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What is this article about?According to the Monro-Kellie hypothesis, the three components of the cranial vault (brain matter, cerebrospinal fluid and blood) can be considered to have a fixed total volume; therefore, if one of the three components increases in volume, there is little capacity for the total intracranial volume to increase. This results in raised intracranial pressure, which can have a variety of serious consequences Learning you'll loveAn Ausmed Subscription will unlock access to 1,000+ learning resources. High quality education helps you provide high quality care. ContentsTest Your Knowledge
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Meet the educatorsAusmed Editorial Team Ausmed’s editorial team is committed to providing high-quality, well-researched and reputable education to our users, free of any commercial bias or conflict of interest. All education produced by Ausmed is developed in consultation with healthcare professionals and undergoes a regular rigorous review process to ensure the relevancy of all healthcare information and updates to changes in practice. If you have identified an issue with the education offered by Ausmed or wish to submit feedback to Ausmed's editorial team, please email with your concerns. View Profile Sally Moyle Clinical Nurse Specialist, Clinical Nurse Educator Sally Moyle is a rehabilitation nurse educator with Epworth HealthCare. She has completed her masters of nursing (clinical nursing and teaching) and has experience in many nursing sectors including rehabilitation, orthopaedic, neurosurgery, emergency, aged care and general surgery. Sally is passionate about education in nursing in order to produce the best nurses possible. View Profile Here's some further inspirationPractice AreasAusmed PremiumTo access this resource, sign up for Ausmed Premium. With Premium, you’ll have unlimited access to everything you need to take your education and care to the next level. There are so many different subjects on Ausmed! I thought it'd be hard to find the resources I need for complicated procedures or rarer conditions, but they've had everything I've looked for so far. - Jacob, Enrolled Nurse
Practice Mode – Questions and choices are randomly arranged, the answer is revealed instantly after each question, and there is no time limit for the exam. Choose the letter of the correct answer. Good luck! Congratulations - you have completed MSN Exam for Increased
Intracranial Pressure (PM). You scored %%SCORE%% out of %%TOTAL%%. Your performance has been rated as %%RATING%% Your answers are highlighted below. Shaded items are complete.
Exam ModeExam Mode – Questions and choices are randomly arranged, time limit of 1min per question, answers and grade will be revealed after finishing the exam. Choose the letter of the correct answer. You got 25 minutes to finish the exam .Good luck! Congratulations - you have completed MSN Exam for Increased Intracranial Pressure (EM).
You scored %%SCORE%% out of %%TOTAL%%. Your performance has been rated as %%RATING%% Your answers are highlighted below. Shaded items are complete.
Text ModeText Mode – Text version of the exam 1) Which of the following signs of increased intracranial pressure (ICP) would appear first after head trauma?
2) The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid?
3) Whether Mr Snyder’s tumor is benign or malignant, it will eventually cause increased intracranial pressure. Signs and symptoms of increasing intracranial pressure may include all of the following except:
4) For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to:
5) The nurse is teaching family members of a patient with a concussion about the early signs of increased intracranial pressure (ICP). Which of the following would she cite as an early sign of increased ICP?
6) Later signs of increased intracranial pressure (ICP) later include which of the following?
7) A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mmHG and the ICP is 18 mmHg; therefore his cerebral perfusion pressure (CPP) is:
8) Which of the following types of drugs might be given to control increased intracranial pressure (ICP)?
9) A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning?
10) A nurse in the emergency department is observing a 4-year-old child for signs of increased intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the following signs or symptoms would be cause for concern?
11) A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning?
12) A male client is brought to the emergency department due to motor vehicle accident. While monitoring the client, the nurse suspects increasing intracranial pressure when:
13) Kate with severe head injury is being monitored by the nurse for increasing intracranial pressure (ICP). Which finding should be most indicative sign of increasing intracranial pressure?
14) A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances?
15) A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons?
16) A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective?
17) Which of the following values is considered normal for ICP?
18) Which of the following symptoms may occur with a phenytoin level of 32 mg/dl?
19) Which of the following signs and symptoms of increased ICP after head trauma would appear first?
20) Problems with memory and learning would relate to which of the following lobes?
21) While cooking, your client couldn’t feel the temperature of a hot oven. Which lobe could be dysfunctional?
22) The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client’s peripheral response to pain?
23) The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure?
24) A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has:
25) The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising?
Which set of vital signs would best indicate an increase in intracranial pressure?Remember head trauma, cerebral hemorrhage, hematoma, hydrocephalus, tumor, encephalitis etc. can all increase ICP. 7. A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14, oxygen saturation of 95%.
Which are signs of increased intracranial pressure select all that apply?What are the symptoms of increased ICP?. Headache.. Blurred vision.. Confusion.. High blood pressure.. Shallow breathing.. Vomiting.. Changes in your behavior.. Weakness or problems with moving or talking.. Which nursing actions should the nurse initiate for a client with signs of increased intracranial pressure ICP )?Nursing Interventions
Interventions to lower or stabilize ICP include elevating the head of the bed to thirty degrees, keeping the neck in a neutral position, maintaining a normal body temperature, and preventing volume overload.
Which assessment findings are consistent with head trauma with increased intracranial pressure ICP?Cushing's triad refers to a set of signs that are indicative of increased intracranial pressure (ICP), or increased pressure in the brain. Cushing's triad consists of bradycardia (also known as a low heart rate), irregular respirations, and a widened pulse pressure.
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