Increased Intracranial Pressure (Icp) By Rnpedia.Com

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

Bradycardia.

Large amounts of very dilute urine.

Restlessness and confusion.

Widened pulse pressure.

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.

Explanation

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. 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?

Intermittent tachycardia

Polydipsia

Tachypnea

Increased restlessness

Restlessness indicates a lack of oxygen to the brain stem which impairs the reticular activating system.

Explanation

Restlessness indicates a lack of oxygen to the brain stem which impairs the reticular activating system.

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

Head mildline

Head turned to the side

Neck in neutral position

Head of bed elevated 30 to 45 degrees

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.

Explanation

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.

4. 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?

Bulging anterior fontanel.

Repeated vomiting.

Signs of sleepiness at 10 PM.

Inability to read short words from a distance of 18 inches.

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.

Explanation

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.

5. 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?

Phenytoin (Dilantin)

Mannitol (Osmitrol)

Lidocaine (Xylocaine)

Furosemide (Lasix)

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.

Explanation

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.

6. 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?

Decreased systolic blood pressure

Headache and vomiting

Inability to wake the patient with noxious stimuli

Dilated pupils that don’t react to light

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.

Explanation

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.

7. 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?

Phenytoin (Dilantin)

Mannitol (Osmitrol)

Lidocaine (Xylocaine)

Furosemide (Lasix)

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.

Explanation

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.

8. 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:

Headache, nausea, and vomiting

Papilledema, dizziness, mental status changes

Obvious motor deficits

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.

Explanation

As ICP increases, the pulse rate decreases and the BP rise. However, as ICP continues to rise, vital signs may vary considerably.

9. 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:

Client is oriented when aroused from sleep, and goes back to sleep immediately.

Blood pressure is decreased from 160/90 to 110/70.

Client refuses dinner because of anorexia.

Pulse is increased from 88-96 with occasional skipped beat.

This suggests that the level of consciousness is decreasing.

Explanation

This suggests that the level of consciousness is decreasing.

10. 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:

52 mm Hg

88 mm Hg

48 mm Hg

68 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.

Explanation

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.

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

Barbiturates

Carbonic anhydrase inhibitors

Anticholinergics

Histamine receptor blockers

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.

Explanation

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.

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

Prevent respiratory alkalosis.

Lower arterial pH.

Promote carbon dioxide elimination.

Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg

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.

Explanation

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.

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

Projectile vomiting

Increased pulse rate

Decreased blood pressure

Narrowed pulse pressure

Projectile vomiting may occur with increased pressure on the reflex center in the medulla.

Explanation

Projectile vomiting may occur with increased pressure on the reflex center in the medulla.