INTRACRANIAL PRESSURE EXAM WITH
QUESTIONS AND ANSWERS LATEST
VERSION (ALREADY GRADED A+).
A nurse is assessing a client who was admitted to the facility for observation
following a closed head injury. Which of the following is the priority
assessment the nurse should perform to determine a change in the client's
neurological status? - CorreCt Answers -Level of consciousness
When applying the urgent vs. nonurgent priority-setting framework, the
nurse should
consider urgent needs to be the priority because they pose more of a risk to
the client.
The nurse might also use Maslow's hierarchy of needs, the ABC priority-
setting
framework, and/or nursing knowledge to identify the most urgent finding.
Therefore,
the priority assessment is level of consciousness. A change in the client's
level of
consciousness can be the first indication of a change in neurologic status.
Vital sign changes can indicate increasing intracranial pressure and
pressure on the
hypothalamus. - CorreCt Answers -Changes in the client's vital signs such
as bradycardia and a widening pulse pressure are later findings that
indicate a change in neurological status; therefore, there is another
assessment that is the priority.
,Posturing is seen when cortical control over motor function is lost. -
CorreCt Answers -Abnormal posturing (e.g. decerebrate or decorticate
posturing) are later findings that indicate a change in the client's
neurological status; therefore; there is another assessment that is the
priority.
A change in pupils (e.g. dilated or fixed pupils) can indicate increasing
intracranial
pressure or discrete areas of brain ischemia. - CorreCt Answers -A change
in the client's pupils is a later finding that can indicate a change in
neurological status; therefore, there is another assessment that is the
priority.
A nurse is caring for a preschooler who is immediately postoperative
following the removal of a brainstem tumor. Which of the following actions
should the nurse take? - CorreCt Answers -Monitor the child's temperature
every 30 minutes
The nurse should monitor the child's temperature every 15 to 30 minutes.
Surgery on
the brainstem can cause hyperthermia.
Immediately postoperative following the removal of a brainstem tumor, the
nurse should have the child avoid coughing because - CorreCt Answers -this
can increase intracranial pressure
Immediately postoperative following the removal of a brainstem tumor, the
nurse should not offer the child clear liquids for at least 24 hours following
the procedure. - CorreCt Answers -The gag and swallow reflexes are
frequently depressed, increasing the risk of aspiration.
, Immediately postoperative following the removal of a brainstem tumor, the
nurse should not place the child in the Trendelenburg position because -
CorreCt Answers -it increases intracranial pressure and raises the risk of
postoperative hemorrhage
A nurse is assessing a client who has cataracts. Which of the following
findings should the nurse expect? - CorreCt Answers -Opacity visible
behind the pupil
With a cataract, the lens of the eye becomes thick and opaque with age and
appears as
opacity behind the pupil when the nurse shines a light on the area.
Pupils that are not reactive to light do not indicate cataracts. - CorreCt
Answers -This finding indicates changes in intracranial pressure and other
alterations.
A white circle around the outside border of the iris is an - CorreCt Answers
-arcus senilis, not a cataract
Glaucoma, not cataracts, causes - CorreCt Answers -an increase in
intraocular pressure
A nurse is assessing a client who has increased intracranial pressure and
has received intravenous mannitol. Which of the following findings
indicates a therapeutic effect of this medication? - CorreCt Answers -
Increased urine output
Mannitol is an osmotic diuretic used to reduce intracranial pressure by
mobilizing
QUESTIONS AND ANSWERS LATEST
VERSION (ALREADY GRADED A+).
A nurse is assessing a client who was admitted to the facility for observation
following a closed head injury. Which of the following is the priority
assessment the nurse should perform to determine a change in the client's
neurological status? - CorreCt Answers -Level of consciousness
When applying the urgent vs. nonurgent priority-setting framework, the
nurse should
consider urgent needs to be the priority because they pose more of a risk to
the client.
The nurse might also use Maslow's hierarchy of needs, the ABC priority-
setting
framework, and/or nursing knowledge to identify the most urgent finding.
Therefore,
the priority assessment is level of consciousness. A change in the client's
level of
consciousness can be the first indication of a change in neurologic status.
Vital sign changes can indicate increasing intracranial pressure and
pressure on the
hypothalamus. - CorreCt Answers -Changes in the client's vital signs such
as bradycardia and a widening pulse pressure are later findings that
indicate a change in neurological status; therefore, there is another
assessment that is the priority.
,Posturing is seen when cortical control over motor function is lost. -
CorreCt Answers -Abnormal posturing (e.g. decerebrate or decorticate
posturing) are later findings that indicate a change in the client's
neurological status; therefore; there is another assessment that is the
priority.
A change in pupils (e.g. dilated or fixed pupils) can indicate increasing
intracranial
pressure or discrete areas of brain ischemia. - CorreCt Answers -A change
in the client's pupils is a later finding that can indicate a change in
neurological status; therefore, there is another assessment that is the
priority.
A nurse is caring for a preschooler who is immediately postoperative
following the removal of a brainstem tumor. Which of the following actions
should the nurse take? - CorreCt Answers -Monitor the child's temperature
every 30 minutes
The nurse should monitor the child's temperature every 15 to 30 minutes.
Surgery on
the brainstem can cause hyperthermia.
Immediately postoperative following the removal of a brainstem tumor, the
nurse should have the child avoid coughing because - CorreCt Answers -this
can increase intracranial pressure
Immediately postoperative following the removal of a brainstem tumor, the
nurse should not offer the child clear liquids for at least 24 hours following
the procedure. - CorreCt Answers -The gag and swallow reflexes are
frequently depressed, increasing the risk of aspiration.
, Immediately postoperative following the removal of a brainstem tumor, the
nurse should not place the child in the Trendelenburg position because -
CorreCt Answers -it increases intracranial pressure and raises the risk of
postoperative hemorrhage
A nurse is assessing a client who has cataracts. Which of the following
findings should the nurse expect? - CorreCt Answers -Opacity visible
behind the pupil
With a cataract, the lens of the eye becomes thick and opaque with age and
appears as
opacity behind the pupil when the nurse shines a light on the area.
Pupils that are not reactive to light do not indicate cataracts. - CorreCt
Answers -This finding indicates changes in intracranial pressure and other
alterations.
A white circle around the outside border of the iris is an - CorreCt Answers
-arcus senilis, not a cataract
Glaucoma, not cataracts, causes - CorreCt Answers -an increase in
intraocular pressure
A nurse is assessing a client who has increased intracranial pressure and
has received intravenous mannitol. Which of the following findings
indicates a therapeutic effect of this medication? - CorreCt Answers -
Increased urine output
Mannitol is an osmotic diuretic used to reduce intracranial pressure by
mobilizing
