ICP, head and spinal injury QUESTIONS || with 100% Correct
Answers.
which components are able to adapt to small increases in ICP (select all that apply)
A. blood
B. skull bone
C. brain tissue
D. scalp tissue
E. cerebrospinal fluid correct answers A. blood
C. brain tissue
E. cerebrospinal fluid
which events causes increased ICP (select all that apply)
A. vasodilation
B. necrotic tissue edema
C. blood vessel compression
D. edema from initial brain insult
E. brainstem compression and herniation correct answers A. vasodilation
B. necrotic tissue edema
D. edema from initial brain insult
an early sign of increased ICP that the nurse should assess for is?
A. Cushing's triad
B. unexpected vomiting
C. decreased LOC
,D. dilated pupil with sluggish response to light correct answers C. decreased LOC
a patient has ICP monitoring with an intraventricular catheter. what is the priority nursing
intervention for the patient?
A. aseptic technique to prevent infection
B. constant monitoring of ICP waveforms
C. removal of CSF to maintain normal ICP
D. sampling CSF to determine abnormalities correct answers A. aseptic technique to prevent
infection
which drug treatment helps to decrease ICP by expanding plasma and the osmotic effect to move
fluid?
A. O2 administration
B. pentobarbital
C. mannitol
D. dexamethasone correct answers C. mannitol
how are the metabolic nutritional needs of the patient with increased ICP best met?
A. enteral feedings that are low in sodium
B. simple glucose available in D5W IV
C. fluid restrictions that promotes a moderate dehydration
D. balanced, essential nutrition in a form that the patient can tolerate correct answers D.
balanced, essential nutrition in a form that the patient can tolerate
why is the Glasgow Coma scale used?
, A. to quickly assess the LOC
B. to assess the patient's ability to communicate
C. to assess the patient's ability to respond to commands
D. to assess the patient's coordination with motor responses correct answers A. to quickly assess
the LOC
a patient with an intracranial problem does not open his eyes to any stimulus, has no verbal
response except moaning and muttering when stimulated, and flexes his arms in response to
painful stimuli. what should the nurse report as the GCS score?
A. 6
B. 7
C. 9
D. 11 correct answers B. 7
when assessing the body functions of a patient with increased ICP, what should the nurse assess
first?
A. corneal reflex testing
B. pupilllary reaction to light
C. extremity strength testing
D. circulatory and respiratory status correct answers D. circulatory and respiratory status
a patient has a nursing diagnosis o risk for ineffective cerebral tissue perfusion related to cerebral
edema. what is an appropriate nursing intervention for the patient
A. avoid positioning the patient with neck and hip flexion
B. maintain hyperventilation to a PaCO2 of 15-20
Answers.
which components are able to adapt to small increases in ICP (select all that apply)
A. blood
B. skull bone
C. brain tissue
D. scalp tissue
E. cerebrospinal fluid correct answers A. blood
C. brain tissue
E. cerebrospinal fluid
which events causes increased ICP (select all that apply)
A. vasodilation
B. necrotic tissue edema
C. blood vessel compression
D. edema from initial brain insult
E. brainstem compression and herniation correct answers A. vasodilation
B. necrotic tissue edema
D. edema from initial brain insult
an early sign of increased ICP that the nurse should assess for is?
A. Cushing's triad
B. unexpected vomiting
C. decreased LOC
,D. dilated pupil with sluggish response to light correct answers C. decreased LOC
a patient has ICP monitoring with an intraventricular catheter. what is the priority nursing
intervention for the patient?
A. aseptic technique to prevent infection
B. constant monitoring of ICP waveforms
C. removal of CSF to maintain normal ICP
D. sampling CSF to determine abnormalities correct answers A. aseptic technique to prevent
infection
which drug treatment helps to decrease ICP by expanding plasma and the osmotic effect to move
fluid?
A. O2 administration
B. pentobarbital
C. mannitol
D. dexamethasone correct answers C. mannitol
how are the metabolic nutritional needs of the patient with increased ICP best met?
A. enteral feedings that are low in sodium
B. simple glucose available in D5W IV
C. fluid restrictions that promotes a moderate dehydration
D. balanced, essential nutrition in a form that the patient can tolerate correct answers D.
balanced, essential nutrition in a form that the patient can tolerate
why is the Glasgow Coma scale used?
, A. to quickly assess the LOC
B. to assess the patient's ability to communicate
C. to assess the patient's ability to respond to commands
D. to assess the patient's coordination with motor responses correct answers A. to quickly assess
the LOC
a patient with an intracranial problem does not open his eyes to any stimulus, has no verbal
response except moaning and muttering when stimulated, and flexes his arms in response to
painful stimuli. what should the nurse report as the GCS score?
A. 6
B. 7
C. 9
D. 11 correct answers B. 7
when assessing the body functions of a patient with increased ICP, what should the nurse assess
first?
A. corneal reflex testing
B. pupilllary reaction to light
C. extremity strength testing
D. circulatory and respiratory status correct answers D. circulatory and respiratory status
a patient has a nursing diagnosis o risk for ineffective cerebral tissue perfusion related to cerebral
edema. what is an appropriate nursing intervention for the patient
A. avoid positioning the patient with neck and hip flexion
B. maintain hyperventilation to a PaCO2 of 15-20
