MSN Exam for Increased Intracranial Pressure

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1) Which of the following signs of increased intracranial pressure (ICP) would appear first after head trauma?

1. Bradycardia.
2. Large amounts of very dilute urine.
3. Restlessness and confusion.
4. Widened pulse pressure.

2) The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid?

1. Head mildline
2. Head turned to the side
3. Neck in neutral position
4. Head of bed elevated 30 to 45 degrees

3) Whether Mr Snyder’s tumor is benign or malignant, it will eventually cause increased intracranial pressure. Signs and symptoms of increasing intracranial pressure may include all of the following except:

1. Headache, nausea, and vomiting
2. Papilledema, dizziness, mental status changes
3. Obvious motor deficits
4. increased pulse rate, drop in blood pressure

4) For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to:

1. Prevent respiratory alkalosis.
2. Lower arterial pH.
3. Promote carbon dioxide elimination.
4. Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg

5) The nurse is teaching family members of a patient with a concussion about the early signs of increased intracranial pressure (ICP). Which of the following would she cite as an early sign of increased ICP?

1. Decreased systolic blood pressure
2. Headache and vomiting
3. Inability to wake the patient with noxious stimuli
4. Dilated pupils that don’t react to light

6) Later signs of increased intracranial pressure (ICP) later include which of the following?

1. Projectile vomiting
2. Increased pulse rate
3. Decreased blood pressure
4. Narrowed pulse pressure

7) A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mmHG and the ICP is 18 mmHg; therefore his cerebral perfusion pressure (CPP) is:

1. 52 mm Hg
2. 88 mm Hg
3. 48 mm Hg
4. 68 mm Hg

8) Which of the following types of drugs might be given to control increased intracranial pressure (ICP)?

1. Barbiturates
2. Carbonic anhydrase inhibitors
3. Anticholinergics
4. Histamine receptor blockers

9) A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning?

1. Phenytoin (Dilantin)
2. Mannitol (Osmitrol)
3. Lidocaine (Xylocaine)
4. Furosemide (Lasix)

10) A nurse in the emergency department is observing a 4-year-old child for signs of increased intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the following signs or symptoms would be cause for concern?

1. Bulging anterior fontanel.
2. Repeated vomiting.
3. Signs of sleepiness at 10 PM.
4. Inability to read short words from a distance of 18 inches.

11) A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning?

1. Phenytoin (Dilantin)
2. Mannitol (Osmitrol)
3. Lidocaine (Xylocaine)
4. Furosemide (Lasix)

12) A male client is brought to the emergency department due to motor vehicle accident. While monitoring the client, the nurse suspects increasing intracranial pressure when:

1. Client is oriented when aroused from sleep, and goes back to sleep immediately.
2. Blood pressure is decreased from 160/90 to 110/70.
3. Client refuses dinner because of anorexia.
4. Pulse is increased from 88-96 with occasional skipped beat.

13) Kate with severe head injury is being monitored by the nurse for increasing intracranial pressure (ICP). Which finding should be most indicative sign of increasing intracranial pressure?

1. Intermittent tachycardia
2. Polydipsia
3. Tachypnea
4. Increased restlessness

14) A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances?

1. Vomiting continues
2. Intracranial pressure (ICP) is increased
3. The client needs mechanical ventilation
4. Blood is anticipated in the cerebralspinal fluid (CSF)

15) A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons?

1. To reduce intraocular pressure
2. To prevent acute tubular necrosis
3. To promote osmotic diuresis to decrease ICP
4. To draw water into the vascular system to increase blood pressure

16)      A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective?

1. Urine output increases
2. Pupils are 8 mm and nonreactive
3. Systolic blood pressure remains at 150 mm Hg
4. BUN and creatinine levels return to normal

17) Which of the following values is considered normal for ICP?

1. 0 to 15 mm Hg
2. 25 mm Hg
3. 35 to 45 mm Hg
4. 120/80 mm Hg

18) Which of the following symptoms may occur with a phenytoin level of 32 mg/dl?

1. Ataxia and confusion
2. Sodium depletion
3. Tonic-clonic seizure
4. Urinary incontinence

19) Which of the following signs and symptoms of increased ICP after head trauma would appear first?

1. Bradycardia
2. Large amounts of very dilute urine
3. Restlessness and confusion
4. Widened pulse pressure

20)      Problems with memory and learning would relate to which of the following lobes?

1. Frontal
2. Occipital
3. Parietal
4. Temporal

21) While cooking, your client couldn’t feel the temperature of a hot oven. Which lobe could be dysfunctional?

1. Frontal
2. Occipital
3. Parietal
4. Temporal

22) The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client’s peripheral response to pain?

1. Sternal rub
2. Pressure on the orbital rim
3. Squeezing the sternocleidomastoid muscle
4. Nail bed pressure

23)  The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure?

1. Side-lying, with legs pulled up and head bent down onto the chest
2. Side-lying, with a pillow under the hip
3. Prone, in a slight Trendelenburg’s position
4. Prone, with a pillow under the abdomen.

24)  A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has:

1. A cerebral lesion
2. A temporal lesion
3. An intact brainstem
4. Brain death

25)  The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising?

1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure.
2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.
3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure.
4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

Answers and Rationales

1. C. Restlessness and confusion. The earliest sign of increased ICP is a change in mental status. Bradycardia and widened pulse pressure occur later. The patient may void a lot of very dilute urine if his posterior pituitary is damaged.
2. B. Head turned to the side. The head of the client with increased intracranial pressure should be positioned so the head is in a neutral midline position. The nurse should avoid flexing or extending the client’s neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.
3. D. increased pulse rate, drop in blood pressure . As ICP increases, the pulse rate decreases and the BP rise. However, as ICP continues to rise, vital signs may vary considerably.
4. C. Promote carbon dioxide elimination. The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this case. It isn’t necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients.
5. B. Headache and vomiting . Headache and projectile vomiting are early signs of increased ICP. Decreased systolic blood pressure, unconsciousness, and dilated pupils that don’t reac to light are considered late signs.
6. A. Projectile vomiting . Projectile vomiting may occur with increased pressure on the reflex center in the medulla.
7. A. 52 mm Hg . CPP is derived by subtracting the ICP from the mean arterial pressure (MAP). For adequate cerebral perfusion to take place, the minimum goal is 70 mmHg. The MAP is derived using the following formula:
   • MAP = ((diastolic blood pressure x 2) + systolic blood pressure) / 3
   • MAP = ((60 x2) + 90) / 3
   • MAP = 70 mmHg
   • To find the CPP, subtract the client’s ICP from the MAP; in this case , 70 mmHg – 18 mmHg = 52 mmHg.
8. A. Barbiturates . Barbiturates may be used to induce a coma in a patient with increased ICP. This decreases cortical activity and cerebral metabolism, reduces cerebral blood volume, decreases cerebral edema, and reduces the brain’s need for glucose and oxygen. Carbonic anhydrase inhibitors are used to decrease ocular pressure or to decrease the serum pH in a patient with metabolic alkalosis. Anticholinergics have many uses including reducing GI spasms. Histamine receptor blockers are used to decrease stomach acidity.
9. C. Lidocaine (Xylocaine) . Administering lidocaine via an endotracheal tube may minimize elevations in ICP caused by suctioning. Although mannitol and furosemide may be given to reduce ICP, they’re administered parenterally, not endotracheally. Phenytoin doesn’t reduce ICP directly but may be used to abolish seizures, which can increase ICP. However, phenytoin isn’t administered endotracheally.
10. B. Repeated vomiting. Increased pressure caused by bleeding or swelling within the skull can damage delicate brain tissue and may become life threatening. Repeated vomiting can be an early sign of pressure as the vomit center within the medulla is stimulated. The anterior fontanel is closed in a 4-year-old child. Evidence of sleepiness at 10 PM is normal for a four year old. The average 4-year-old child cannot read yet, so this too is normal.
11. C. Lidocaine (Xylocaine) . Administering lidocaine via an endotracheal tube may minimize elevations in ICP caused by suctioning. Although mannitol and furosemide may be given to reduce ICP, they’re administered parenterally, not endotracheally. Phenytoin doesn’t reduce ICP directly but may be used to abolish seizures, which can increase ICP. However, phenytoin isn’t administered endotracheally.
12. A. Client is oriented when aroused from sleep, and goes back to sleep immediately.This suggests that the level of consciousness is decreasing.
13. D. Increased restlessness . Restlessness indicates a lack of oxygen to the brain stem which impairs the reticular activating system.
14. B. Intracranial pressure (ICP) is increased. Sudden removal of CSF results in pressures lower in the lumbar area than the brain and favors herniation of the brain; therefore, LP is contraindicated with increased ICP. Vomiting may be caused by reasons other than increased ICP; therefore, LP isn’t strictly contraindicated. An LP may be preformed on clients needing mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage and was obtained before signs and symptoms of ICP.
15. C. To promote osmotic diuresis to decrease ICP.  Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern.
16. A. Urine output increases. Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. No information is given about abnormal BUN and creatinine levels or that mannitol is being given for renal dysfunction or blood pressure maintenance.
17. A. 0 to 15 mm Hg. Normal ICP is 0-15 mm Hg.
18. A. Ataxia and confusion. A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 32 mg/dl indicates toxicity. Symptoms of toxicity include confusion and ataxia. Phenytoin doesn’t cause hyponatremia, seizure, or urinary incontinence. Incontinence may occur during or after a seizure.
19. C. Restlessness and confusion. The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there’s damage to the posterior pituitary.
20. D. Temporal.  The temporal lobe functions to regulate memory and learning problems because of the integration of the hippocampus. The frontal lobe primarily functions to regulate thinking, planning, and judgment. The occipital lobe functions regulate vision. The parietal lobe primarily functions with sensory function.
21. C. Parietal. The parietal lobe regulates sensory function, which would include the ability to sense hot or cold objects. The frontal lobe regulates thinking, planning, and judgment, and the occipital lobe is primarily responsible for vision function. The temporal lobe regulates memory.
22. D. Nail bed pressure. Motor testing on the unconscious client can be done only by testing response to painful stimuli. Nailbed pressure tests a basic peripheral response. Cerebral responses to pain are testing using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
23. A. Side-lying, with legs pulled up and head bent down onto the chest. The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen, and with the head bent down onto the chest. This position helps to open the spaces between the vertebrae.
24. C. An intact brainstem. Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected in the auditory canal. A normal response that indicates intact function of cranial nerves III, IV, and VIII is conjugate eye movements toward the side being irrigated, followed by rapid nystagmus to the opposite side. Absent or dysconjugate eye movements indicate brainstem damage.
25. B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise.