Quiz

Intracranial pressure

Gelöschter Nutzer 22 Fragen Aktualisiert am 13 Feb 2020

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11. Select the main structures below that play a role with altering intracranial pressure:
1. AA. Brain
2. BB. Neurons
3. CC. Cerebrospinal Fluid
4. DD. Blood
5. EE. Periosteum
6. FF. Dura mater
22. The Monro-Kellie hypothesis explains the compensatory relationship among the structures in the skull that play a role with intracranial pressure. Which of the following are NOT compensatory mechanisms performed by the body to decrease intracranial pressure naturally? Select all that apply:
1. AA. Shifting cerebrospinal fluid to other areas of the brain and spinal cord
2. BB. Vasodilation of cerebral vessels
3. CC. Decreasing cerebrospinal fluid production
4. DD. Leaking proteins into the brain barrier
33. A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing?
1. AA. Coughing
2. BB. Sneezing
3. CC. Talking
4. DD. Valsalva maneuver
5. EE. Vomiting
6. FF. Keeping the head of the bed between 30- 35 degrees
44. A patient is experiencing hyperventilation and has a PaCO2 level of 52. The patient has an ICP of 20 mmHg. As the nurse you know that the PaCO2 level will?
1. AA. cause vasoconstriction and decrease the ICP
2. BB. promote diuresis and decrease the ICP
3. CC. cause vasodilation and increase the ICP
4. DD. cause vasodilation and decrease the ICP
55. You’re providing education to a group of nursing students about ICP. You explain that when cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies. A student asks, “What is a normal cerebral perfusion pressure level?” Your response is:
1. AA. 5-15 mmHg
2. BB. 60-100 mmHg
3. CC. 30-45 mmHg
4. DD. >160 mmHg
66. Which patient below is at MOST risk for increased intracranial pressure?
1. AA. A patient who is experiencing severe hypotension.
2. BB. A patient who is admitted with a traumatic brain injury.
3. CC. A patient who recently experienced a myocardial infarction.
4. DD. A patient post-op from eye surgery.
77. A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 ‘F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these findings you would?
1. AA. Administered PRN dose of a vasopressor
2. BB. Administer 2 L of oxygen
3. CC. Remove extra blankets and give the patient a cool bath
4. DD. Perform suctioning
88. A patient has a ventriculostomy. Which finding would you immediately report to the doctor?
1. AA. Temperature 98.4 ‘F
2. BB. CPP 70 mmHg
3. CC. ICP 24 mmHg
4. DD. PaCO2 35
99. External ventricular drains monitor ICP and are inserted where?
1. AA. Subarachnoid space
2. BB. Lateral Ventricle
3. CC. Epidural space
4. DD. Right Ventricle
1010. Which of the following is contraindicated in a patient with increased ICP?
1. AA. Lumbar puncture
2. BB. Midline position of the head
3. CC. Hyperosmotic diuretics
4. DD. Barbiturates medications

1111. You’re collecting vital signs on a patient with ICP. The patient has a Glascoma Scale rating of 4. How will you assess the patient’s temperature?
1. AA. Rectal
2. BB. Oral
3. CC. Axillary
1212. A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication?
1. AA. Bradycardia
2. BB. Decerebrate posturing
3. CC. Restlessness
4. DD. Unequal pupil size
1313. Select all the signs and symptoms that occur with increased ICP:
1. AA. Decorticate posturing
2. BB. Tachycardia
3. CC. Decrease in pulse pressure
4. DD. Cheyne-stokes
5. EE. Hemiplegia
6. FF. Decerebrate posturing
1414. You’re maintaining an external ventricular drain. The ICP readings should be?
1. AA. 5 to 15 mmHg
2. BB. 20 to 35 mmHg
3. CC. 60 to 100 mmHg
4. DD. 5 to 25 mmHg
1515. Which patient below with ICP is experiencing Cushing’s Triad? A patient with the following:
1. AA. BP 150/112, HR 110, RR 8
2. BB. BP 90/60, HR 80, RR 22
3. CC. BP 200/60, HR 50, RR 8
4. DD. BP 80/40, HR 49, RR 12
1616. The patient has a blood pressure of 130/88 and ICP reading of 12. What is the patient’s cerebral perfusion pressure, and how do you interpret this as the nurse?
1. AA. 90 mmHg, normal
2. BB. 62 mmHg, abnormal
3. CC. 36 mmHg, abnormal
4. DD. 56 mmHg, normal
1717. According to question 16, the patient’s blood pressure is 130/88. What is the patient’s mean arterial pressure (MAP)?
1. AA. 42
2. BB. 74
3. CC. 102
4. DD. 88
1818. During the assessment of a patient with increased ICP, you note that the patient’s arms are extended straight out and toes pointed downward. You will document this as:
1. AA. Decorticate posturing
2. BB. Decerebrate posturing
3. CC. Flaccid posturing
1919. While positioning a patient in bed with increased ICP, it important to avoid?
1. AA. Midline positioning of the head
2. BB. Placing the HOB at 30-35 degrees
3. CC. Preventing flexion of the neck
4. DD. Flexion of the hips
2020. During the eye assessment of a patient with increased ICP, you need to assess the oculocephalic reflex. If the patient has brain stem damage what response will you find?
1. AA. The eyes will move in the same direction as the head is moved side to side.
2. BB. The eyes will move in the opposite direction as the head is moved side to side.
3. CC. The eyes will roll back as the head is moved side to side.
4. DD. The eyes will be in a fixed position as the head is moved side to side.
2121. A patient is receiving Mannitol for increased ICP. Which statement is INCORRECT about this medication?
1. AA. Mannitol will remove water from the brain and place it in the blood to be removed from the body.
2. BB. Mannitol will cause water and electrolyte reabsorption in the renal tubules.
3. CC. When a patient receives Mannitol the nurse must monitor the patient for both fluid volume overload and depletion.
4. DD. Mannitol is not for patients who are experiencing anuria.
2222. What assessment finding requires immediate intervention if found while a patient is receiving Mannitol?
1. AA. An ICP of 10 mmHg
2. BB. Crackles throughout lung fields
3. CC. BP 110/72
4. DD. Patient complains of dry mouth and thirst

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Beschreibung: Der Nutzer hat seine Fachbereichs-Information gelöscht. Quiz am Intracranial pressure, erstellt von Gelöschter Nutzer am 13/02/2020.
Autor: Gelöschter Nutzer
Sprache: English
Aufrufe: 22
Verlauf: Erstellt am 13 Feb 2020 · aktualisiert am 13 Feb 2020
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Intracranial pressure

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