For the patient after a craniotomy, which intracranial pressure (ICP) reading would the nurse report immediately to the healthcare provider?

An ICP of 10 mm HG

An ICP of 15 mm HG

An ICP of 20 mm HG

An ICP of 5 mm HG

Answer and Explanation

The Correct Answer is C

A.   An ICP of 10 mm HG is within normal limits.
B.   An ICP of 15 mm HG is within normal limits.
C.   An ICP of 20 mm Hg is elevated and should be reported immediately as it can indicate worsening conditions like brain swelling or herniation. Normal ICP is typically 5 to 15 mm Hg.
D.   An ICP of 5 mm HG is also normal and would not require immediate reporting.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Blepharitis is an inflammation of the eyelid margin causing symptoms such as itching, irritation, light intolerance, and crusting.
B. Retinal detachment involves sudden visual disturbances such as flashes of light or a curtain-like shadow, not itching or crusting.
C. Allergic conjunctivitis involves redness, itching, and watery discharge, not crusty debris on the lid margins.
D. Cataracts lead to blurred vision and glare, not irritation or crusting.

A. Movement of the eye in the sideward direction occurs, with neck extension B. When flexing the neck, eye movement is in the upward direction C. Movement of the eye is in the opposite direction of the turned head D. When extending the neck, eye movement is in the downward direction

Correct Answer is C

Explanation

A. The oculocephalic reflex test should cause the eyes to move in the opposite direction to the head turn, indicating intact brainstem function.
B. Movement of the eyes in an upward direction upon neck flexion indicates an abnormal response, suggesting a lesion.
C. A lesion could result in abnormal eye movement, as the eyes should move opposite to head movement.
D. Eye movement in the downward direction during neck extension is not a normal response and suggests a brainstem issue.

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For the patient after a craniotomy, which intracranial pressure (ICP) reading would the nurse report immediately to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which visual disorder would the nurse associate with the patient's clinical manifestations of itching, irritation, intolerance of light, and crusty debris of the lid margins and lashes?

Correct Answer is A

Explanation

After performing an assessment of the oculocephalic reflex, the nurse suspects that the patient has an intracranial lesion. Which patient behavior supports the nurse's assessment findings?

Correct Answer is C

Explanation

A nurse observes a patient whose right eye is fixed and dilated, for which cranial nerve (CN) would the nurse suspect nerve compression?

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?

A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying?

Which laboratory result would the nurse anticipate when reviewing the cerebrospinal fluid analysis of a patient with bacterial meningitis?

Which are would be a priority of care for a patient who is being admitted to the hospital and its demonstrating signs of delirium?

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

Which method of measurement is the gold standard for obtaining intracranial pressures?