Head Injury/Increased ICP/Stroke Review || Questions and Correct
Detailed Answers.
how is ICP monitored? correct answers a screw, catheter, or sensor put through a burr hole into
the ventricle
what is the expected ICP reference range? correct answers 10-15 mm Hg
a nurse is caring for a client who was recently admitted to the emergency department following a
head-on motor vehicle crash. the client is unresponsive, has spontaneous respirations of 22/min,
and has a laceration on the forehead that is bleeding. which of the following is the priority
nursing action at this time?
A. keep neck stabilized
B. insert nasogastric tube
C. monitor pulse and blood pressure frequently
D. establish IV assess and start fluid replacement correct answers A
a nurse is caring for a client who has just been admitted following surgical evacuation of a
subdural hematoma. which of the following is the priority assessment?
A. Glasgow Coma Scale
B. Cranial nerve function
C. oxygen saturation
D. pupillary response correct answers C
a nurse is caring for a client who has a closed-head injury with ICP readings ranging from 16 to
22 mm Hg. which of the following actions should the nurse take to decrease the potential for
raising the client's ICP? (select all that apply)
A. suction the endotracheal tube frequently
B. decrease the noise level in the client's room
C. elevate the client's head on two pillows
, D. administer a stool softener
E. keep the client well hydrated correct answers BD
a nurse in the critical care unit is completing an admission assessment of a client who has a
gunshot wound to the head. which of the following assessment findings are indicative of
increased ICP? (select all that apply)
A. headache
B. dilated pupils
C. tachycardia
D. decorticate posturing
E. hypotension correct answers ABD
a nurse is caring for a client who has increased ICP and a new prescription for mannitol. for
which of the following adverse effects should the nurse monitor?
A. hyperglycemia
B. hyponatremia
C. hypervolemia
D. oliguria correct answers B
Select the main structures below that play a role with altering intracranial pressure:
A. Brain
B. Neurons
C. Cerebrospinal Fluid
D. Blood
E. Periosteum
F. Dura mater correct answers ACD
Detailed Answers.
how is ICP monitored? correct answers a screw, catheter, or sensor put through a burr hole into
the ventricle
what is the expected ICP reference range? correct answers 10-15 mm Hg
a nurse is caring for a client who was recently admitted to the emergency department following a
head-on motor vehicle crash. the client is unresponsive, has spontaneous respirations of 22/min,
and has a laceration on the forehead that is bleeding. which of the following is the priority
nursing action at this time?
A. keep neck stabilized
B. insert nasogastric tube
C. monitor pulse and blood pressure frequently
D. establish IV assess and start fluid replacement correct answers A
a nurse is caring for a client who has just been admitted following surgical evacuation of a
subdural hematoma. which of the following is the priority assessment?
A. Glasgow Coma Scale
B. Cranial nerve function
C. oxygen saturation
D. pupillary response correct answers C
a nurse is caring for a client who has a closed-head injury with ICP readings ranging from 16 to
22 mm Hg. which of the following actions should the nurse take to decrease the potential for
raising the client's ICP? (select all that apply)
A. suction the endotracheal tube frequently
B. decrease the noise level in the client's room
C. elevate the client's head on two pillows
, D. administer a stool softener
E. keep the client well hydrated correct answers BD
a nurse in the critical care unit is completing an admission assessment of a client who has a
gunshot wound to the head. which of the following assessment findings are indicative of
increased ICP? (select all that apply)
A. headache
B. dilated pupils
C. tachycardia
D. decorticate posturing
E. hypotension correct answers ABD
a nurse is caring for a client who has increased ICP and a new prescription for mannitol. for
which of the following adverse effects should the nurse monitor?
A. hyperglycemia
B. hyponatremia
C. hypervolemia
D. oliguria correct answers B
Select the main structures below that play a role with altering intracranial pressure:
A. Brain
B. Neurons
C. Cerebrospinal Fluid
D. Blood
E. Periosteum
F. Dura mater correct answers ACD
