What is one of the earliest signs of increased intracranial pressure (ICP)?

Cushing triad.

Decreased level of consciousness (LOC).

Headache.

Coma.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Cushing triad is a late sign of increased ICP, characterized by bradycardia, hypertension, and irregular respirations, appearing after other symptoms like decreased LOC.

Choice B rationale

Decreased LOC is one of the earliest signs of increased ICP as it reflects the brain's response to pressure changes, alerting the need for immediate intervention.

Choice C rationale

Headache can be an early sign but is not as sensitive or specific as changes in LOC when assessing for increased ICP.

Choice D rationale

Coma is a late sign of significantly increased ICP, indicating severe brain dysfunction, often following initial symptoms like decreased LOC.

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Correct Answer is B

Explanation

Choice A rationale

Dysfunction in the cerebrum would likely result in different types of posturing, such as decorticate posturing, rather than decerebrate. The cerebrum is involved in controlling voluntary motor functions and damage here typically does not lead to decerebrate posturing.

Choice B rationale

Dysfunction in the brain stem results in decerebrate posturing, characterized by rigid extension of the arms and legs, downward pointing of the toes, and backward arching of the head. The brain stem is crucial for controlling basic life functions and its impairment leads to severe motor response issues.

Choice C rationale

Dysfunction in the spinal column typically does not lead to decerebrate posturing but may lead to different types of paralysis or movement issues depending on the location and severity of the damage.

Choice D rationale

Dysfunction in the motor cortex usually leads to abnormalities in voluntary movement, muscle tone, and coordination rather than decerebrate posturing which is more linked to brain stem issues.

A. Check the equipment. B. Continue the assessment because no actions are indicated at this time. C. Document the reading because it reflects that the treatment has been effective. D. Contact the health care provider to review the care plan.

Correct Answer is A

Explanation

Choice A rationale

The nurse should check the equipment first when an ICP reading of 0 mm Hg is noted, as this may indicate equipment malfunction. An accurate ICP reading is critical for assessing and managing intracranial pressure to ensure the client's safety.

Choice B rationale

Continuing the assessment without checking the equipment may lead to incorrect conclusions based on a potentially faulty reading. It’s crucial to ensure the accuracy of the equipment before proceeding.

Choice C rationale

Documenting the reading as an effective treatment outcome without verifying its accuracy can be dangerous. An ICP reading of 0 mm Hg is unusual and warrants equipment verification.

Choice D rationale

Contacting the health care provider to review the care plan is premature until the equipment has been checked to rule out a false reading, ensuring the nurse provides accurate information.

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What is one of the earliest signs of increased intracranial pressure (ICP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates:

Correct Answer is B

Explanation

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

Correct Answer is A

Explanation

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