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Adulth Hlth 2 Test 3
Neuro Part II
| Question | Answer |
|---|---|
| _____ is a bruising of the brain tissue most often at the site of injury (coup)? | contusion |
| A mild _____ is a brief loss of consciousness, usually from a acceleration/deacceleration injury with shearing stress on the reticular formation (a meshed structure of gray & white matter found on the medulla oblongata, spinal cord, midbrain and pons.)? | Concussion |
| A _____ causes actual tearing of the cortical surface vessels, which may lead to secondary hemorrhage and significant cerebral edema and inflammation. This condition is more serious than a contusion? | laceration |
| _____injuries involve site of injury and _____ injuries are opposite the site of injury? | Coup injuries involve site of injury and contrecoup injuries are opposite the site of injury |
| What physical sign would be indicative of a basilar skull fracture? | It occurs at the base of the skull, usually extending into the anterior, middle, or posterior fossa & results in CSF leakage from the nose/ears. |
| What fracture has the potential development of hemorrhage caused by damage to the internal carotid artery; damage to CN I, II, VII, & VIII; and infection? | basilar skull fracture |
| ___ results typically from venous bleeding into the space beneath the dura and above the arachnoid? | subdural hematoma (SDH) |
| _______ results most often from a tearing of the bridging veins within the cerebral hemispheres or from a laceration of brain tissue? | subdural hematoma (SDH) |
| Bleeding from ____ injury occurs more slowly than from an epidural hematoma and mirrors the slower development of symptoms? | subdural hematoma (SDH) |
| SDHs are subdivided into acute, subacute, and chronic. An acute SDH presents within_____ hours after impact? | 48 hours after impact; |
| An subacute SDH occurs between ___ & ___ following the injury? | 48 hours and 2 weeks |
| The chronic SDH occurs ___ to ____ following the injury? | 2 weeks to several months following injury. |
| What type of hematoma has the highest mortality rate? | SDHs have the highest mortality rate. |
| _____ results from arterial bleeding into the space between the dura and the inner table of the skull? | An epidural hematoma results from arterial bleeding into the space between the dura and the inner table of the skull (Figure 48-8). |
| ____ hematoma is often caused by a fracture of the temporal bone, which houses the middle meningeal artery? | epidural hematomas |
| _____may be characterized by the presence of a "lucid interval" that lasts for minutes, during which time the client is awake and talking. This follows a momentary unconsciousness that occurred within minutes of the injury? | Epidural hematomas |
| Following the initial lucid interval, symptoms progress very quickly with potentially catastrophic ICP elevation and structural changes. The client becomes increasingly symptomatic, loses consciousness, and may become increasingly unstable. What type of h | epidural hematomas |
| ____ is a neurosurgical emergency? | Epidural hematomas |
| _____is the accumulation of blood within the brain tissue caused by the teraing of small arteries and veins in the subcortical white matter? | intracerebral hemorrhage (ICH) |
| _____ may act as a space-occupying lesion & may be potentially devastating, depending on its location? | Intracerbral hemorrhage (ICH) |
| ____ may produce significant brain edema and ICP elevations. A brainstem hemorrhage occurs as a result of direct trauma, fractures, or torsion injuries to the brainstem? | Intracerbral hemorrhage (ICH) |
| What is an early sign of increased intracranial pressure? | level of consciousness |
| What is a late sign of increased intracranial pressure? | Cushing reflex (severe HTN, widened pulse pressure & bradycardia) |
| What are the 2 types of abnormal posturing and describe them? | Decerebrate-arms flexed outward; Decorticate-Arms flexed inward; and flaccidity |
| What does the Halo test indicate? | Basilar skull fracture |
| How would you do the Halo test? | CSF placed on a white absorbent background can be distinguished from other fluids by the "halo" sign, a yellowish stain surrounded by bloody drainage. |
| What are the nursing care precautions with a head injury? | position (HOB elevated) & suctioning precautions due to rise in intracranial pressure |
| ____ is an osmotic diuretic given to decrease intracranial pressure following a head injury? | Mannitol |
| When the ICP is _____mg Hg you should notify the physician? | 10 to 15 mg Hg normal (p. 1046) ; 150/100 mm Hg blood pressure acceptable….. |
| ____ stroke is caused by the occlusion of a cerebral artery by either a thrombus or an embolus? | ischemic stroke |
| A stroke that is caused by a thrombus is referred to as a ____ stroke, whereas a stroke caused by an embolus is referred to as an ______stroke? | thrombotic stroke; embolic stroke |
| About _____of all strokes are ischemic? | 80% |
| _______ vessel integrity is interrupted, and bleeding occurs into the brain tissue or into the spaces surrounding the brain (ventricular, subdural, subarachnoid)? | Hemorrhagic stroke |
| _____into the brain tissue generally results from a ruptured aneurysm (localized weakening and distortion of vessel wall); rupture of an arteriovenous malformation; or, more commonly, severe hypertension? | Hemorrhge |
| With what type of stroke are there usually seizures? | Hemorrhagic stroke |
| What stroke has a contributing factor of cardiac disease associated with it? | Embolic ischemic stroke |
| Hypertension; DM; Heart disease; Hypercholesteremia; hypercoagulable (increasing clotting) state; Illicit drug use (especially cocaine); Obesity; Nonvalvular atrial fibrillation are risk factors that most likely lead to ___ stroke? | ischemic stroke |
| Ischemic strokes are often preceded by warning signs, such as a _______, also called a "silent" stroke (Chart 48-1) or a _________? | transient ischemic attack (TIA) or a reversible ischemic neurologic deficit (RIND) |
| Both warning signs of ____ or ____ cause transient focal neurologic dysfunction resulting from a brief interruption in cerebral blood flow, possibly resulting from cerebral vasospasm or transient systemic arterial hypertension? | transient ischemic attack (TIA) or a reversible ischemic neurologic deficit (RIND) |
| What is the difference between a TIA and an RIND? | The difference between a TIA and an RIND is the length of time the client is symptomatic. A TIA lasts a few minutes to fewer than 24 hours, whereas RIND symptoms last longer than 24 hours but less than a week |
| Left vs. Right CVA; Which results in aphasia? | Left |
| Left vs. Right CVA; which results in unilateral neglect? | right |
| TPA for what type of stroke? When? | TPA is for an ischemic stroke to be given within 3 hours of the onset of symptoms |
| Nimotop is given for what type of stroke? | Calcium channel blocker used to treat or prevent cerebral vasospasm following a subarachnoid hemorrhage, which usually occurs between 4 and 14 days after the stroke, inhibits blood flow to the area, and worsens ischemia. |
| How does Nimotop work? | It work by relaxing the smooth muscles of the vessel wall and reducing the incidence and severity of the spasm. |
| What are the priority nursing diagnosis with stroke and TBI? | ineffective tissue perfusion (cerebral) r/t interruption of arterial blood flow & a possible increase in ICP; Impaired physical mobility & self-care deficit r/t neuromuscular impairment or cognitive impairment; Disturbed sensory perception… |
| T/F Disturbed Sensory Perception related to altered sensory reception, transmission, and integration is a priority nursing Dx of stroke and TBI? | True |
| T/F Unilateral Neglect related to effects of disturbed perceptual abilities or hemianopsia is not a priority nursing Dx of stroke and TBI? | False it is |
| T/F Impaired Verbal Communication related to decreased circulation in the brain is a priority nursing Dx of stroke and TBI? | true |
| T/F Impaired swallowing r/t neuromuscular impairment is not a nursing dx of stroke and TBI? | False it is |
| T/F Total Urinary Incontinence and Bowel Incontinence related to neurologic dysfunction is a nursing dx of stroke and TBI? | True |
| Explain widening pulse pressure with a TBI and how it relates to ICP? | Cerebral blood flow increases in response to hypertension and vasogenic edema may occur, further increasing ICP. |
| What do nursing personal monitor in a pt that has had a TBI? | Nursing personnel monitors cl's bp & pulse to detect possible changes in cerebral blood flow caused by impaired auto regulation as a result of hypotension or hypertension. |
| _____ is a classic yet late sign of increased ICP, is manifested by severe hypertension with a widened pulse pressure and bradycardia? | Cushing reflex |
| As ICP increases, the pulse becomes thready, irregular, and rapid. Cerebral blood flow increases in response to ______, and vasogenic edema may occur, further increasing ICP? | HTN |
| Which of the following statements about traumatic brain injury is correct: a. TBIs are the leading cause of death of persons between 50 and 64 years of age; b. TBIs are most often caused by falls. (And motor vehicle accidents p.1049) | B Note: TBI’s occur most with males from 10-39 y/o |
| What age group do TBIs occur most in and are they male or female? | **TBI’s occur most with males from 10-39 y/o |
| The head hits a stationary object is what type of trauma? | deceleration |
| There is a simple, clean break in the skull is what type of trauma? | linear fracture |
| Cortical surface is torn is what type of trauma? | Laceration |
| The head is in motion is what type of trauma? | Acceleration |
| Bone presses inward into brain tissue is what type of trauma? | Depressed fracture |
| CSF leaks from nose or ears is what type of trauma? | Basilar skull fracture |
| There is a direct opening to brain tissue is what type of trauma? | Open fracture |
| Fragments of bone are in brain tissue is what type of trauma? | Communited fracture |
| There is a brief loss of consciousness is what type of trauma? | concussion |
| A ___ hematoma is caused by terrain of small vessels with brian tissue? | subdural hematoma |
| A ____ hematoma occurs between the skull and the dura? | epidural hematoma |
| A ___ hematoma may be present as acute, sub acute, or chronic? | intracranial hemorrhage |
| List questions that are important to ask when obtaining an initial history from the client/family with traumatic brain injury and why? | When; how; loss of consciousness, how long; change in LOC; gather as much info about the events as possible; seizures; hand dominance; eye disease or injury; allergies (particularly SEAFOOD); alcohol or drug use… |
| The first priority in assessment of the client with traumatic brain injury is to determine which of the following: a. whether a spinal injury is present; b. whether the client is hypotensive; c. whether a patent airway is present; d. level of consciousnes | c |
| What are the signs of increased intracranial pressure? | Symptoms of increased ICP include severe headache, deteriorating level of consciousness, restlessness, irritability, and dilated or pinpoint pupils that are slow to react or nonreactive to light. |
| Nursing interventions for the client with traumatic brain injury include which of the following: a. Assessment of vital signs every 8 hours; b. Positioning to avoid extreme flexion; c. Encourage fluid intake for the first 48 hours to compensate for diabet | C |
| Nursing interventions for the client with _____ include: Administration of Mannitol; elevation of HOB to 30 unless otherwise directed; VS Q4H; fluid overload can occur & should be titrated to compensate for volume resuscitation, edema and ICP elevation? | Traumatic brain injury |
Created by:
cgwayland
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