ICP || with Errorless Answers.
The nurse is assessing a client with a traumatic head injury and suspects increased intracranial
pressure (IICP). Which assessment finding supports this suspicion? (Select all that apply.)
A.
Double vision
B.
Drowsiness
C.
Increased heart rate
D.
Hemiparesis
E.
Blurred vision correct answers A,B,D,E
Rationale: Hemiparesis or hemiplegia of the contralateral side may be an early sign of IICP.
Drowsiness can occur with IICP. Double vision and blurred vision can occur with IICP.
Headache is common with IICP. The client may also report other generalized manifestations such
as dizziness. The heart rate generally decreases with IICP.
The nurse caring for a client with increased intracranial pressure should recognize that which
compensatory mechanism stimulates the cerebral blood vessels to regulate cerebral pressure?
(Select all that apply.)
A.
Potassium
B.
Carbonic acid
C.
Lactic acid
D.
Serum uric acid
, E.
Carbon dioxide correct answers B,C,E
Rationale: Lactic acid, carbonic acid, and carbon dioxide are chemicals that stimulate the dilation
or contraction of blood vessels within the brain, which aids in regulation of cerebral pressure.
Cerebral hemorrhage also regulates dilation or constriction of the cerebral blood vessels in
response to the amount of blood flow within the brain. Serum uric acid and potassium do not
affect cerebral pressure.
Which client is most at risk for increased intracranial pressure? (Select all that apply.)
A.
Newborn infant
B.
Older adult
C.
School-aged child
D.
Pregnant obese woman
E.
Adolescent correct answers A,B,C,D,E
Rationale: Falls continue to be the major cause of traumatic brain injury leading to increased
intracranial pressure (IICP). Older adults are more prone to falls due to sensory and motor losses,
as well as medication use. Adolescents are at risk for motor vehicle crashes and trauma resulting
from violence. Premature newborn infants are at an increased risk of IICP. School-aged children
are prone to falling. School-aged children are at risk for bicycle, swimming, or activity-related
accidents that cause IICP. Obese women of childbearing age often have idiopathic intracranial
hypertension. During pregnancy, these women must be closely monitored for increased
intracranial pressure.
The nurse assessing a client who presents with an altered level of consciousness (LOC) should
suspect which condition? (Select all that apply.)
The nurse is assessing a client with a traumatic head injury and suspects increased intracranial
pressure (IICP). Which assessment finding supports this suspicion? (Select all that apply.)
A.
Double vision
B.
Drowsiness
C.
Increased heart rate
D.
Hemiparesis
E.
Blurred vision correct answers A,B,D,E
Rationale: Hemiparesis or hemiplegia of the contralateral side may be an early sign of IICP.
Drowsiness can occur with IICP. Double vision and blurred vision can occur with IICP.
Headache is common with IICP. The client may also report other generalized manifestations such
as dizziness. The heart rate generally decreases with IICP.
The nurse caring for a client with increased intracranial pressure should recognize that which
compensatory mechanism stimulates the cerebral blood vessels to regulate cerebral pressure?
(Select all that apply.)
A.
Potassium
B.
Carbonic acid
C.
Lactic acid
D.
Serum uric acid
, E.
Carbon dioxide correct answers B,C,E
Rationale: Lactic acid, carbonic acid, and carbon dioxide are chemicals that stimulate the dilation
or contraction of blood vessels within the brain, which aids in regulation of cerebral pressure.
Cerebral hemorrhage also regulates dilation or constriction of the cerebral blood vessels in
response to the amount of blood flow within the brain. Serum uric acid and potassium do not
affect cerebral pressure.
Which client is most at risk for increased intracranial pressure? (Select all that apply.)
A.
Newborn infant
B.
Older adult
C.
School-aged child
D.
Pregnant obese woman
E.
Adolescent correct answers A,B,C,D,E
Rationale: Falls continue to be the major cause of traumatic brain injury leading to increased
intracranial pressure (IICP). Older adults are more prone to falls due to sensory and motor losses,
as well as medication use. Adolescents are at risk for motor vehicle crashes and trauma resulting
from violence. Premature newborn infants are at an increased risk of IICP. School-aged children
are prone to falling. School-aged children are at risk for bicycle, swimming, or activity-related
accidents that cause IICP. Obese women of childbearing age often have idiopathic intracranial
hypertension. During pregnancy, these women must be closely monitored for increased
intracranial pressure.
The nurse assessing a client who presents with an altered level of consciousness (LOC) should
suspect which condition? (Select all that apply.)
