A nurse is caring for a patient with severe TBI receiving mechanical ventilation. ICP is 28 mmHg.CPP (cerebral perfusion pressure) is 55 mmHg. The patient's PaCO2, is 60 mmHg.
The ICP value indicates:
Normal ICP
Mildly elevated ICP
Critically elevated ICP
The Correct Answer is C
A. Normal ICP is incorrect because normal intracranial pressure ranges from 5 to 15 mmHg in adults. Values above 20 mmHg are considered elevated, and sustained ICP above 20–25 mmHg is critically high and requires urgent intervention.
B. Mildly elevated ICP is incorrect because ICP of 28 mmHg exceeds mild elevation, which is generally considered 20–25 mmHg. This patient’s ICP is above that range and represents a dangerous level.
C. Critically elevated ICP is correct. An ICP of 28 mmHg indicates critically elevated intracranial pressure, especially when accompanied by low CPP (normal 60–70 mmHg) and hypercapnia (PaCO2 60 mmHg). Hypercapnia causes cerebral vasodilation, further increasing ICP and worsening cerebral perfusion. Immediate interventions are required to reduce ICP, optimize CPP, and prevent secondary brain injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Decrease in secretion of hydrogen ions is correct because in acute kidney injury (AKI), the kidneys lose their ability to excrete hydrogen ions effectively. This leads to accumulation of acids in the blood, resulting in metabolic acidosis. Additionally, impaired kidney function reduces bicarbonate reabsorption, further worsening acidosis.
B. Increase in production of bicarbonate from the kidneys is incorrect because bicarbonate production is reduced in AKI, not increased. Adequate bicarbonate is necessary to buffer acids, and its reduction contributes to metabolic acidosis.
C. Rapid breathing is incorrect because rapid breathing (Kussmaul respirations)is a compensatory response to metabolic acidosis, not a cause. It occurs as the body attempts to blow off CO₂to reduce acid levels.
D. Increased blood pressure is incorrect because while hypertension may be associated with kidney injury, it does not directly contribute to metabolic acidosis. The acid-base imbalance is primarily due to renal failure to excrete hydrogen ions and conserve bicarbonate.
Correct Answer is B
Explanation
A. Increase hydrogen ions in blood is incorrect because metabolic acidosis (accumulation of hydrogen ions) can occur in CKD but does not directly cause anemia. It contributes more to bone demineralization and other metabolic disturbances rather than affecting red blood cell production.
B. Decreased erythropoietin production is correct because the kidneys produce erythropoietin, a hormone that stimulates the bone marrow to produce red blood cells. In CKD, damaged kidneys cannot produce sufficient erythropoietin, leading to decreased red blood cell production and anemia. This is the most common cause of anemia in CKD and often requires treatment with recombinant erythropoietin or iron supplementation.
C. Change in white blood cell function is incorrect because alterations in white blood cells may occur with CKD-related immune dysfunction, but they do not cause anemia. Anemia is specifically related to red blood cell production and lifespan.
D. Hyperinsulinemia is incorrect because elevated insulin levels are not directly linked to anemia in CKD. Insulin abnormalities are more commonly associated with metabolic syndrome or diabetes, which may coexist with CKD but are not primary causes of anemia in this condition.
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