elevation to 30 degrees Rationale: Reducing the head elevation to 30 degrees may help improve CPP by optimizing systemic blood pressure and venous return, thereby decreasing ICP.

Answer 370

C. Turn the patient slowly and gently to reduce discomfort and ICP Rationale: Turning the patient slowly and gently helps prevent increases in ICP and minimizes discomfort. Rapid movements can elevate ICP, while flexing the hips may raise intraabdominal pressure.

Answer 371

A. Turn the patient at least every 2 hours C. Perform passive range of motion exercises regularly E. Provide frequent oral care to prevent dryness and discomfort Rationale: Turning the patient every 2 hours, performing passive range of motion, and providing oral care are important for preventing complications of immobility and promoting comfort. Sedatives and restricted mobility may not be beneficial for overall care.

Answer 372

A. Reposition the patient to a midline, neutral position Rationale: Repositioning the patient to a neutral, midline position helps to reduce posturing and minimize ICP. Elevating the head of the bed too high or using medications without proper assessment may worsen the situation.

Answer 373

D. Increased intraabdominal pressure, which may increase ICP Rationale: Flexing the hips can increase intraabdominal pressure, which can obstruct venous return from the brain and subsequently increase ICP. It is essential to avoid extreme hip flexion in patients with increased ICP.

Answer 374

B. Place the patient on seizure precautions with padded side rails and suction equipment Rationale: Placing the patient on seizure precautions, including padded side rails and suction equipment, is essential to protect the patient from injury. Restraints should only be used cautiously and with sedation to prevent further agitation.

Answer 375

B. Provide a quiet, nonstimulating environment C. Administer sedatives to manage agitation D. Allow family members to stay with the patient for comfort Rationale: A quiet, nonstimulating environment, administering sedatives when necessary, and allowing family members to stay with the patient can help calm the patient and prevent injury. Restraints should only be used if absolutely necessary, and allowing the patient to move freely is not appropriate for safety.

Answer 376

A. Administer antiseizure prophylaxis as ordered Rationale: Administering antiseizure prophylaxis as ordered is critical to prevent seizures, especially in the first 7-10 days following severe brain injury. The other options do not address the patient’s immediate safety concerns.

Answer 377

A. Place padded side rails on both sides of the bed Rationale: Padded side rails and suction equipment should be readily available to protect the patient from injury during a seizure. Immediate sedation after a seizure is not appropriate without a medical assessment.

Answer 378

B. Administer sedative medications to calm the patient Rationale: Administering sedative medications can help calm the patient and reduce agitation, making the patient less likely to harm themselves. Physical restraints should only be used if absolutely necessary and with sedation. Family presence can provide comfort.

Answer 379

A. Place the patient on seizure precautions with padded side rails B. Provide a calm, reassuring environment D. Ensure timely administration of antiseizure drugs Rationale: Seizure precautions, a calm environment, and timely administration of antiseizure medications are essential to prevent injury. Restricting fluids is not an appropriate intervention without further assessment, and positioning the patient sitting up is not indicated unless in a safe environment.

Answer 380

A. Observe the skin area under the restraints regularly for irritation Rationale: It is essential to regularly assess the skin under the restraints for irritation to prevent pressure injuries. Restraints should be secure but not overly tight, and sedation should only be used when necessary.

Answer 381

C. The patient may experience irritation or pressure injuries under the restraints Rationale: The nurse’s primary concern should be preventing skin irritation or pressure injuries under the restraints. While agitation and sedation are concerns, preventing harm from the restraints is paramount.

Answer 382

A. Provide a quiet, nonstimulating environment B. Place padded side rails on the bed E. Provide family members with instructions on how to assist with care Rationale: A quiet, nonstimulating environment and padded side rails help reduce the risk of injury. Family members can provide emotional support and assist in calming the patient. Walking around the room may not be safe, and sedatives should be administered before a seizure occurs, not after.

Answer 383

D) Offer simple, clear explanations, and allow the family to ask questions. Rationale: Providing simple, clear explanations and allowing the family to ask questions helps reduce anxiety and ensures the family receives the necessary information without feeling overwhelmed.

Answer 384

B) Administer sedation to manage the agitation. Rationale: Sedation can help manage agitation, making the patient safer and more comfortable, especially in a state of confusion or agitation. Restraints should only be used when absolutely necessary.

Answer 385

B) “I understand your concern. We are carefully monitoring and managing your loved one’s condition.” Rationale: Acknowledging the family’s concern and providing reassurance that the situation is being actively managed is the best response. This helps reduce anxiety and provides the family with a sense of security.

Answer 386

D) Administer sedative medications as ordered. Rationale: Administering sedative medications as prescribed helps manage agitation effectively, making the patient safer and more comfortable.

Answer 387

C) Offer short, clear explanations and allow the family to ask questions. Rationale: Offering short, clear explanations and allowing the family to ask questions ensures they are informed without becoming overwhelmed by excessive details.

Answer 388

B) The patient has a cerebral perfusion pressure (CPP) of 62 mm Hg and ICP of 14 mm Hg. Rationale: A CPP of 62 mm Hg and an ICP of 14 mm Hg are within acceptable limits, indicating adequate cerebral perfusion and controlled ICP. This reflects that interventions are effective in maintaining ICP and cerebral perfusion within normal parameters.

Answer 389

B) The patient remains in a semi-Fowler’s position with no signs of foot drop or atelectasis. Rationale: Maintaining positioning and preventing complications like foot drop or atelectasis are indicators that the patient has no complications of immobility, which reflects a successful nursing outcome.

Answer 390

b. disrupting the blood-brain barrier.

Answer 391

d. a normal balance among brain tissue, blood, and cerebrospinal fluid.

Answer 392

b. elevate the head of the bed to 30 degrees.

Answer 393

b. controlling fever with prescribed drugs and cooling techniques.

Answer 394

a. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min Rationale: Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing‘s triad. These findings indicate that the intracranial pressure (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.

Answer 395

c. Decorticate posturing Rationale: Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.

Answer 396

c. Intracranial pressure Rationale: Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not parameters for evaluation of the effectiveness of the drug. O 2 saturation will not directly improve because of mannitol administration.

Answer 397

c. Keep the head of the bed elevated to 30 degrees. Rationale: The patient with increased intracranial pressure (ICP) would be maintained in the head-up position with the head in neutral position to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.

Answer 398

b. Check the drainage for glucose content. Rationale: Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.

Answer 399

b. Ensure that the patient‘s neck is in neutral position. Rationale: Because suctioning will cause a transient increase in ICP, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation. There is no indication that anxiety has contributed to the increase in ICP.

Answer 400

a. Administer IV hypertonic saline. Rationale: The patient‘s low sodium indicates that hyponatremia may be causing the cerebral edema. The nurse‘s first action would be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased intracranial pressure (ICP). Drawing ABGs and obtaining a CT scan may provide some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.

Answer 401

d. A 50-yr-old patient whose right pupil is 10 mm and unresponsive to light Rationale: The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure. The other patients are not at immediate risk for complications such as herniation.

Answer 402

b. Temperature of 101.6°F Rationale: Infection is a serious complication of ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse only require ongoing monitoring at this time.

Ch 61: ICP Flashcards

(429 cards)