Quiz
Intracranial pressure
Perguntas do quiz (22)
11. Select the main structures below that play a role with altering intracranial pressure:
- AA. Brain
- BB. Neurons
- CC. Cerebrospinal Fluid
- DD. Blood
- EE. Periosteum
- 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:
- AA. Shifting cerebrospinal fluid to other areas of the brain and spinal cord
- BB. Vasodilation of cerebral vessels
- CC. Decreasing cerebrospinal fluid production
- 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?
- AA. Coughing
- BB. Sneezing
- CC. Talking
- DD. Valsalva maneuver
- EE. Vomiting
- 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?
- AA. cause vasoconstriction and decrease the ICP
- BB. promote diuresis and decrease the ICP
- CC. cause vasodilation and increase the ICP
- 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:
- AA. 5-15 mmHg
- BB. 60-100 mmHg
- CC. 30-45 mmHg
- DD. >160 mmHg
66. Which patient below is at MOST risk for increased intracranial pressure?
- AA. A patient who is experiencing severe hypotension.
- BB. A patient who is admitted with a traumatic brain injury.
- CC. A patient who recently experienced a myocardial infarction.
- 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?
- AA. Administered PRN dose of a vasopressor
- BB. Administer 2 L of oxygen
- CC. Remove extra blankets and give the patient a cool bath
- DD. Perform suctioning
88. A patient has a ventriculostomy. Which finding would you immediately report to the doctor?
- AA. Temperature 98.4 ‘F
- BB. CPP 70 mmHg
- CC. ICP 24 mmHg
- DD. PaCO2 35
99. External ventricular drains monitor ICP and are inserted where?
- AA. Subarachnoid space
- BB. Lateral Ventricle
- CC. Epidural space
- DD. Right Ventricle
1010. Which of the following is contraindicated in a patient with increased ICP?
- AA. Lumbar puncture
- BB. Midline position of the head
- CC. Hyperosmotic diuretics
- 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?
- AA. Rectal
- BB. Oral
- 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?
- AA. Bradycardia
- BB. Decerebrate posturing
- CC. Restlessness
- DD. Unequal pupil size
1313. Select all the signs and symptoms that occur with increased ICP:
- AA. Decorticate posturing
- BB. Tachycardia
- CC. Decrease in pulse pressure
- DD. Cheyne-stokes
- EE. Hemiplegia
- FF. Decerebrate posturing
1414. You’re maintaining an external ventricular drain. The ICP readings should be?
- AA. 5 to 15 mmHg
- BB. 20 to 35 mmHg
- CC. 60 to 100 mmHg
- DD. 5 to 25 mmHg
1515. Which patient below with ICP is experiencing Cushing’s Triad? A patient with the following:
- AA. BP 150/112, HR 110, RR 8
- BB. BP 90/60, HR 80, RR 22
- CC. BP 200/60, HR 50, RR 8
- 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?
- AA. 90 mmHg, normal
- BB. 62 mmHg, abnormal
- CC. 36 mmHg, abnormal
- 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)?
- AA. 42
- BB. 74
- CC. 102
- 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:
- AA. Decorticate posturing
- BB. Decerebrate posturing
- CC. Flaccid posturing
1919. While positioning a patient in bed with increased ICP, it important to avoid?
- AA. Midline positioning of the head
- BB. Placing the HOB at 30-35 degrees
- CC. Preventing flexion of the neck
- 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?
- AA. The eyes will move in the same direction as the head is moved side to side.
- BB. The eyes will move in the opposite direction as the head is moved side to side.
- CC. The eyes will roll back as the head is moved side to side.
- 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?
- AA. Mannitol will remove water from the brain and place it in the blood to be removed from the body.
- BB. Mannitol will cause water and electrolyte reabsorption in the renal tubules.
- CC. When a patient receives Mannitol the nurse must monitor the patient for both fluid volume overload and depletion.
- 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?
- AA. An ICP of 10 mmHg
- BB. Crackles throughout lung fields
- CC. BP 110/72
- DD. Patient complains of dry mouth and thirst
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- Criado em 13 fev 2020 · atualizado em 13 fev 2020
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