WITH CORRECT ANSWERS 2026
A nurse is caring for a client who has a closed head injury and has an intraventricular catheter pla
ced. Which of the following findings indicates that the client is experiencing increased intracranial
pressure (ICP)? (Select all that apply)
-Flat jugular veins
-A Glasgow Coma Scale score of 15
-Sleepiness exhibited by the client
-Widening pulse pressure
-Decerebrate posturing - CORRECT ANSWER -Correct:
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client from sleep i
s an indication of increased ICP.
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with concurrent
decrease in diastolic blood pressure) is an indication of increased ICP.
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate increased ICP.
Signs of increased ICP: - CORRECT ANSWER -Irritability
Severe headache
Distended jugular veins
Decreased LOC (Glascow coma scale would not be 15).
Dilated or pinpoint pupils
Altered breathing (cheyne-stokes, hyperventilation, apnea)
Sleepiness or difficulty arousing the client from sleep is an indication of increased ICP.
Widening pulse pressure. A widening pulse pressure (increase in systolic with concurrent decrease i
n diastolic blood pressure) is an indication of increased ICP.
Abnormal posturing. Both decerebrate and decorticate posturing indicate increased ICP.
, Normal ICP: - CORRECT ANSWER -10-15
Pulse pressure - CORRECT ANSWER -The difference between the systolic and diastolic pressures.
X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2
Cheyne-stokes - CORRECT ANSWER - X 2 X 2 X 2 X 2
Regular cycle where the rate and depth of breathing increase, then decrease until apnea (usuall
X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2
y a bout 20 seconds) occurs Duration of apnea may vary and progressively lengthen; therefore,
X 2 X2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2
it is ti med and reported. Associated with heart failure and damage to the respiratory center
X 2 X 2 X 2 X2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X
2(drug induc ed, tumor, trauma) X 2 X2 X 2 X 2
Hyper ventilation - CORRECT ANSWER -
X 2 X 2 X 2 X 2 X 2
Increased rate and depth of breathing that results in decreased PaCO2 level Inspiration and exp
X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2
irat ion nearly equal in duration Associated with exertion, anxiety, and metabolic acidosis Called Kussm
X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X 2
aul's respiration if associated with diabetic ketoacidosis or renal origin
X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2
Biot's respiration - CORRECT ANSWER -
X 2 X 2 X 2 X 2 X 2
Periods of normal breathing (3- X 2 X 2 X 2 X 2
4 breaths), followed by a varying period of apnea (usually 10-
X2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2
60 seconds) Also called ataxic breathing; associated with complete irregularity Associated with resp irator
X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2
y depression resulting from drug overdose and brain injury, normally at the level of the med
X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X2
ulla
Cheyne-stokes vs Biot's respirations - CORRECT ANSWER - X 2 X 2 X 2 X 2 X 2 X 2 X 2
There are subtle differences between Cheyne-
X2 X 2 X 2 X 2 X 2 X 2
Stokes and Biot's respiration patterns. Between regularly cycled periods of apnea, Cheyne-
X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2
Stokes respirations demonstrate a regular pattern with the rate and depth of breathing increasi
X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2
ng and then decreasing. In Biot's respiration, irregularly cycled periods of apnea are interspersed
X2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X
2with cycles of normal rate and depth.
X2 X 2 X 2 X 2 X 2 X 2
A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Wh
X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2
ich of the following prescribed medications should the nurse instruct the client to withhold fo
X2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2
r 48 hr prior to cardioversion?
X 2 X 2 X2 X 2 X 2
-Enoxaparin
-Metformin
-Diazepam