The health care provider prescribes IV mannitol for a client with an intracranial pressure (ICP) of 22. How will the nurse determine that the medication had the intended effect?

Intracranial pressure (ICP) is now 15.

The patient voids 250 mL over 2 hours.

The patient's pupils are dilated and sluggish.

Seizure behavior is absent.

Answer and Explanation

The Correct Answer is A

A. Intracranial pressure (ICP) is now 15: Mannitol is an osmotic diuretic used to reduce intracranial pressure (ICP). The intended effect of the medication is to lower ICP. A decrease in ICP to 15 mmHg is within the normal range and indicates the medication has worked effectively.

B. The patient voids 250 mL over 2 hours is incorrect. While mannitol promotes diuresis, the amount of urine output alone does not directly indicate a reduction in ICP. The goal is to lower ICP, which is best assessed by measuring the ICP itself.

C. The patient's pupils are dilated and sluggish is incorrect. Dilated and sluggish pupils can be a sign of increased ICP, not a response to effective treatment.

D. Seizure behavior is absent is incorrect. While mannitol can help reduce ICP and potentially prevent seizures, the absence of seizure behavior is not a direct indicator of the medication's effect on ICP.

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Correct Answer is D

Explanation

A. Maintain hyperventilation to a PaCO2 of 15 to 20 mm Hg. Hyperventilation can reduce ICP by causing vasoconstriction of cerebral blood vessels; however, a PaCO2 as low as 15–20 mmHg may lead to excessive vasoconstriction, reducing cerebral blood flow and causing cerebral ischemia. A PaCO2 target closer to 30–35 mmHg is typically recommended, and even this is used cautiously.

B. Routinely suction to prevent accumulation of respiratory secretions. Suctioning can increase ICP due to stimulation of the cough reflex. It should be performed only as needed and in a way that minimizes stimulation, such as preoxygenation and limiting suction duration.

C. Encourage visitation to prevent feelings of isolation. While social support is important, minimizing environmental stimuli (including limiting visitation) is crucial for clients with increased ICP to prevent overstimulation and further increases in ICP.

D. Avoid positioning the client with neck and hip flexion. Maintaining proper alignment of the head and neck is essential to promote venous drainage and reduce intracranial pressure (ICP). Flexion of the neck or hips can impede venous outflow, exacerbate ICP, and compromise cerebral perfusion.

A. First degree heart block B. Second degree heart block C. Bundle branch block D. Sinus arrhythmia

Correct Answer is A

Explanation

A. First-degree heart block: A prolonged PR interval greater than 0.20 seconds, as seen in this case, indicates first-degree heart block, which is a delay in conduction at the AV node.

B. Second-degree heart block. Second-degree heart block is characterized by some PR intervals being prolonged with occasional dropped beats (non-conducted P waves).

C. Bundle branch block. Bundle branch block causes a wide QRS complex (greater than 0.12 seconds), which is not seen here.

D. Sinus arrhythmia. Sinus arrhythmia involves changes in heart rate due to respiratory cycles, not prolonged PR intervals.

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The health care provider prescribes IV mannitol for a client with an intracranial pressure (ICP) of 22. How will the nurse determine that the medication had the intended effect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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