Question

The nurse caring for a client with a closed head injury obtains an intracranial pressure (ICP) reading of 17mmHg. The nurse recognizes that:

The ICP is elevated and the doctor should be notified.
The ICP is normal; therefore, no further action is needed.
The ICP is low and the client needs additional IV fluids.
The ICP reading is not as reliable as the Glascow coma scale.

Answer 1

A nurse recognizing an intracranial pressure (ICP) reading of 17 mmHg as (1) elevated should notify the doctor, as normal ICP ranges from 5 to 12 mm Hg. Elevated ICP can lead to severe complications and requires urgent attention to prevent further brain injury.

Step-by-step explanation:

The nurse caring for a client with a closed head injury who obtains an intracranial pressure (ICP) reading of 17 mmHg recognizes that the ICP is elevated. Normally, ICP should range from 5 to 12 mm Hg, which means this patient's pressure reading is above the normal range. Given this information, the correct course of action is to notify the doctor that the ICP is elevated. An elevated ICP can be dangerous and may require immediate medical intervention to prevent further injury to the brain.

This assessment of ICP is crucial because cerebrospinal fluid (CSF) serves many purposes, including providing flotation to the brain to reduce its effective weight. This protective mechanism of buoyancy can be compromised if ICP is abnormal. While the Glasgow Coma Scale (GCS) is another important diagnostic tool used to assess consciousness level following a head injury, ICP provides specific data on the pressure within the skull and is directly related to the patient's neurologic status and potential for increased damage if not managed properly.