A 45-year-old patient with a traumatic brain injury is admitted to the emergency department. The nurse notes increased intracranial pressure (ICP) and altered level of consciousness. Which intervention should the nurse prioritize?
a) Administer a sedative
b) Elevate the head of the bed
c) Administer IV fluids rapidly
d) Encourage coughing and deep breathing
e) Apply a cold compress to the forehead
Rationale: Elevating the head of the bed promotes venous drainage from the brain, reducing intracranial pressure. This position helps optimize cerebral blood flow and minimizes the risk of further complications associated with increased ICP. Correct Answer: b) Elevate the head of the bed
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NCLEX Questions Critical Thinking: Increased Intracranial Pressure Symptoms
A patient diagnosed with a brain tumor is experiencing increased intracranial pressure. The nurse is assessing the patient’s vital signs. Which vital sign is a critical indicator of increased ICP?
a) Increased heart rate
b) Decreased respiratory rate
c) Elevated blood pressure
d) Lowered temperature
e) Normal pulse oximetry
Rationale: An increased heart rate is a compensatory response to decreased cerebral perfusion caused by elevated intracranial pressure. It reflects the body’s attempt to maintain an adequate blood supply to the brain despite the increased resistance. Correct Answer: a) Increased heart rate
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Understanding Increased Intracranial Pressure: NCLEX Priority Questions
A patient with a history of head injury is at risk for increased intracranial pressure. The nurse is monitoring the patient for early signs of elevated ICP. Which symptom should the nurse be particularly alert for?
a) Bradycardia
b) Hypotension
c) Pupillary constriction
d) Nuchal rigidity
e) Sudden improvement in headache
Rationale: Nuchal rigidity, or stiffness in the neck, is an early sign of increased intracranial pressure. It indicates irritation of the meninges and may be associated with conditions such as meningitis or elevated ICP. Prompt recognition of this symptom is crucial for early intervention and prevention of further complications. Correct Answer: d) Nuchal rigidity
Understanding Increased Intracranial Pressure: NCLEX Delegation Questions
A 30-year-old patient is admitted to the hospital following a severe head injury. The nurse is monitoring for signs of increased intracranial pressure (ICP). Which early sign would the nurse recognize as indicative of increased ICP?
a) Dilated pupils
b) Slurred speech
c) Hypertension
d) Hypothermia
e) Increased level of consciousness
Rationale: Dilated pupils are an early sign of increased intracranial pressure, reflecting compression of the cranial nerves. As ICP rises, it can lead to impaired pupillary reflexes. Recognizing dilated pupils is crucial for timely intervention to prevent further neurological compromise. Correct Answer: a) Dilated pupils
Understanding Increased Intracranial Pressure: Causes and Symptoms
A patient with a history of brain tumor is at risk for increased intracranial pressure. The nurse is providing education on measures to reduce ICP. Which action by the patient would demonstrate an understanding of ICP management?
a) Consuming a high-sodium diet
b) Performing Valsalva maneuver
c) Maintaining a flat head position
d) Engaging in strenuous physical activity
e) Avoiding caffeine intake
Rationale: Maintaining a flat head position promotes venous drainage from the brain and helps minimize intracranial pressure. This position aids in optimizing cerebral blood flow and reducing the risk of complications associated with increased ICP. Correct Answer: c) Maintaining a flat head position
NCLEX Practice Questions: Understanding Increased Intracranial Pressure Causes and Symptoms
A patient admitted with a subarachnoid hemorrhage is being closely monitored for complications, including increased intracranial pressure. Which nursing intervention is essential in the care of a patient at risk for increased ICP?
a) Administering sedatives regularly
b) Encouraging deep and rapid breathing
c) Administering IV fluids rapidly
d) Limiting sensory stimuli
e) Applying a warm compress to the forehead
Rationale: Limiting sensory stimuli is crucial in managing increased intracranial pressure. Minimizing external stimuli reduces the risk of exacerbating symptoms and helps maintain a stable intracranial environment. This intervention supports the overall goal of preventing further neurological compromise in patients at risk for increased ICP. Correct Answer: d) Limiting sensory stimuli
NCLEX Questions: Focus on Medications for Increased Intracranial Pressure
A 50-year-old patient is admitted to the neurology unit following a severe head injury sustained in a motor vehicle accident. The patient is unconscious and exhibits signs of increased intracranial pressure (ICP). The healthcare team is preparing for interventions. What is the priority nursing action in managing increased ICP in this patient?
a) Administering a diuretic
b) Administering an opioid analgesic
c) Elevating the head of the bed
d) Administering a hypertonic saline solution
e) Encouraging vigorous coughing
Rationale: Elevating the head of the bed is a priority intervention in managing increased intracranial pressure. This position helps promote venous drainage from the brain, reducing ICP. It is a non-invasive and immediate measure to optimize cerebral blood flow and prevent further complications associated with elevated ICP. Correct Answer: c) Elevating the head of the bed
A 35-year-old patient with a brain tumor is scheduled for surgery to alleviate increased intracranial pressure. The nurse is reviewing the preoperative care plan. Which action should the nurse prioritize to minimize the risk of increased ICP during the surgical procedure?
a) Administering a sedative
b) Administering an antipyretic
c) Administering a beta-blocker
d) Administering prophylactic antibiotics
e) Administering an antiemetic
Rationale: Administering prophylactic antibiotics is essential in the preoperative care of a patient with a brain tumor. Infection can exacerbate increased intracranial pressure, and prophylactic antibiotics help minimize the risk of infection during the surgical procedure, reducing the potential impact on ICP. Correct Answer: d) Administering prophylactic antibiotics
NCLEX Focus Exploring Increased Intracranial Pressure: Causes and Diagnosis
A 28-year-old patient diagnosed with meningitis is admitted to the medical-surgical unit. The nurse is assessing the patient for signs of increased intracranial pressure. Which neurological sign is characteristic of increased ICP in a patient with meningitis?
a) Pupillary constriction
b) Hyperactive deep tendon reflexes
c) Presence of seizures
d) Nuchal rigidity
e) Hypotonia
Rationale: Nuchal rigidity, or stiffness in the neck, is a characteristic sign of increased intracranial pressure in a patient with meningitis. It indicates irritation of the meninges and the potential for elevated ICP. Recognizing this sign is crucial for prompt intervention and prevention of further neurological complications. Correct Answer: d) Nuchal rigidity
A 40-year-old patient with a history of hydrocephalus presents to the emergency department with worsening headaches and visual disturbances. The nurse suspects increased intracranial pressure. Which diagnostic test is essential for confirming the presence of increased ICP in this patient?
a) Electroencephalogram (EEG)
b) Magnetic Resonance Imaging (MRI)
c) Lumbar puncture
d) Computed Tomography (CT) scan
e) Positron Emission Tomography (PET) scan
Rationale: A Computed Tomography (CT) scan is the diagnostic test of choice for confirming the presence of increased intracranial pressure. It provides detailed images of the brain structures, helping identify any abnormalities or signs of elevated ICP. Timely diagnosis through imaging is crucial for initiating appropriate interventions and preventing further complications. Correct Answer: d) Computed Tomography (CT) scan