NR 340 Week 3 EVOLVE
Questions
1. 1.ID: 43154241
What is the therapeutic effect of head-of-the-bed elevation and neutral
head and neck alignment on increased intracranial pressure (ICP)?
o Lowering ICP by allowing for elevations in CO2 to dilate
cerebral arteries
o Lowering ICP by facilitating venous drainage and
decreasing venous obstruction Correct
o Lowering ICP by maintaining an open airway
o Lowering ICP by reducing the risk of snoring
Head-of-the-bed elevation and a neutral head position that avoids
hyperextension or hyperflexion facilitate jugular venous drainage,
helping to minimize increases in ICP. Elevated CO2 contributes to
cerebral vessel vasodilation, which can increase cerebral blood
volume and further elevate ICP. Maintaining an open airway alone
does not minimize increases in ICP. Reducing the risk of snoring
by maintaining an open airway alone does not minimize increases
in ICP.
Awarded 0.0 points out of 1.0 possible points.
2. 2.ID: 43154255
Under normal circumstances the cerebral vasculature exhibits
,pressure and chemical autoregulation. What happens when
autoregulation is lost?
, o Central venous engorgement occurs.
o Cerebral blood flow is not affected.
o Hypertension increases cerebral blood flow. Correct
o Shunting of cerebrospinal fluid (CSF) is blocked.
Autoregulation is the ability of the cerebral vessels to adjust their
diameter in response to arterial pressure changes within the brain.
If mean arterial blood pressure rises, cerebral vessels will constrict
to prevent excessive distention of the cerebral arteries. When
autoregulation is lost, cerebral vessels are no longer able to
regulate diameter and as a result hypertension increases cerebral
perfusion pressure. Cerebral vessels may become engorged as a
result of the loss of autoregulation. Cerebral blood flow is affected
with the loss of autoregulation. Loss of autoregulation does not
block CSF flow.
Awarded 0.0 points out of 1.0 possible points.
3. 3.ID: 43154263
The nurse is monitoring a patient’s intracranial pressure (ICP).
While the nurse is providing hygiene measures, she observes that
the ICP reading is sustained at 18 mm Hg. What is the priority
nursing action?
o Cease stimulating the patient. Correct
o Continue with hygiene measures.
, o Lower the head of the bed to 10 degrees.
o Open the ICP monitor to continuous drainage.
Sustained increases in ICP should be avoided. Nursing care
activities should be spaced to prevent an increase in ICP. Actions
that cause a sustained elevation in ICP should be avoided until ICP
returns to baseline resting values. Elevating the head of the bed to
30 degrees or more can help reduce ICP. Continuous drainage of
CSF fluid will result in herniation.
Awarded 0.0 points out of 1.0 possible points.
4. 4.ID: 43154273
Questions
1. 1.ID: 43154241
What is the therapeutic effect of head-of-the-bed elevation and neutral
head and neck alignment on increased intracranial pressure (ICP)?
o Lowering ICP by allowing for elevations in CO2 to dilate
cerebral arteries
o Lowering ICP by facilitating venous drainage and
decreasing venous obstruction Correct
o Lowering ICP by maintaining an open airway
o Lowering ICP by reducing the risk of snoring
Head-of-the-bed elevation and a neutral head position that avoids
hyperextension or hyperflexion facilitate jugular venous drainage,
helping to minimize increases in ICP. Elevated CO2 contributes to
cerebral vessel vasodilation, which can increase cerebral blood
volume and further elevate ICP. Maintaining an open airway alone
does not minimize increases in ICP. Reducing the risk of snoring
by maintaining an open airway alone does not minimize increases
in ICP.
Awarded 0.0 points out of 1.0 possible points.
2. 2.ID: 43154255
Under normal circumstances the cerebral vasculature exhibits
,pressure and chemical autoregulation. What happens when
autoregulation is lost?
, o Central venous engorgement occurs.
o Cerebral blood flow is not affected.
o Hypertension increases cerebral blood flow. Correct
o Shunting of cerebrospinal fluid (CSF) is blocked.
Autoregulation is the ability of the cerebral vessels to adjust their
diameter in response to arterial pressure changes within the brain.
If mean arterial blood pressure rises, cerebral vessels will constrict
to prevent excessive distention of the cerebral arteries. When
autoregulation is lost, cerebral vessels are no longer able to
regulate diameter and as a result hypertension increases cerebral
perfusion pressure. Cerebral vessels may become engorged as a
result of the loss of autoregulation. Cerebral blood flow is affected
with the loss of autoregulation. Loss of autoregulation does not
block CSF flow.
Awarded 0.0 points out of 1.0 possible points.
3. 3.ID: 43154263
The nurse is monitoring a patient’s intracranial pressure (ICP).
While the nurse is providing hygiene measures, she observes that
the ICP reading is sustained at 18 mm Hg. What is the priority
nursing action?
o Cease stimulating the patient. Correct
o Continue with hygiene measures.
, o Lower the head of the bed to 10 degrees.
o Open the ICP monitor to continuous drainage.
Sustained increases in ICP should be avoided. Nursing care
activities should be spaced to prevent an increase in ICP. Actions
that cause a sustained elevation in ICP should be avoided until ICP
returns to baseline resting values. Elevating the head of the bed to
30 degrees or more can help reduce ICP. Continuous drainage of
CSF fluid will result in herniation.
Awarded 0.0 points out of 1.0 possible points.
4. 4.ID: 43154273
