NCLEX- in class Q

The nurse would place a client who sustained a head injury in which position to prevent increased intracranial pressure (ICP)?

• In reverse Trendelenburg’s position

• In modified left lateral position

• With the head elevated on a small, flat pillow

• With the head of the bed elevated at least 30 degrees

The nurse is monitoring an unconscious client who sustained a head injury. Which observed posturing supports the suspicion that the client sustained an upper brainstem injury?

• Abnormal involuntary flexion of the extremities

• Abnormal involuntary extension of the extremities

• Upper extremity extension with lower extremity flexion

• Upper extremity flexion with lower extremity extension

A nurse is assessing a client with increased ICP following a traumatic brain injury. Which finding requires immediate action?

• Glasgow Coma Scale score of 15

• Blood pressure 142/88 mmHg

• New onset of pupillary asymmetry

• Client reports mild headache

The nurse is caring for a client with a ventriculostomy. Which action by the nurse requires intervention?

• Clamping the drainage system before repositioning the client

• Leveling the transducer to the tragus of the ear

• Documenting output and ICP values every hour

• Flushing the system to clear a blockage

A client with increased ICP has a new order for Mannitol 25% IV. Which pre-administration assessment is most important?

• Pupillary responses

• Deep tendon reflexes

• Serum osmolality and renal function

• Pain level using numeric scale

Which of the following is the priority goal in caring for a client with increased ICP?

• Maintaining blood glucose below 120 mg/dL

• Preventing infection from external devices

• Promoting cerebrospinal fluid drainage

• Maintaining adequate cerebral perfusion pressure (CPP)

A nurse is providing care for a client at risk for increased ICP. Which activity should be avoided?

• Administering stool softeners

• Performing frequent suctioning

• Monitoring fluid and electrolyte balance

• Keeping the head midline

A client with a traumatic brain injury becomes agitated and attempts to get out of bed. What is the nurse's best initial action?

• Apply soft wrist restraints

• Turn off environmental stimuli and speak calmly

• Increase sedation

• Call the provider immediately

The provider orders 0.9% NaCl at 100 mL/hr for a client with increased ICP whose blood pressure is 98/64 mmHg. Which action by the nurse is most appropriate?

• Administer as ordered; isotonic fluid helps maintain cerebral perfusion

• Question the order; 0.9% NaCl may worsen cerebral edema

• Change to 0.45% NaCl to reduce fluid overload

• Reduce the rate to 50 mL/hr to prevent increased volume

Which of the following is a late sign of increased intracranial pressure?

• Irritability

• Projectile vomiting

• Altered LOC

• Cushing’s triad