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N4117
Exam III Neuro
| Question | Answer |
|---|---|
| Pts with seizure has what injury to what part of the brain? | Temporal |
| interventions with pts with increased ICP? | Elevate HOB. Put head in neutra position. Hyperventilate with PaCo2 low end or 35. |
| Pts eye remain in a fixed position after 10mls of ice water is instilled into left the ear. The nurse interpretes this reflex as? | Abnormal oculvestibular reflex |
| Glascow of 11, unconscious for 1hr, and no memory of event for the past 2 days after the car accident. this indicates...? | moderate traumatic brain injury |
| Post ruptured subarachnoid hemorrhage (SAH)... drowisiness with occassional inability to state place and time and nuchal rigidity. Which grade is this SAH according to Hunt and Hess? | Grade III |
| Calculate CPP? | MAP - ICP = CPP |
| Pt with ICP of 28...nurse doea what intervention to optimize cerebral perfusion pressure? | Administer dopamine to increase MAP |
| Pt with a head injury had an imediate loss of consciousness, followed by regain consciousness, then loss of consciousness again... Pt has? | Epidural hematoma |
| Purpose of HHH after aneurism clipping is to prevent | Vasospasm |
| Pt recovering from head injury has excess thirst and increase UOP...Which endocrine gland was affected? | Pituitary gland |
| Pt post-ops for transsphenoidal hypophysectomy (TPH)... nursing intervention? | Educate on mouth breathing |
| Pt with post-op craniotomy has blurred vision...nursing intervention? | Monitor for alteration in cranial nerve II (Optic nerve) |
| Pt with brain tissue coming out of the skull has? | Transcaverical herniation |
| Pt with inability to drink through a straw has alteration of which cranial nerve? | Facial (VII) |
| Pt diagonosed with brain death is getting an EEG test. The nurse makes sure? | CORE TEMPERATURE IS > 32 DEGREES CELCIUS (89.6F) |
| What drives cerebral blood flow? | Cerebral perfusion pressure (CPP) |
| Which part of the brain controls life essentials such as breathing, heartbeat and articulate speech | Brainstem |
| the Brainstem consists of what? | – Midbrain – Pons – medulla Oblangata |
| cerebellum is responsible for? | Maintaining overall balance, motor coordination, learning repetitive asks, muscle tone and sens of equilibrum |
| Damage to the cerebellum will result in what? | Atxic gait |
| CSF is secreted by what structure of the brain? | Cortex plexus |
| CSF serves as what? | Shock absorbers to the brain |
| Blockade of the CSF @ any pathway will lead to what? | Hydrocephalus |
| Non-convolution/smotthness of the brain indicates what? | ICP |
| CFS is produced @? | 20ml/hr |
| Circulating volume of CSF at anytime should be? | 135 - 150ml |
| Volume of CSF produced in a 24 hr window is? | 500cc/24hrs |
| Smokey colored CFS indicates what? | RBC present |
| Cloudy colored CFS indicates what? | Infection |
| Yellow colored CSF indicates what? | Increased protien present |
| What is pathological reflex | A return of reflexes that one had when a baby such as sucking, babinski etc) |
| Name the five components of neuro assessments? | LOC (first & foremost in neuro checks), Motor functions, pupilliary/eye movement, respiratory patterns, vital signs. |
| What causes a pt to have partholigical reflex? | Brain damage. Baby reflex may returns when there is a brain damage |
| An oval eye shape indicates? | Pressure in the brain |
| Define localizing pain? | Application of cubital pressure on the rt hand, the lt habd reaches over to stop the pain |
| Define generalizing pain? | Trying to get away from the painful stimuli by moving arm away from the stimuli |
| No motor response to pain | 1 |
| extensor posturing to pain | 2 |
| flexor posturing to pain | 3 |
| Generlaized withdrawal to pain | 4 |
| Localizing response to pain | 5 |
| obeys command | 6 |
| No speech | 1 |
| Incomprhensible speech | 2 |
| inapropriate conversation | 3 |
| Confused conversation | 4 |
| oriented | 5 |
| no eye opening | 1 |
| eye open to pain | 2 |
| eye open to speech | 3 |
| spontaneous eye opening | 4 |
| If pt has noting in GCS, the score will be | 3 |
| if the pt is oriented and good, the GCS score will be | 15 |
| What drives cerebral blood flow? | CPP |
| What are The four factors we try to control to improve autoregulation? | Hypoxia, Hypercapnia, Hypotension, Hypovolemia. |
| What is ICP | The combination of the pressure exerted by brain tissue, blood and CSF |
| Normal range of ICP | 5 - 15 mmHg |
| We typically treat ICP when it...? | > 20 mm Hg that is sustained for 5 minutes |
| Care of pt with ICP | DOn't cluster cares @ one time. Provide adequate rest periods. Do one thing @ a time. Don't do position change & suction all the time. |
| Nurses will help ICP pts avoid what? | Bearing down for BM, cough, vomit, blow their nose, - Valsalva maneuvers, coughing, suctioning, noxious stimuli, seizure activity, |
| Normal CPP range | 70 - 95 mmHg |
| CPP < 60 mmHg indicates what? | Hypoperfusion |
| CPP < 40 mmHg indicates what? | Brain ischemia |
| In early rescusicitation, what do you use? | 100% FiO2 |
| Hypoxia + hypotension in ICP pts has...? | 75% mortality |
| If pt have sudden increase in ICP... nurse knows to? | hyperventilate (breath faster) to decrease CO2. This is for a short time so pt do not develop CPP problem |
| Etiology of Increased ICP? | Disorders of brain substance. Mass lesion with local edema. Ischemic brain injury with cytotoxic edema. Increased cerebral metabolic rate. |
| We use tripple H therapy to prevent what in SAH? | Vasospasm |
| CSF is produced in which part of the brain? | Choroid plexus |
| Resorbtion of CSF is done by? | Arachnoid villi |
| What is cushing's triad? | Bradycardia, systolic HTN (widened pulse pressure) and abnormal respiration. |
| early sighn of ICP | Decrease in LOC |
| late sign of ICP | Cushing's triad |
| When pts get to cushing's response, it is close to what? | Irreversible damage |
| Periorbital edema & scleral edema is not due to what? | ICP |
| Periorbital edema & scleral edema is due to what? | Fluid overload |
| Periorbital edema & scleral edema is not thesame thing as what? | Papilledema. |
| Uncal herniation | Unilaterally (one side) expanding mass of lession |
| Central herniation | Bilaterally expanding mass of lession |
| singulate herniation | An expanding lession of one hemisphere shifts laterally across midline an forces the singulate gyrus ubder the falx cerebri |
| Types of ICP monitor | Intraventricular catheter. Subarachnoid bolt. Subdural or Epidural ctheter and fiber optic transducer. |
| Which of the following is not a determinant of brain dead? | Vestibulocular reflex |
| TBI classification: Mild (Grade I) | Altered or LOC <30 min with normal CT &/or MRI, GCS 13-15, PTA < 24 hrs. (post-traumatic amnesia) |
| TBI classification: Moderate (Grade II) | LOC < 6 hrs with abnormal CT &/or MRI, GCS 9 - 12, PTA < 7 days. |
| TBI classification: Severe (Grade III) | LOC > 6hrs with abnormal CT &/or MRI, GCS <9, PTS > 7 days. |
| Sign of Frontal or orbital fracture and Anterior fossa? | Racoon eye. |
| Sign of Basilar skull fracture? | Battle sign. |
| describe battle sign | ecchymosis overlaying the mastoid process behind the ear |
| describe racoon eye? | Black eye, subconjuctival and periorbital ecchymosis |
| Fossas of the skull can cause what during trauma? | damage to the brain tissue |
| hallmark sign of concussion is? | Retrograde amnesia |
| What two things does brain not store? | O2 and glucose |
| TBI: Nursing management? | Stabilization of vital signs. Prevention of secondary injury. Reduction of elevated intracranial pressure. Hemodynamic management. Fluid management. Cerebral perfusion pressure 70 mmHg or more. Aggressive pulmonary care. Reduce environmental stimul |
| Types of aneurysms | Berry or saccular & Fusiform |
| describe berry or saccular aneurism | Looks like berry, handgs down fron a vessel like a berry |
| describe fusiform aneurism | an outpouching of vessel all around |
| define focal deficit? | eyelid drooping, rt arm weaker than left side |
| Define Global deficit? | not as awake as used to be |
| Differenciat between rebleeding & vasospasm? | REBLEED is sudden onset of HA, increases in BP, RR, & N/V. VASOSPASM is gradual in onset, an ischemich event, U see changes over a period of hrs and days |
| What is embolisation used for? | The securing of an aneurism that is surgically inaccessible because of size, location, type or medical instability of pt |
Created by:
nze
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