ICP || Already Graded A+.
A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial pressure of 24
mm Hg. The nurse determines that the cerebral perfusion pressure (CPP) of this patient indicates
a. high blood flow to the brain.
b. normal intracranial pressure (ICP).
c. impaired brain blood flow.
d. adequate cerebral perfusion. correct answers Correct Answer: C
Rationale: The patient's CPP is 56, below the normal of 70 to 100 mm Hg and approaching the
level of ischemia and neuronal death. The patient has low cerebral blood flow/perfusion. Normal
ICP is 0 to 15 mm Hg.
Cognitive Level: Application Text Reference: p. 1468
Nursing Process: Assessment NCLEX: Physiological Integrity
A patient with a head injury has an arterial blood pressure is 92/50 mm Hg and an intracranial
pressure of 18 mm Hg. Which action by the nurse is appropriate?
a. Document and continue to monitor the parameters.
b. Elevate the head of the patient's bed.
c. Notify the health care provider about the assessments.
d. Check the patient's pupillary response to light. correct answers Correct Answer: C
Rationale: The patient's cerebral perfusion pressure is only 46 mm Hg, which will rapidly lead to
cerebral ischemia and neuronal death unless rapid action is taken to reduce ICP and increase
arterial BP. Documentation and monitoring are inadequate responses to the patient's problem.
Elevating the head of the bed will lower the ICP but may also lower cerebral blood flow and
further decrease CPP. Changes in pupil response to light are signs of increased ICP, so the nurse
will only take more time doing this without adding any useful information.
Cognitive Level: Analysis Text Reference: pp. 1468-1469
Nursing Process: Implementation NCLEX: Physiological Integrity
, The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements
related to inability to feed self for a patient with right-sided hemiplegia. An appropriate nursing
intervention is to
a. assist the patient to eat with the left hand.
b. provide oral care before and after meals.
c. teach the patient the "chin-tuck" technique.
d. provide a wide variety of food choices. correct answers Correct Answer: A
Rationale: Because the nursing diagnosis indicates that the patient's imbalanced nutrition is
related to the right-sided hemiplegia, the appropriate interventions will focus on teaching the
patient to use the left hand for self-feeding. The other interventions are appropriate for patients
with other etiologies for the imbalanced nutrition.
Cognitive Level: Application Text Reference: p. 1522
Nursing Process: Implementation NCLEX: Physiological Integrity
The nurse expects that management of the patient who experiences a brief episode of tinnitus,
diplopia, and dysarthria with no residual effects will include
a. heparin via continuous intravenous infusion.
b. prophylactic clipping of cerebral aneurysms.
c. therapy with tissue plasminogen activator (tPA).
d. oral administration of ticlopidine (Ticlid). correct answers Correct Answer: D
Rationale: The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs
that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin
infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are
not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, but not for
TIA.
Cognitive Level: Application Text Reference: p. 1505
Nursing Process: Implementation NCLEX: Physiological Integrity
A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial pressure of 24
mm Hg. The nurse determines that the cerebral perfusion pressure (CPP) of this patient indicates
a. high blood flow to the brain.
b. normal intracranial pressure (ICP).
c. impaired brain blood flow.
d. adequate cerebral perfusion. correct answers Correct Answer: C
Rationale: The patient's CPP is 56, below the normal of 70 to 100 mm Hg and approaching the
level of ischemia and neuronal death. The patient has low cerebral blood flow/perfusion. Normal
ICP is 0 to 15 mm Hg.
Cognitive Level: Application Text Reference: p. 1468
Nursing Process: Assessment NCLEX: Physiological Integrity
A patient with a head injury has an arterial blood pressure is 92/50 mm Hg and an intracranial
pressure of 18 mm Hg. Which action by the nurse is appropriate?
a. Document and continue to monitor the parameters.
b. Elevate the head of the patient's bed.
c. Notify the health care provider about the assessments.
d. Check the patient's pupillary response to light. correct answers Correct Answer: C
Rationale: The patient's cerebral perfusion pressure is only 46 mm Hg, which will rapidly lead to
cerebral ischemia and neuronal death unless rapid action is taken to reduce ICP and increase
arterial BP. Documentation and monitoring are inadequate responses to the patient's problem.
Elevating the head of the bed will lower the ICP but may also lower cerebral blood flow and
further decrease CPP. Changes in pupil response to light are signs of increased ICP, so the nurse
will only take more time doing this without adding any useful information.
Cognitive Level: Analysis Text Reference: pp. 1468-1469
Nursing Process: Implementation NCLEX: Physiological Integrity
, The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements
related to inability to feed self for a patient with right-sided hemiplegia. An appropriate nursing
intervention is to
a. assist the patient to eat with the left hand.
b. provide oral care before and after meals.
c. teach the patient the "chin-tuck" technique.
d. provide a wide variety of food choices. correct answers Correct Answer: A
Rationale: Because the nursing diagnosis indicates that the patient's imbalanced nutrition is
related to the right-sided hemiplegia, the appropriate interventions will focus on teaching the
patient to use the left hand for self-feeding. The other interventions are appropriate for patients
with other etiologies for the imbalanced nutrition.
Cognitive Level: Application Text Reference: p. 1522
Nursing Process: Implementation NCLEX: Physiological Integrity
The nurse expects that management of the patient who experiences a brief episode of tinnitus,
diplopia, and dysarthria with no residual effects will include
a. heparin via continuous intravenous infusion.
b. prophylactic clipping of cerebral aneurysms.
c. therapy with tissue plasminogen activator (tPA).
d. oral administration of ticlopidine (Ticlid). correct answers Correct Answer: D
Rationale: The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs
that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin
infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are
not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, but not for
TIA.
Cognitive Level: Application Text Reference: p. 1505
Nursing Process: Implementation NCLEX: Physiological Integrity
