When explaining normal intracranial pressure (ICP) balance to the patient's family, which three components would the nurse include?

Glucose level, BP, and brain tissue

BP, brain tissue, and cerebrospinal fluid

BP, brain tissue, body mass index

BP, brain tissue, and ventricles of the brain

Answer and Explanation

The Correct Answer is B

A.   Glucose level, BP, and brain tissue: Glucose level is not a key component of ICP balance.
B.   BP, brain tissue, and cerebrospinal fluid: These are the primary components that contribute to ICP balance. Changes in any of these can affect pressure inside the skull.
C.   BP, brain tissue, body mass index: BMI is not directly related to ICP balance.
D.   BP, brain tissue, and ventricles of the brain: The ventricles are involved in cerebrospinal fluid production but are not one of the primary components of ICP balance as a whole.

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Correct Answer is B

Explanation

A. Increased intracranial pressure (ICP) typically causes hypertension (increased blood pressure) rather than hypotension.
B. A decreased level of consciousness is one of the hallmark signs of increased ICP, as pressure on the brainstem affects consciousness.
C. Tachypnea may occur with ICP, but it is less specific compared to decreased consciousness.
D. This can occur with brain injury but is not as directly indicative of ICP as decreased consciousness.

A. Managing sedation B. Monitoring volume status C. Completing hourly endotracheal suctioning D. Ensuring proper ventriculostomy transducer levels E. Elevating the head of the bed 30°

Correct Answer is ["A","B","D","E"]

Explanation

A. Managing sedation helps prevent agitation and decreases metabolic demands, which can exacerbate ICP.
B. Monitoring volume status is essential to prevent fluid imbalances that can worsen ICP.
C. Completing hourly endotracheal suctioning is not appropriate for this patient. Excessive suctioning can cause increased ICP and should be done cautiously.
D. Ensuring proper ventriculostomy transducer levels is critical for accurate measurement of ICP.
E. Elevating the head of the bed 30° helps improve venous drainage and reduces ICP.

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When explaining normal intracranial pressure (ICP) balance to the patient's family, which three components would the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Correct Answer is B

Explanation

A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse plan to include in the plan of care? (Select All that Apply.)

Correct Answer is ["A","B","D","E"]

Explanation

Which intervention would the nurse implement as the priority when providing care for a patient with a ventriculostomy to measure increased intra-cranial pressure (ICP) caused by a brain tumor?

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