Question

The nurse cares for a client with a ventro-peritoneal shunt. The nurse recognizes which signs of increased intracranial pressure (ICP)?

a. The client demonstrates bradycardia.
b. The client demonstrates sluggish pupils.
c. The client reports headache.
d. The client demonstrates hypotension.
e. The client experiences vomiting.

Answer 1

Increased intracranial pressure (ICP) in a client with a ventro-peritoneal shunt can be indicated by sluggish pupils, headaches, and vomiting.

Step-by-step explanation:

The nurse recognizes several signs of increased intracranial pressure (ICP) in a client with a ventro-peritoneal shunt. These signs include:

1. The client demonstrates sluggish pupils. Increased ICP can compress the cranial nerves responsible for controlling pupillary reflexes, causing the pupils to react slowly or sluggishly.
2. The client reports headache. Headache is a common symptom of increased ICP as the brain's tissues are under pressure.
3. The client experiences vomiting. Vomiting can be a result of increased ICP as the body tries to relieve the pressure in the brain.