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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 Increased intracranial pressure (ICP) NCLEX practice questions for nursing students. Increased intracranial pressure is a medical emergency and results from too much pressure building within the skull. In the previous NCLEX review, I
explained about other neurological disorders, so be sure to check those reviews out. As the nurse, it is important to know the pathophysiology of increased ICP, the types of drugs used to treat this condition, signs and symptoms, and the nursing interventions. Don’t forget to watch the lecture on increased intracranial pressure before taking the quiz. Increased Intracranial Pressure (ICP) NCLEX QuestionsThis quiz will test your knowledge on increased ICP in preparation for the NCLEX exam.
(NOTE: When you hit submit, it will refresh this same page. Scroll down to see your results.) 1. Select the main structures below that play a role with altering intracranial pressure: A. Brain B. Neurons C. Cerebrospinal Fluid D. Blood E. Periosteum F. Dura mater The answers are A, C, and D. Inside the skull are three structures that can alter intracranial pressure. They are the brain, cerebrospinal fluid (CSF), and blood. 2. The Monro-Kellie hypothesis explains the compensatory relationship among the structures in the skull that play a role with intracranial pressure. Which of the following are NOT compensatory mechanisms performed by the body to decrease intracranial pressure naturally? Select all that apply: A. Shifting cerebrospinal fluid to other areas of the brain and spinal cord B. Vasodilation of cerebral vessels C. Decreasing cerebrospinal fluid production D. Leaking proteins into the brain barrier The answers are B and D. These are NOT compensatory mechanisms, but actions that will actually increase intracranial pressure. Vasoconstriction (not dilation) decreases blood flow and helps lower ICP. Leaking of protein actually leads to more swelling of the brain tissue. Remember water is attracted to protein (oncotic pressure). 3. A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing? A. Coughing B. Sneezing C. Talking D. Valsalva maneuver E. Vomiting F. Keeping the head of the bed between 30- 35 degrees The answers are A, B, D, and E. These activities can increase ICP. 4. A patient is experiencing hyperventilation and has a PaCO2 level of 52. The patient has an ICP of 20 mmHg. As the nurse you know that the PaCO2 level will? A. cause vasoconstriction and decrease the ICP B. promote diuresis and decrease the ICP C. cause vasodilation and increase the ICP D. cause vasodilation and decrease the ICP The answer is C. An elevated carbon dioxide level (52 is high…normal 35-45) in the blood will cause vasodilation (NOT constriction), which will increase ICP (normal ICP 5 to 15 mmHg). Therefore, many patients with severe ICP may need to be mechanical ventilated so PaCO2 levels can be lowered (30-35), which will lead to vasoconstriction and decrease ICP (with constriction there is less blood volume and flow going to the brain and this helps decrease pressure)….remember Monro-Kellie hypothesis. 5. You’re providing education to a group of nursing students about ICP. You explain that when cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies. A student asks, “What is a normal cerebral perfusion pressure level?” Your response is: A. 5-15 mmHg B. 60-100 mmHg C. 30-45 mmHg D. >160 mmHg The answer is B. This is a normal CPP. Option A represents a normal intracranial pressure. 6. Which patient below is at MOST risk for increased intracranial pressure? A. A patient who is experiencing severe hypotension. B. A patient who is admitted with a traumatic brain injury. C. A patient who recently experienced a myocardial infarction. D. A patient post-op from eye surgery. The answer is B. 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%. ICP reading is 21 mmHg. Based on these findings you would? A. Administered PRN dose of a vasopressor B. Administer 2 L of oxygen C. Remove extra blankets and give the patient a cool bath D. Perform suctioning The answer is C. It is important to monitor the patient for hyperthermia (a fever). A fever increases ICP and cerebral blood volume, and metabolic needs of the patient. The nurse can administer antipyretics per MD order, remove extra blankets, decrease room temperature, give a cool bath or use a cooling system. Remember it is important to prevent shivering (this also increases metabolic needs and ICP). 8. A patient has a ventriculostomy. Which finding would you immediately report to the doctor? A. Temperature 98.4 ‘F B. CPP 70 mmHg C. ICP 24 mmHg D. PaCO2 35 The answer is C. A ventriculostomy is a catheter inserted in the area of the lateral ventricle to assess ICP. It will help drain CSF during increase pressure readings and measure ICP. The nurse must monitor for ICP levels greater than 20 mmHg and report it to the doctor. 9. External ventricular drains monitor ICP and are inserted where? A. Subarachnoid space B. Lateral Ventricle C. Epidural space D. Right Ventricle The answer is B. External ventricular drains (also called ventriculostomy) are inserted in the lateral ventricle. 10. Which of the following is contraindicated in a patient with increased ICP? A. Lumbar puncture B. Midline position of the head C. Hyperosmotic diuretics D. Barbiturates medications The answer is A. LPs are avoided in patients with ICP because they can lead to possible brain herniation. 11. You’re collecting vital signs on a patient with ICP. The patient has a Glascoma Scale rating of 4. How will you assess the patient’s temperature? A. Rectal B. Oral C. Axillary The answer is A. This GCS rating demonstrates the patient is unconscious. If a patient is unconscious the nurse should take the patient’s temperature either via the rectal, tympanic, or temporal method. Oral and axillary are not reliable. 12. A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication? A. Bradycardia B. Decerebrate posturing C. Restlessness D. Unequal pupil size The answer is C. Mental status changes are the earliest indicator a patient is experiencing increased ICP. All the other signs and symptoms listed happen later. 13. Select all the signs and symptoms that occur with increased ICP: A. Decorticate posturing B. Tachycardia C. Decrease in pulse pressure D. Cheyne-stokes E. Hemiplegia F. Decerebrate posturing The answers are A, D, E, and F. Option B is wrong because bradycardia (not tachycardia) happens in the late stage along with an INCREASE (not decrease) in pulse pressure. 14. You’re maintaining an external ventricular drain. The ICP readings should be? A. 5 to 15 mmHg B. 20 to 35 mmHg C. 60 to 100 mmHg D. 5 to 25 mmHg The answer is A. Normal ICP should be 5 to 15 mmHg. 15. Which patient below with ICP is experiencing Cushing’s Triad? A patient with the following: A. BP 150/112, HR 110, RR 8 B. BP 90/60, HR 80, RR 22 C. BP 200/60, HR 50, RR 8 D. BP 80/40, HR 49, RR 12 The answer is C. These vital signs represent Cushing’s triad. There is an increase in the systolic pressure, widening pulse pressure of 140 (200-60=140), bradycardia, and bradypnea. 16. The patient has a blood pressure of 130/88 and ICP reading of 12. What is the patient’s cerebral perfusion pressure, and how do you interpret this as the nurse? A. 90 mmHg, normal B. 62 mmHg, abnormal C. 36 mmHg, abnormal D. 56 mmHg, normal The answer is A. CPP is calculated by the following formula: CPP=MAP-ICP. The patient’s CPP is 90 and this is normal. A normal CPP is 60-100 mmHg. 17. According to question 16, the patient’s blood pressure is 130/88. What is the patient’s mean arterial pressure (MAP)? A. 42 B. 74 C. 102 D. 88 The answer is C. MAP is calculated by taking the DBP (88) and multiplying it by 2. This equals 176. Then take this number and add the SBP (130). This equals 306. Then take this number and divide by 3, which equal 102. 18. During the assessment of a patient with increased ICP, you note that the patient’s arms are extended straight out and toes pointed downward. You will document this as: A. Decorticate posturing B. Decerebrate posturing C. Flaccid posturing The answer is B. 19. While positioning a patient in bed with increased ICP, it important to avoid? A. Midline positioning of the head B. Placing the HOB at 30-35 degrees C. Preventing flexion of the neck D. Flexion of the hips The answer is D. Avoid flexing the hips because this can increase intra-abdominal/thoracic pressure, which will increase ICP. 20. During the eye assessment of a patient with increased ICP, you need to assess the oculocephalic reflex. If the patient has brain stem damage what response will you find? A. The eyes will roll down as the head is moved side to side. B. The eyes will move in the opposite direction as the head is moved side to side. C. The eyes will roll back as the head is moved side to side. D. The eyes will be in a fixed mid-line position as the head is moved side to side. The answer is D. This is known as a negative doll’s eye and represents brain stem damage. It is a very bad sign. 21. A patient is receiving Mannitol for increased ICP. Which statement is INCORRECT about this medication? A. Mannitol will remove water from the brain and place it in the blood to be removed from the body. B. Mannitol will cause water and electrolyte reabsorption in the renal tubules. C. When a patient receives Mannitol the nurse must monitor the patient for both fluid volume overload and depletion. D. Mannitol is not for patients who are experiencing anuria. The answer is B. All the other options are correct. Mannitol will PREVENT (not cause) water and electrolytes (specifically sodium and chloride) from being reabsorbed….hence it will leave the body as urine. 22. What assessment finding requires immediate intervention if found while a patient is receiving Mannitol? A. An ICP of 10 mmHg B. Crackles throughout lung fields C. BP 110/72 D. Patient complains of dry mouth and thirst The answer is B. Mannitol can cause fluid volume overload that leads to heart failure and pulmonary edema. Crackles in the lung fields represent pulmonary edema and requires immediate intervention. Option A is a normal ICP reading and shows the mannitol is being effective. BP is within normal limits, and dry mouth/thirst will occur with this medication because remember we are trying to dehydrate the brain to keep edema and intracranial pressure decreased. More NCLEX Quizzes Don’t forget to tell your friends about this quiz by sharing it your Facebook, Twitter, and other social media. You can also take more fun nursing quizzes. *Disclaimer: While we do our best to provide students with accurate and in-depth study quizzes, this quiz/test is for educational and entertainment purposes only. Please refer to the latest NCLEX review books for the latest updates in nursing. This quiz is copyright RegisteredNurseRn.com. Please do not copy this quiz directly; however, please feel free to share a link to this page with students, friends, and others. When caring for an unconscious client with increasing ICP The nursing intervention that is contraindicated would be?Which of the following is contraindicated in a patient with increased ICP? The answer is A. LPs are avoided in patients with ICP because they can lead to possible brain herniation. 11.
Which signs and symptoms indicate an increase in intracranial pressure ICP in a child select all that apply?Table I.. Which is an appropriate position to place a child who is unconscious for a long period?If a person is unconscious but is breathing and has no other life-threatening conditions, they should be placed in the recovery position. Putting someone in the recovery position will keep their airway clear and open. It also ensures that any vomit or fluid won't cause them to choke.
Which measurement scale does the nurse use to assess the level of consciousness in a child?The tool we use to assess the level of consciousness is the Glasgow Coma Scale (GCS).
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Which interventions does the nurse implement to prevent the elevation of intracranial pressure ICP in an unconscious child?
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