A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)
Slurred speech.
Bradycardia with a bounding pulse.
Confusion.
Hypertension with an increasing pulse pressure.
Nonreactive dilated pupils.
Hypotension with a decreasing pulse pressure.
Correct Answer : B,D,E
The correct answers are b, d, and e.
Choice A: Slurred speech.
Slurred speech can be associated with increased ICP due to the pressure effects on the brain areas responsible for speech production. However, it is not typically considered a late sign of increased ICP. It may occur earlier in the progression as the brain's ability to coordinate muscle movements is affected.
Choice B: Bradycardia with a bounding pulse.
Bradycardia with a bounding pulse is a classic sign of Cushing's triad, which is a late and ominous sign of significantly increased ICP. It indicates that the body is attempting to increase arterial blood pressure to overcome the increased ICP and maintain cerebral perfusion. The normal range for adult heart rate is 60-100 beats per minute.
Choice C: Confusion.
Confusion can be an early sign of increased ICP as it can indicate changes in cerebral function. However, it is not specifically a late sign of increased ICP. Early signs of increased ICP can include headache, nausea, and confusion, as the brain is initially responding to the pressure changes.
Choice D: Hypertension with an increasing pulse pressure.
Hypertension with an increasing pulse pressure is another component of Cushing's triad. It reflects the body's compensatory mechanism to preserve cerebral blood flow in the face of rising ICP. An increasing pulse pressure (the difference between systolic and diastolic blood pressure) is a late sign of increased ICP. Normal pulse pressure is typically 30-40 mm Hg.
Choice E: Nonreactive dilated pupils.
Nonreactive dilated pupils are a late sign of increased ICP and indicate pressure on the cranial nerves that control pupil size and reaction to light. This is a grave sign and often indicates impending brain herniation.
Choice F: Hypotension with a decreasing pulse pressure.
Hypotension with a decreasing pulse pressure is not typically associated with increased ICP. In fact, hypertension with a widening pulse pressure would be more indicative of increased ICP as part of Cushing's triad.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because turning off the lights and TV and closing the door may increase the client's anxiety and confusion. The nurse should provide adequate lighting and familiar objects to help orient the client.
Choice B Reason: This is incorrect because using restraints may increase the risk of injury, infection, and psychological distress for the client. The nurse should use restraints only as a last resort and with a physician's order.
Choice C Reason: This is incorrect because asking for a sedative may not address the underlying cause of the agitation. The nurse should use non-pharmacological interventions first, such as calming music, massage, or aromatherapy.
Choice D Reason: This is correct because identifying the cause of the agitation may help resolve it. The nurse should assess for possible triggers, such as pain, hunger, thirst, infection, or environmental factors.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because encouraging coughing and deep breathing can increase intracranial pressure (ICP), which is the pressure inside
the skull that can affect brain function. Coughing and deep breathing can increase blood flow and oxygen demand to the brain, which can worsen cerebral edema. The nurse should suction the patient as needed and maintain a patent airway.
Choice B Reason: This is incorrect because positioning the patient with knees and hips flexed can increase ICP by reducing venous drainage from the head. The nurse should position the patient with neck and body in alignment and avoid extreme flexion or extension of any joints.
Choice C Reason: This is incorrect because performing nursing interventions once an hour can disturb the patient's sleep and increase ICP by stimulating brain activity. The nurse should cluster nursing interventions and provide quiet and dark environment to promote rest and reduce stress.
Choice D Reason: This is correct because keeping the head of the bed elevated to 30 degrees can decrease ICP by facilitating venous drainage from the head and reducing cerebral blood volume. The nurse should monitor the patient's blood pressure and pulse to ensure adequate cerebral perfusion.
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