The nurse assessing the patient with increased intracranial pressure (ICP) understands which factors are associated with increased ICP (Select all that apply)
increased bone tissue
Increased cerebral blood volume
increased systemic blood volume
increased cerebrospinal fluid (CSF)
increased brain volume
Correct Answer : B,D,E
A. Increased bone tissue: Skull bones in adults are rigid and do not increase in mass; changes in bone tissue are not a factor in acute increases in intracranial pressure. The cranial vault’s rigidity limits compensation for added volume.
B. Increased cerebral blood volume: Elevations in cerebral blood volume from vasodilation, hypercapnia, or impaired venous outflow can raise intracranial pressure. Vascular engorgement contributes directly to volume expansion within the fixed cranial space.
C. Increased systemic blood volume: Overall systemic blood volume does not directly impact intracranial pressure unless it affects cerebral perfusion or leads to increased cerebral blood volume. Systemic volume alone is not a primary determinant of ICP.
D. Increased cerebrospinal fluid (CSF): Accumulation of CSF due to overproduction, impaired absorption, or obstructed flow increases intracranial pressure. Hydrocephalus is a common example of CSF-related ICP elevation.
E. Increased brain volume: Brain tissue swelling from edema, trauma, hemorrhage, or tumors increases intracranial pressure by occupying space within the fixed cranial vault. Edematous tissue directly contributes to elevated ICP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. 6–12 hours: Initiating enteral nutrition this early is typically reserved for critically ill patients who are hemodynamically stable and require immediate nutritional support. It is not the standard time frame for all patients unable to meet oral intake.
B. 12–24 hours: Early feeding within this window may be appropriate for certain high-risk critically ill patients, but standard practice generally recommends initiation within a slightly longer period for most patients.
C. 24–48 hours: Guidelines recommend starting enteral nutrition within 24–48 hours for patients who cannot meet nutritional needs orally. Early enteral feeding helps maintain gut integrity, prevent malnutrition, and reduce complications associated with prolonged fasting.
D. 5 days: Delaying enteral nutrition for several days increases the risk of malnutrition, impaired wound healing, and weakened immune response. Waiting this long is not recommended for patients who cannot meet caloric and protein needs orally.
Correct Answer is B
Explanation
A. Sinus bradycardia: Bradycardia is typically associated with hypothyroidism or medication effects, not thyroid storm. Low heart rate is uncommon in the hypermetabolic state of thyroid storm.
B. Tachycardia: Thyroid storm produces excessive thyroid hormone levels, increasing metabolic demand and sympathetic activity. Tachycardia, often severe and sometimes leading to atrial fibrillation, is a hallmark cardiac manifestation requiring close monitoring.
C. Idioventricular rhythm: This rhythm usually occurs in severe ventricular conduction disturbances or cardiac arrest, not as a typical presentation of thyroid storm. It is less likely to be seen in a hyperthyroid crisis.
D. Junctional rhythm: Junctional rhythms arise from the atrioventricular node when sinus node activity is impaired. In thyroid storm, increased sinus node activity usually dominates, making junctional rhythms uncommon.
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