Essential NCLEX® Practice Questions for Intracranial Pressure (ICP)

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In this lecture, we’ll be focusing on the five test questions about intracranial pressure (ICP) that are usually asked on major nursing tests and the NCLEX®.

Let’s begin.

Question #1

Your client has a change in his or her Glasgow Coma Scale (GCS), when do you tell the doctor about it?

Answer:

There are two instances wherein you have to tell the doctor about changes in the GCS of your client.

The first instance is within the first 48 hours. If there is a slight change, either good or bad, immediately inform the doctor about it. Telling the doctor within the first 48 hours of the changes, whether good or bad, is a priority regarding your client care.

For a coma client, if 48 hours have passed and the GCS is eight or less, this is the second instance that the doctor must be alerted. Usually, comatose clients have an endotracheal tube that goes inside their lungs. However, even with the presence of an endotracheal tube and you notice that your client is deteriorating after you’ve done a neurological assessment, you have to inform the doctor the condition ASAP.

Now, if the after 48 hours and the client’s GCS is getting better, there is no need to inform the doctor about it because this is an expected outcome.

Question #2

When do you give an endotracheal tube in terms of your GCS?

Answer:

As mentioned earlier, clients who have a GCS of anything less than eight should have an endotracheal tube. This is due to the knowledge that if the client’s GCS is below eight, his or her condition is highly critical and will probably be inside the neurology ICU.

Question #3

What are the three things that you have to make sure of when positioning your client?

Answer:

  1. You have to keep the client in a neutral position which means that there should be no neck bending, flexing, or any motion. As much as possible, keep your client at a 30-degree neutral position to facilitate cerebral drainage.
  2. Log roll. When moving the client, log roll is a priority. When doing a log roll, you need to have an assistant to keep the client in one straight line. One should hold the head while the other moves the body. Therefore, if you are going to clean your client, coordination is a must.
  3. No flexing (Matrix). As mentioned, make sure that when you are moving your client, there will be no flexing and bending of any part of the body, even the extremities.

Question #4

When it comes to increased carbon dioxide (CO2) levels, what is the number that you have to watch-out-for?

Answer:

Increased CO2 inside the brain will cause blood vessel dilation; which should be avoided. Decreasing the amount of circulation to the brain is another priority so as not to increase the pressure. Therefore, the number that you have to take note of when assessing for CO2 increase is anything greater than 40 mm/Hg.

Anything that is more than 45 mm/Hg is considered a hazard. In hospital settings, the CO2 is usually kept underneath the borderline to maintain an alkalosis, oxygenated state.

Question #5

Do you cluster your care with your ICP clients if your client is in a coma with an endotracheal tube?

Answer:

Clustering care basically means that the medical provider will do all care at specific times instead of constantly going in and bother the client. Cluster care is usually seen in pediatrics with the newborn assessment.

So, when dealing with an ICP client, you have to cluster your neurological assessment depending on the hospital policy – can either be every 15 minutes or hourly, depending on the client’s condition. However, you should not do cluster care for activities of daily living, feeding times, oral hygiene, and monitoring.  

For those who wanted to check out our GCS scale lecture, we have a video via SimpleNursing.com. The lecture and video will provide everything you need to know about Glasgow Coma Scale and it even comes with a GCS dance. So check that out.

On our next lecture, we’ll be going over the GCS quiz.

NCLEX® Practice Part 3: The Respiratory System

Hello, guys. So, here’s an intensive NCLEX® practice test review where we will be solely discussing the signs and symptoms, diagnostic tests, and nursing management involving the three main respiratory system conditions – lung cancer, tuberculosis (TB), and pulmonary embolism (PE).

Let’s begin.

Signs and Symptoms

First, we will be focusing our discussion on the main signs and symptoms or quick pathophysiology of every illness. We will be pointing out the manifestations that make one condition different from the other.

Scenario: If a client comes into the ER presenting signs and symptoms of respiratory affectation, how would you know what type of lung illness it is? So, this NCLEX® practice is beneficial in ruling out what the client is or is not experiencing.

  1. Lung Cancer

Usually, with lung cancer, there is a tumor that grows in the lungs and spreads up the respiratory tract, affecting the vocal chords, larynx, and pharynx. Therefore, the primary signs and symptoms are the following:

  • Hoarse or raspy voice
  • A cough with bloody sputum
  • Shortness of breath
  • Weight loss
  • Fatigue
  • Effusion – when the lungs start to fill up with pus (needs to be drained)
  1. Tuberculosis

Bacteria that reside inside the lungs cause tuberculosis; its main manifestations are:

  • Dry, purulent cough with blood-tinged sputum (spots of blood)

Note: One of the main signs and symptoms of a TB client is a cough. Unlike lung cancer’s cough which is bloody sputum (like that of the protagonist in Breaking Bad), TB’s cough produces blood-tinged sputum which is speckles of blood.

  • Anorexia
  • Weight loss
  • Night sweats
  1. Pulmonary Embolism

Blood clots in the lungs cause pulmonary embolism; therefore, the signs and symptoms are:

  • Increased respiratory rate
  • Increase heart rate
  • Increased chest pain
  • Decreased blood pressure
  • Jugular vein distention (JVD)

Take note that chest pain in PE is a primary manifestation due to the blood clots inside or outside the alveolar sac. The occlusion prevents oxygen exchange at the capillaries. For this reason, deep breathing causes chest pain because the heart is compensating for the increased respiratory rate.

How do the heart and lung co-mingle in pulmonary embolism?

Basic anatomy. A lot of nursing students fail to recognize how the anatomy of the heart and the lung co-mingles with each other. The right side of the heart is responsible for transporting deoxygenated blood to the lungs for oxygen and carbon dioxide exchange; at the same time, the lungs eliminate carbon dioxide through respiration. After oxygen exchange, oxygenated blood is then transported to the left side of the heart which is the side responsible for pumping blood throughout the body.

If there is a pulmonary embolism, the blockage causes backing up of fluid or blood from the lungs to the right side of the heart causing cor pulmonale or right-sided heart failure. Blood will continuously back up that it will go back to the body; thus, creating bounding pulses and jugular vein distention.

Why is there decreased blood pressure and not an increased blood pressure?

The different aspect of right-sided heart failure when it comes to pulmonary embolism clients is that there is low blood pressure due to inadequate perfusion to the left ventricle. The left ventricle is mainly responsible for pushing out the cardiac output and stroke volume; thus pushing the oxygenated blood out of the heart and into the different parts of the body. Signs and symptoms of right-sided heart failure are also evident in clients with pulmonary embolism.

Note: There might be chances of experiencing chest pain with lung cancer and tuberculosis, but with pulmonary embolism, there is 100% possibility of the client having chest pain.

Diagnostic Tests

To get a medically accurate conclusion, diagnostic tests are required. Here, we will be discussing the different kinds of tests that are specifically ordered for the three lung disorders.

  1. Lung Cancer Test

The different tests for lung cancer are the following:

  • Spit/sputum culture
  • Chest X-ray and CT scan (to locate tumors or masses)
  • Bronchoscopy

Bronchoscopy is divided into “broncho” which refers to the bronchioles of the respiratory tract, and “scopy” which means video or camera recording. A bronchoscopy is a diagnostic tool that is used to check for masses or tumors and is inserted by shoving it down the throat of the client while doing a biopsy. A biopsy is taking a tissue sample from the suspected mass or tumor and is sent to the laboratory for further testing.

As a nurse, there are important things to remember before bronchoscopy:

  • Don’t give clients anything to eat before the procedure (NPO).
  • After the test, wait until the client’s gag reflex has returned before feeding anything.
  1. Tuberculosis Test

As previously mentioned in the quick pathophysiology above, TB is caused by bacteria growth inside the lungs; therefore, the tests involved are:

  • Spit/sputum culture – tests what kind of bacteria is residing inside the lungs (whether it’s TB or not, ruling out the disease)

Note: All it requires is one positive sputum culture for a client to be declared positive TB. Treatment will ensue. On the other hand, it takes three negative sputum cultures for a client to be discharged, cleared for work, and allowed to mingle and be active in the community.

  1. Pulmonary Embolism Test

As previously mentioned, PE is caused by blood clots; therefore the following tests are required:

  • CT scan (to verify the presence of blood clots in the lungs)

Note: If the CT scan shows a positive result, the nursing management would be putting the client under a heparin drip.

  • D-dimer
  • PTT and INR (coagulating factor tests)

Note: PTT and INR tests determine the client’s clotting rates. Risk factors that affect clotting would be anticoagulation therapy, sedentary lifestyle, and smoking.

Nursing Management

Every respiratory problem requires very specific nursing management.

  1. Lung Cancer Management

Once the tumor inside the lung is diagnosed with lung cancer, the following nursing management processes will take place:

  • No smoking (carcinogen) – can worsen the condition
  • No exposure to asbestos
  • No exposure to heavy metal (carcinogen) – leads to toxic lungs causing cancer
  • Chemotherapy, radiation therapy, or surgery

Since there is a cancerous mass inside the lung, the priority is to stop the tumor from spreading to nearby tissues. Therefore, the primary goal is to prevent cancer from growing and eventually eliminate it.

Understanding the Cancer Line of Treatment

So, the first line of treatment is the least invasive, mildest type of therapy which is the chemotherapeutic drugs. It’s NOT surgery; it should be the last line of treatment since it’s the most invasive type of treatment.

It is important to remember that chemotherapy can severely affect the client’s health because it destroys not only the cancer cells but also the normal surrounding tissues. Chemotherapy kills everything in its path, even the white blood cells.

Chemotherapy stops the tumor from growing by destroying the fastest producing cancer cells. Alopecia is a notable side effect.

Side note: For those who are interested in knowing the different types of chemotherapy drugs, head on to SimpleNursing.com and look for the Medical-Surgical tab, scroll down and find the cancer icon.

Radiation therapy would come in second if chemotherapy did not work. Radiation therapy shrinks the tumor.

Lastly, surgery is done if chemotherapy and radiation therapy did not work. Surgery is done by cutting out the tumor. However, this procedure is not done unless necessary.

  1. Tuberculosis Management

Tuberculosis is caused by bacteria that sits inside the lungs and travels all over the body, blood, and even affects the lymph nodes.

Question: How is TB spread?

Answer: TB is spread through the air; therefore, airborne precaution is required. This information is from the Center for Disease Control.

For the longest time, a lot of medical professionals thought that TB is spread through droplets; however, the CDC has stated that TB is an airborne disease which is why clients with TB are put in a negative pressure room. The thing is, TB is spread by airborne droplets, say, for example, you sneeze on a tissue, and someone grabs that tissue, that person can now be infected with TB. For a more elaborate discussion on TB, drop by SimpleNursing.com.

So, what are the different nursing management?

  • Tuberculosis clients will have six to 12 months’ worth of drug therapy, and they are prescribed two to four drugs
  • All of these medications can severely affect the liver; therefore watch out for jaundice.
  • Teach your clients to wear a mask for two to three weeks to have it quarantined and stop the spread of bacteria to other people and in the community.
  1. Pulmonary Embolism Management

Since PE clients have big clots inside the alveolar sacs and the goal is to stabilize the clot, you need to provide the following nursing management:

  • Anticoagulation therapy (Heparin)
  • Clot buster (TPA)

Warfarin (Coumadin) is not given because it is taken orally and the therapeutic range is about two to three days. PE clients need immediate anti-coagulating drugs since their condition is critical due to respiratory distress.

After stabilizing the clots with Heparin, a clot buster is given in the form of TPA. Since TPA is a strong anti-coagulant, the client is at risk for bleeding and can even go into DIC. Therefore, monitoring is necessary. For those who are unaware of what DIC is, there is an entire lecture about that at SimpleNursing.com.

Conclusion

Hopefully, this article has helped you how to think critically about determining the different signs and symptoms, diagnostic tests, nursing management, treatment options, and respiratory complications.

At SimpleNursing.com, we have a lot more discussions like this which focuses on prioritizing and organizing care for your clients depending on their conditions. So go check out our website and become a member to gain unlimited access to intensive lectures like this.

Until the next lecture!