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ICP/Head Injury NCLEX Style Questions & Detailed Answers
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ICP/Head Injury NCLEX Style Questions & Detailed Answers
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ICP/Head Injury NCLEX Style Questions &Detailed Answers
The ED nurse is caring for a patient who has been brought in by ambulance after
sustaining a fall at home. What physical assessment finding is suggestive of a
basilar skull fracture?
A) Epistaxis
B) Periorbital edema
C) Bruising over the mastoid
D) Unilateral facial numbness - ANS C
An area of ecchymosis (bruising) may be seen over the mastoid (Battles sign) in a
basilar skull fracture.
A patient is brought to the trauma center by ambulance after sustaining a high
cervical spinal cord injury 1 hours ago. Endotracheal intubation has been deemed
necessary and the nurse is preparing to assist. What nursing diagnosis should the
nurse associate with this procedure?
A) Risk for impaired skin integrity
B) Risk for injury
C) Risk for autonomic dysreflexia
D) Risk for suffocation - ANS B
If endotracheal intubation is necessary, extreme care is taken to avoid flexing or
extending the patients neck, which can result in extension of a cervical injury.
Intubation does not directly cause autonomic dysreflexia and the threat to skin
,integrity is a not a primary concern. Intubation does not carry the potential to
cause suffocation.
A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical
manifestations would the nurse expect in this patient?
A) Respiratory distress and projectile vomiting
B) Bradycardia and hypertension
C) Tachycardia and agitation
D) Third-spacing and hyperthermia - ANS B
Autonomic dysreflexia is characterized by a pounding headache, profuse sweating,
nasal congestion, piloerection (goose bumps), bradycardia, and hypertension. It
occurs in cord lesions above T6 after spinal shock has resolved; it does not result in
vomiting, tachycardia, or third-spacing
The nurse is caring for a patient with increased intracranial pressure (ICP) caused
by a traumatic brain injury. Which of the following clinical manifestations would
suggest that the patient may be experiencing increased brain compression causing
brain stem damage?
A) Hyperthermia
B) Tachycardia
C) Hypertension
D) Bradypnea - ANS A
Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing
systolic BP, and widening pulse pressure. As brain compression increases,
respirations become rapid, BP may decrease, and the pulse slows further. A rapid
, rise in body temperature is regarded as unfavorable. Hyperthermia increases the
metabolic demands of the brain and may indicate brain stem damage.
A patient is brought to the ED by her family after falling off the roof. A family
member tells the nurse that when the patient fell she was knocked out, but came
to and seemed okay. Now she is complaining of a severe headache and not feeling
well. The care team suspects an epidural hematoma, prompting the nurse to
prepare for which priority intervention?
A) Insertion of an intracranial monitoring device
B) Treatment with antihypertensives
C) Emergency craniotomy
D) Administration of anticoagulant therapy - ANS C
An epidural hematoma is considered an extreme emergency. Marked neurologic
deficit or respiratory arrest can occur within minutes. Treatment consists of
making an opening through the skull to decrease ICP emergently, remove the clot,
and control the bleeding. Anticoagulant therapy should not be ordered for a
patient who has a cranial bleed. Insertion of an intracranial monitoring device may
be done during the surgery, but is not priority for this patient.
The staff educator is precepting a nurse new to the critical care unit when a
patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting
manifestations of neurogenic shock. In addition to monitoring the patient closely,
what would be the nurses most appropriate action?
A) Prepare to transfuse packed red blood cells.
B) Prepare for interventions to increase the patients BP.
C) Place the patient in the Trendelenberg position.
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