NCLEX Intracranial Pressure (ICP) Practice Exam

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• In the emergency department after head injury, a patient who had a brief lucid interval but then loses consciousness most classically indicates which complication?
• A patient with severe brain injury has no eye opening, incomprehensible verbal responses, and withdrawal to painful stimuli. What is the GCS score?
• Which vital signs pattern on admission indicates Cushing's triad and potentially impending brain herniation?
• Calculate CPP given BP 106/52 and ICP 14.
• Which assessment is a component of the Glasgow Coma Scale?
• What is the normal cerebral perfusion pressure (CPP) range?
• Why is glucose testing unreliable for detecting CSF in nasal drainage?
• A patient opens eyes to no stimulus, makes incomprehensible sounds, and withdraws limb to pain. What is the GCS score?
• Which statement best describes potential long-term neuropsychologic changes after head injury?
• The nurse recognizes the presence of Cushing's triad in the patient with
• Which presentation suggests an arterial epidural hematoma?
• Which type of hematoma is considered the most acute neurologic emergency?
• Which option indicates an acute subdural hematoma?
• What is the normal intracranial pressure range?
• After cranial surgery, which finding indicates the best possible outcome?
• During discharge planning, which statement best prepares the family for the patient's recovery after a skull fracture with subdural hematoma?
• Which is an early sign of increased intracranial pressure?
• Which component does not adapt to small increases in intracranial pressure?
• In the care of a patient with increased ICP, what is the best way to position the patient?
• Which statement about craniectomy is true?
• Increased ICP management includes maintaining PaCO2 in which range to avoid cerebral ischemia?
• For ICP monitoring using an intraventricular catheter, what is the priority nursing intervention to prevent complications?
• Positioning to manage increased ICP: which statement is correct?
• Which sign is the most sensitive indication of increased intracranial pressure?
• Which of these vital signs, taken 1 hour after admission, will be of most concern to the nurse in a patient with head injury?
• Which sign on a dressing indicates CSF leakage when drainage is bloody?
• For the patient undergoing craniotomy, when should the nurse provide information about wigs/hairpieces or other methods to disguise hair loss?
• For a patient with ICP monitored by a fiberoptic catheter, which order is a priority?
• Elevating the head of the bed to 30 degrees in ICP management is intended to?
• Which is a late sign of increased intracranial pressure (ICP)?
• Which statement accurately differentiates acute and chronic subdural hematomas?
• Skull radiographs and a CT scan indicate a depressed skull fracture with a subdural hematoma. In planning care, the nurse anticipates that the patient will:
• When a patient is admitted to the emergency department following a head injury, the nurse's first priority in management once a patent airway is confirmed is
• What are the earliest signs of increased intracranial pressure?
• During assessment of a patient who has had a head injury, which finding is of most concern for impending icp elevation requiring prompt action?
• Which of the following is NOT a component of the Glasgow Coma Scale?
• After a patient with head trauma has a confirmed patent airway, what should the nurse's first priority in management be?
• What is the normal range for brain tissue oxygen tension (PbtO2) to maintain cerebral oxygen supply and demand?
• Normal intracranial pressure (ICP) ranges from which of the following?
• A patient with a subacute subdural hematoma shows residual mental and emotional changes; what should be explained to family?
• What is the normal intracranial pressure (ICP) range?
• What is the normal range for cerebral perfusion pressure (CPP) in adults?
• Bloody drainage from the ear; which test confirms presence of CSF in the drainage?
• In managing nutrition for a patient with ICP, which approach best supports brain needs while avoiding edema?
• For an ICP patient, which positioning is most appropriate?
• Which assessment information is most concerning to the nurse when caring for a patient with head injury?
• An appropriate nursing intervention for a patient at risk for ineffective cerebral tissue perfusion related to cerebral edema is:
• A 54-year-old man recovering from a skull fracture with a subacute subdural hematoma shows apathy and reduced environmental awareness. When planning discharge, the nurse should explain that:
• A patient who does not open eyes to any stimulus, moans and mutters when stimulated, and withdraws from painful stimuli would have a Glasgow Coma Scale score of:
• A patient with ICP monitoring has pressure of 12 mm Hg. The nurse understands this pressure reflects
• In managing cerebral edema, what PaCO2 target is generally used?
• Calculate CPP given ICP 34 and BP 108/64.
• Which option indicates a sign of Cushing's triad?
• Normal intracranial pressure ranges from
• What is typically the earliest sign of increased ICP?
• Cerebral concussion: which symptoms should the nurse expect?
• Which test will the nurse expect to be ordered to detect a very small brain tumor?
• Which statement best indicates successful achievement of outcomes for a patient who has undergone cranial surgery?
• Head-of-bed elevation at 30 degrees: which statement is correct?
• The nurse notes that a patient with a head injury has clear nasal drainage. The most appropriate nursing action is to:
• During range-of-motion exercises for an unconscious patient with increased ICP, the patient develops severe decerebrate posturing. What should the nurse do first?
• During admission of a patient with a severe head injury to the ED, the nurse places highest priority on assessment for
• In the context of acute subdural hematoma, which surgical option is used to remove blood and control bleeding?
• Before obtaining an ICP reading from an intraventricular system, the drainage device should be closed for how long?
• A patient with ICP monitoring has a pressure of 12 mm Hg. This pressure most likely indicates
• Which statement accurately describes vasogenic edema?
• Post-craniotomy nursing, what should be the primary focus to prevent complications?
• In assessing a patient with a head injury, what is the earliest indication of increased ICP?
• Which MAP range supports effective autoregulation of cerebral blood flow?
• A patient with head injury has clear nasal drainage. What is the most appropriate nursing action?
• The nurse on the clinical unit is assigned to four patients. Which patient should she assess first?
• Which finding most specifically indicates increased intracranial pressure?
• Which manifestation is an early sign of increased intracranial pressure?
• A patient who is unconscious exhibits internal rotation, adduction, and flexion of the arms when a painful stimulus is applied. This posturing is
• Which sign is most consistent with increased ICP?
• Which surgical plan is appropriate for a depressed parietal fracture with subdural hematoma?
• In ICP monitoring, if the P2 wave is higher than the P1 wave, what does this indicate?
• What is the normal intracranial pressure range in adults?
• A patient with a suspected closed head injury has bloody nasal drainage. Which observation indicates a cerebrospinal fluid leak?
• The patient has rhinorrhea after a head injury. What action should you take?
• Which event directly causes increased intracranial pressure?
• Which option best indicates that mannitol is achieving its intended effect for elevated ICP?
• In a trauma scenario, which complication is suggested by an initial loss of consciousness with a brief lucid interval?
• Which vital sign change would indicate increased ICP?
• A patient with bloody nasal drainage is suspected of a CSF leak. Which finding supports CSF presence?
• A patient with head injury has a blood pressure of 120/60 mm Hg and an intracranial pressure (ICP) of 24 mm Hg. The cerebral perfusion pressure (CPP) is 56 mm Hg. This CPP most clearly indicates which of the following?
• A patient with increased ICP has mannitol prescribed. Which option best indicates that the drug is achieving its desired therapeutic effect?
• Emergency department presentation with cortical blindness and visual field defects suggests which head injury?
• Which option is the most sensitive indication of increased intracranial pressure (ICP)?
• Which factor can cause an inaccurate ICP reading with an intraventricular monitoring system?
• What is the best explanation of stereotactic radiosurgery?
• Which statement best describes the mechanism of mannitol in ICP management?
• When applying painful stimuli to an unconscious patient, movement is internal rotation, adduction, and flexion of the arms. This posturing is termed:
• Which symptom is most characteristic of subarachnoid hemorrhage?
• The metabolic and nutritional needs of a patient with increased ICP are best met by:
• Which description best characterizes vasogenic cerebral edema?
• A patient with head injury has a blood pressure of 92/50 mm Hg and an intracranial pressure (ICP) of 18 mm Hg. Which action by the nurse is most appropriate?
• Which of the following is among the earliest signs of increased intracranial pressure?
• In a depressed skull fracture with loose fragments, which surgical approach is indicated to relieve pressure and remove fragments?
• In a depressed skull fracture with a subdural hematoma, which surgical intervention is indicated to elevate the depressed bone and remove free fragments?
• Which nursing intervention helps prevent ineffective cerebral tissue perfusion related to cerebral edema?
• Which nursing action should be implemented for a patient experiencing increased intracranial pressure?
• For ICP monitoring with an intraventricular catheter, what is the priority nursing intervention to prevent complications?
• How should nutrition be provided to a patient with increased ICP to meet metabolic demands?
• A patient being monitored has an ICP of 12 mm Hg. This pressure most likely reflects which of the following?
• During ROM in an unconscious patient with increased ICP, decerebrate posturing occurs. Which action is most appropriate?
• Which presentation most strongly suggests an arterial epidural hematoma?
• Testing the drainage from suspected CSF otorrhea or rhinorrhea for CSF involves looking for what sign?
• Which change in vital signs would indicate increased intracranial pressure in a patient with a subdural hematoma?
• Which statement describes Cushing's triad components?
• A CPP of 50 mm Hg indicates which condition regarding brain blood flow?
• A patient has intracranial pressure (ICP) monitoring with an intraventricular catheter. A priority nursing intervention is:
• Which drug reduces ICP by expanding plasma osmotic pressure to draw fluid from brain tissue into the vasculature?
• Battle's sign is most suggestive of which skull fracture?
• Successful achievement of patient outcomes for the patient with cranial surgery would best be indicated by what?
• Which procedure replaces part of the skull with an artificial plate?
• The best position for a patient with increased ICP is to:
• Are vasoconstrictors typically administered to treat increased intracranial pressure?
• Which cranial procedure would necessitate the patient learning to protect the surgical area from trauma?
• Which is a cause of vasogenic cerebral edema?
• Which sign is a late indicator of intracranial hypertension?
• What is the recommended head-of-bed position for most patients with elevated intracranial pressure?
• Mechanical ventilation with a rate and volume to maintain mild hyperventilation is used for a patient with head injury. To evaluate the effectiveness of this therapy, the nurse should:
• Which diagnostic test could be used to determine blood flow to a suspected brain tumor?
• When assessing the body function of a patient with increased ICP, the nurse should initially assess
• During admission of a patient with a severe head injury to the ED, the nurse places highest priority on assessment for
• A patient has bloody drainage from the ear after head injury. To determine whether CSF is present in the drainage, which nursing action is most appropriate?
• A patient with a head injury has bloody drainage from the ear. To determine whether CSF is present in the drainage, the nurse should
• Which scenario is most consistent with an acute subdural hematoma?
• Which statement about hyperventilation in ICP management is correct?
• In a patient with cerebral edema and hyponatremia, why is administering simple glucose (D5W) alone not adequate for nutrition?
• A patient has rhinorrhea after head injury. What action should you take?
• The nurse's first priority in management of the patient once a patent airway is confirmed is
• What is the primary purpose of the Glasgow Coma Scale (GCS) in ICP assessment?
• Acute subdural hematoma signs typically appear within how many hours after a head injury?
• A patient with cerebral edema has serum sodium 115 mEq/L and decreasing LOC with headache. Which order should the nurse accomplish first?
• Assisting the family to understand what is happening to the patient is especially important when the patient has a brain tumor in which part of the brain?
• An unconscious patient at risk for ineffective cerebral tissue perfusion due to cerebral edema: which nursing intervention is most appropriate?
• For accurate ICP readings with ventriculostomy, the transducer should be leveled at which anatomical landmark?
• Which expression correctly defines CPP?
• An unconscious patient on ventilatory support has ABG results; the nurse should notify the provider if which value is present?
• Burr holes are used in cranial injuries primarily for which purpose?
• An acute subdural hematoma typically presents with which of the following within 24–48 hours after injury?
• What is the classic sign of an epidural hematoma?
• Depressed skull fracture with scalp lacerations communicating with intracranial cavity is best classified as which type of fracture?
• What is the purpose of maintaining mild hyperventilation in the management of head injury?
• A patient with increased intracranial pressure is being monitored with a fiberoptic catheter. Which order should be treated as a priority?
• Which of the following is a cause of vasogenic edema?
• Which finding is a sign of Cushing's triad?
• In a patient with increased ICP, which function should be assessed first when evaluating body functions?
• What is the earliest sign of increased intracranial pressure?
• If CPP is below normal, which action helps to improve cerebral perfusion?
• Decorticate posturing indicates involvement of which structure?
• Which nursing action should be implemented in the care of a patient experiencing increased intracranial pressure (ICP)?
• A patient with head injury has BP 92/50 and ICP 18; which action is appropriate?
• Metabolic and nutritional needs of the patient with increased intracranial pressure are best met with which approach?
• Which drug is used to treat vasogenic edema by stabilizing cell membranes and improving cerebral blood flow?
• Which statement best describes Cushing's triad?
• Which order should be accomplished first for a patient with cerebral edema and hyponatremia (115 mEq/L)?
• Which hematoma is classically associated with arterial bleeding across a skull fracture and can present with a lucid interval?
• Epidural hematoma presents most characteristically with which scenario?
• To evaluate the effectiveness of mechanical ventilation with mild hyperventilation for head injury, the nurse should monitor
• Which statement about testing suspected CSF leakage is correct?
• Which of the following is a manifestation of increased intracranial pressure?
• An inward indentation of the skull is called which type of fracture?
• Which of the following is the earliest indication of increased intracranial pressure (ICP) in a patient after head trauma?
• Increased ICP with left cerebral cortex bleeding causing brain tissue displaced to the right hemisphere beneath the falx cerebri is best described as which type of herniation?
• Which vital-sign pattern is associated with increased ICP?
• Which of the following is NOT an early sign of increased intracranial pressure?
• A patient has BP 120/60 and ICP 24; CPP calculation indicates
• What is the earliest sign of increased intracranial pressure?
• Which assessment is most relevant for early indication of pressure on the brainstem related to CN III function?
• During range-of-motion exercises for an unconscious patient with increased ICP, the patient develops severe decerebrate posturing. The nurse should...
• Which of the following is not an early sign of increased ICP?
• When assessing the body function of a patient with increased ICP, the nurse should initially assess
• The nurse on the clinical unit is assigned to four patients. Which patient should she assess first?
• Cushing's triad consists of three vital sign measures reflecting ICP. Which combination is correct?
• Which imaging study is primarily used to identify the location of a brain lesion?
• A patient with an intracranial pressure of 12 mm Hg most likely reflects which of the following?
• For a patient with an intraventricular catheter, which nursing action is essential to prevent infection?