What happens in stage four of intracranial pressure?
The brain tissue remains stable and does not shift.
The cerebrospinal fluid levels decrease significantly.
There is an increase in cerebral blood flow.
Brain herniation occurs as the brain tissue shifts from an area of greater pressure to an area of lower pressure
The Correct Answer is D
A. In stage four, the brain tissue no longer remains stable; it shifts due to high pressure.
B. CSF levels may decrease initially in compensation but are not the hallmark of stage four.
C. Cerebral blood flow decreases due to increased pressure, leading to ischemia.
D. Stage four is marked by brain herniation, where increased intracranial pressure causes brain tissue to shift from high-pressure areas to lower-pressure areas, which can be life-threatening.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Decorticate posturing is characterized by arms flexed at the elbows with wrists and fingers bent inward toward the chest, indicating damage to the cerebral hemispheres or corticospinal tract.
B. Grimacing and leg movement with neck flexion describe a positive Brudzinski’s sign, related to meningeal irritation, not posturing.
C. Inability to extend the leg with hip flexion causing pain describes a positive Kernig’s sign, also related to meningeal irritation.
D. Arms extended and rigid with palms turned outward describe decerebrate posturing, indicating more severe brainstem injury.
Correct Answer is A
Explanation
A. Initiate isolation precautions — This is the first action the nurse should take. Bacterial meningitis is highly contagious (often spread via droplet transmission), and immediate isolation (droplet precautions) helps prevent spread to others.
B. Administer antibiotics after collecting cultures — This is a critical next step, but only after the client is placed in isolation to protect others.
C. Prepare for a lumbar puncture after ruling out increased ICP — While a lumbar puncture is important for diagnosis, increased ICP must be ruled out first, and this is not the immediate first action.
D. Start IV fluids — Supportive care is important, but it is not the priority over infection control measures.
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