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ICP NCLEX style Questions
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ICP NCLEX style Questions
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ICP NCLEX style QuestionsA 54-year-old man is recovering from a skull fracture with a subacute subdural
hematoma that caused unconsciousness.
He has return of motor control and orientation but appears apathetic and has reduced
awareness of his environment. When
planning discharge of the patient, what should the nurse explain to the patient and the
family?
a. The patient is likely to have long-term emotional and mental changes that may
require professional help.
b. Continuous improvement in the patient's condition should occur until he has returned
to pretrauma status.
c. The patient's complete recovery may take years and the family should plan for his
long-term dependent care.
d. Role changes in family members will be necessary because the patient will be
dependent on his family for care
and support. - ANS-a. Residual mental and emotional changes of brain trauma
with personality changes are often the most incapacitating
problems following head injury and are common in patients
who have been comatose for longer than 6 hours. Families
must be prepared for changes in the patient's behavior
to avoid family-patient friction and maintain family
functioning and professional assistance may be required.
There is no indication the patient will be dependent on
others for care but he likely will not return to pretrauma
status.
A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related
to cerebral edema. What is
an appropriate nursing intervention for the patient?
a. Avoid positioning the patient with neck and hip flexion.
b. Maintain hyperventilation to a PaCO2
of 15 to 20 mm Hg.
c. Cluster nursing activities to provide periods of uninterrupted rest.
d. Routinely suction to prevent accumulation of respiratory secretions. - ANS-a. Nursing
care activities that increase ICP include hip and
neck flexion, suctioning, clustering care activities, and
noxious stimuli. They should be avoided or performed as
little as possible in the patient with increased ICP. Lowering
, the PaCO2
below 20 mm Hg can cause ischemia and
worsening of ICP
A patient with a head injury has bloody drainage from the ear. What should the nurse do
to determine if CSF is
present in the drainage?
a. Examine the tympanic membrane for a tear.
b. Test the fluid for a halo sign on a white dressing.
c. Test the fluid with a glucose-identifying strip or stick.
d. Collect 5 mL of fluid in a test tube and send it to the laboratory for analysis. - ANS-b.
Testing clear drainage for CSF in nasal or ear drainage
may be done with a Dextrostik or Tes-Tape strip but if
blood is present, the glucose in the blood will produce an
unreliable result. To test bloody drainage, the nurse should
test the fluid for a "halo" or "ring" that occurs when a
yellowish ring encircles blood dripped onto a white pad or
towel within a few minutes.
A patient with an intracranial problem does not open his eyes to any stimulus, has no
verbal response except
moaning and muttering when stimulated, and flexes his arm in response to painful
stimuli. What should the nurse
record as the patient's GCS score?
a. 6 c. 9
b. 7 d. 11 - ANS-b. No opening of eyes = 1; incomprehensible words = 2;
flexion withdrawal = 4. Total = 7
An early sign of increased ICP that the nurse should assess for is
a. Cushing's triad. c. decreasing level of consciousness (LOC).
b. unexpected vomiting. d. dilated pupil with sluggish response to light. - ANS-. c. One
of the most sensitive signs of increased ICP is a
decreasing level of consciousness (LOC). A decrease in
LOC will occur before changes in vital signs, ocular signs,
or projectile vomiting occur.
An unconscious patient with increased ICP is on ventilatory support. The nurse notifies
the health care provider
when arterial blood gas (ABG) measurement results reveal what?
a. pH of 7.43 c. PaO2
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