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?

Beware of changes in ICP related to leaking cerebrospinal fluid (CSF)

Maintain hyper-oxygenation through use of a ventilator

Use strict aseptic technique with all procedural dressing changes

Administer IV mannitol (Osmitrol)

Answer and Explanation

The Correct Answer is C

A.   Monitoring for CSF leakage is crucial to avoid infection and to maintain ICP accuracy.
B.   Hyper-oxygenation may be used in certain cases but is not the priority.
C.   Aseptic technique for all procedures and dressing changes is critical to prevent infection.
D.   Administering IV mannitol can be important, but aseptic technique is the priority to prevent infection.

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Correct Answer is A

Explanation

A. Cerebral perfusion pressure (CPP) is crucial for maintaining adequate blood flow to the brain. A CPP of 80 mm Hg is typically considered the lower limit for preserving cerebral perfusion, particularly in patients with elevated ICP.
B. 20 mm Hg is too low and would indicate inadequate perfusion, which could result in brain ischemia.
C. 40 mm Hg is too low for optimal cerebral perfusion in critically ill patients with elevated ICP.
D. 60 mm Hg is also too low for optimal cerebral perfusion in critically ill patients with elevated ICP.

A. The BP must be lower than 130/70 mm Hg to receive fibrinolytic agents. B. Elevated BPs are expected after a stroke, and drug therapy should be initiated. C. A lower BP is a protective response to maintain cerebral perfusion. D. Drugs to lower BP are recommended if the BP is 220/120 mm Hg or higher

Correct Answer is D

Explanation

A. The BP must be lower than 180/105 mm Hg to receive fibrinolytic agents, not 130/70 mm Hg.
B. Elevated BPs are common immediately after a stroke, but drug therapy to lower BP is not initiated unless it reaches high levels (typically > 220/120 mm Hg).
C. A lower BP does not act as a protective response; maintaining a higher BP can be necessary initially after a stroke to ensure adequate cerebral perfusion.

D. If BP is 220/120 mm Hg or higher after ischemic stroke, aggressive antihypertensive therapy is initiated to reduce the risk of hemorrhagic transformation and other complications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To preserve cerebral perfusion of a patient with an elevated intracranial pressure (ICP), which cerebral perfusion pressure (CPP) would the nurse maintain when suctioning the patient?

Correct Answer is A

Explanation

Which statement is accurate about the recommendations for BP management after an ischemic stroke?

Correct Answer is D

Explanation

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