Increased Intracranial Pressure (ICP) FINALS Questions

11. You’re collecting vital signs on a patient with ICP. The patient has a Glascoma Scale rating of 4. How
will you assess the patient’s temperature?
A. Rectal
B. Oral
C. Axillary

The answer is A. This GCS rating demonstrates the patient is unconscious. If a patient is
unconscious the nurse should take the patient’s temperature either via the rectal, tympanic, or
temporal method. Oral and axillary are not reliable.
12. A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign
and symptom below is the EARLIEST indicator the patient is having this complication?
A. Bradycardia
B. Decerebrate posturing
C. Restlessness
D. Unequal pupil size
The answer is C. Mental status changes are the earliest indicator a patient is experiencing
increased ICP. All the other signs and symptoms listed happen later.
13. Select all the signs and symptoms that occur with increased ICP:
A. Decorticate posturing
B. Tachycardia
C. Decrease in pulse pressure
D. Cheyne-stokes
E. Hemiplegia
F. Decerebrate posturing
The answers are A, D, E, and F. Option B is wrong because bradycardia (not tachycardia) happens
in the late stage along with an INCREASE (not decrease) in pulse pressure.
14. You’re maintaining an external ventricular drain. The ICP readings should be?
A. 5 to 15 mmHg
B. 20 to 35 mmHg
C. 60 to 100 mmHg
D. 5 to 25 mmHg
The answer is A. Normal ICP should be 5 to 15 mmHg.
15. Which patient below with ICP is experiencing Cushing’s Triad? A patient with the following:
A. BP 150/112, HR 110, RR 8
B. BP 90/60, HR 80, RR 22
C. BP 200/60, HR 50, RR 8
D. BP 80/40, HR 49, RR 12
The answer is C. These vital signs represent Cushing’s triad. There is an increase in the systolic
pressure, widening pulse pressure of 140 (200-60=140), bradycardia, and bradypnea.
16. The patient has a blood pressure of 130/88 and ICP reading of 12. What is the patient’s cerebral
perfusion pressure, and how do you interpret this as the nurse?
A. 90 mmHg, normal
B. 62 mmHg, abnormal
C. 36 mmHg, abnormal
D. 56 mmHg, normal
The answer is A. CPP is calculated by the following formula: CPP=MAP-ICP. The patient’s CPP is
90 and this is normal. A normal CPP is 60-100 mmHg.
17. According to question 16, the patient’s blood pressure is 130/88. What is the patient’s mean arterial
pressure (MAP)?
A. 42
B. 74
C. 102
D. 88
The answer is C. MAP is calculated by taking the DBP (88) and multiplying it by 2. This equals 176.
Then take this number and add the SBP (130). This equals 306. Then take this number and divide
by 3, which equal 102.
18. During the assessment of a patient with increased ICP, you note that the patient’s arms are extended
straight out and toes pointed downward. You will document this as:
A. Decorticate posturing
B. Decerebrate posturing
C. Flaccid posturing

The answer is B.
19. While positioning a patient in bed with increased ICP, it important to avoid?
A. Midline positioning of the head
B. Placing the HOB at 30-35 degrees
C. Preventing flexion of the neck
D. Flexion of the hips
The answer is D. Avoid flexing the hips because this can increase intra-abdominal/thoracic
pressure, which will increase ICP.
20. During the eye assessment of a patient with increased ICP, you need to assess the oculocephalic
reflex. If the patient has brain stem damage what response will you find?
A. The eyes will roll down as the head is moved side to side.
B. The eyes will move in the opposite direction as the head is moved side to side.
C. The eyes will roll back as the head is moved side to side.
D. The eyes will be in a fixed mid-line position as the head is moved side to side.
The answer is D. This is known as a negative doll’s eye and represents brain stem damage. It is a
very bad sign.