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?

Beware of changes in ICP related to leaking cerebrospinal fluid (CSF)

Maintain hyper-oxygenation through use of a ventilator

Use strict aseptic technique with all procedural dressing changes

Administer IV mannitol (Osmitrol)

Answer and Explanation

The Correct Answer is C

A.   Monitoring for CSF leakage is crucial to avoid infection and to maintain ICP accuracy.
B.   Hyper-oxygenation may be used in certain cases but is not the priority.
C.   Aseptic technique for all procedures and dressing changes is critical to prevent infection.
D.   Administering IV mannitol can be important, but aseptic technique is the priority to prevent infection.

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Correct Answer is A

Explanation

A. The constriction and dilation of blood vessels in the brain helps maintain appropriate cerebral blood flow and cerebral perfusion pressure (CPP) despite fluctuations in blood pressure.
B. Catecholamines regulate other systemic body functions, but they do not directly impact cerebral perfusion pressure.
C. Carbon dioxide exhalation can affect blood flow, but the primary regulation of CPP is through blood vessel constriction and dilation.
D. The amount of blood pumped from the heart can impact overall blood pressure but does not directly regulate cerebral perfusion pressure.

A. CNV B. CN VIII C. CN IV D. CN III

Correct Answer is D

Explanation

A. CN V (Trigeminal nerve) is responsible for sensation in the face and motor function for chewing, not eye movement or pupil constriction.
B. CN VIII (Vestibulocochlear nerve) deals with hearing and balance, not eye function.
C. CN IV (Trochlear nerve) controls eye movement, but it does not typically affect the pupil in this way.
D. Cranial nerve III (Oculomotor nerve) controls most eye movements and pupil constriction. A fixed and dilated pupil typically indicates damage to CN III, which may be due to nerve compression, often from increased intracranial pressure or herniation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is taking care of a client who has sustained a neurologic injury with increased intracranial pressure and decreased cerebral perfusion. Which of the following will keep cerebral perfusion pressure constant?

Correct Answer is A

Explanation

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

Correct Answer is D

Explanation

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

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