NR 341 Exam Questions With 100% Correct Answers
What is the max GCS score? - Answer- 15
What is the minimum GCS score? - Answer- 3
What GCS score should you intubate? - Answer- 8 and under
What are the limitations of the GCS? - Answer- age, drugs, and language
What is normal intracra...
NR 341 Exam Questions With 100%
Correct Answers
What is the max GCS score? - Answer- 15
What is the minimum GCS score? - Answer- 3
What GCS score should you intubate? - Answer- 8 and under
What are the limitations of the GCS? - Answer- age, drugs, and language
What is normal intracranial pressure (ICP)? - Answer- 5-15 mmHg
What are the signs and symptoms of increased ICP? - Answer- change in LOC, change
in speech, change in vital signs, seizures, headache, vomiting, eye changes, posture
changes
What is the first sign of increased ICP? - Answer- changes in LOC
What is cushing's triad? - Answer- an effect of increased ICP of increased systolic BP,
decreased pulse, and cheyne-stokes respirations
What is Cheyne-Stokes respiration? - Answer- it is an abnormal rhythm of breathing
with alternation periods of hyperventilation and apnea
What is Kussmaul respiration? - Answer- deep, rapid breathing often induced by
acidosis
What condition does Kussmaul respirations commonly occur with? - Answer- DKA
What posture changes occurs with increased ICP? - Answer- decerebrate,
decorticate,or flaccid
What is decerebrate posturing? - Answer- Extensor response; problem with midbrain or
pons
What is decorticate posturing? - Answer- Flexor response; problem with cervical spinal
tract or cerebral hemisphere
What are the eye changes that occur with increased ICP? - Answer- papilledema,
pupillary changes, impaired eye movement
, What is a common cause of increased brain volume? - Answer- cerebral edema; can
also be caused by a tumor or meningitis
What causes increased blood volume? - Answer- loss of auto-regulation, decreased
oxygenation, hypercapnia, increased metabolic demands, and obstruction of venous
outflow
What causes increased cerebrospinal fluid? - Answer- hydrocephalus, blockage of
normal flow, obstruction of normal re-absorption, and excess production of CSF
What is cerebral perfusion pressure (CPP) dependent upon? - Answer- intracranial
pressure (ICP) and mean arterial pressure (MAP)
What is a normal cerebral perfusion pressure (CPP)? - Answer- 50-70
What does a low cerebral perfusion pressure (CPP) result in? - Answer- loss of auto-
regulation and hypoxic insult to brain tissue
Nursing Mgmt. ICP: What is the maintenance goal of ICP? - Answer- ICP < 20 mmHg
Nursing Mgmt. ICP: What is the maintenance goal of CPP? - Answer- < 70 mmHg
Nursing Mgmt. ICP: Care should be ________ to allow rest. - Answer- spaced
Nursing Mgmt. ICP: Suctioning should be _______. - Answer- minimum/PRN
Nursing Mgmt. ICP: What should the HOB be at? - Answer- 30-45 degrees (Semi-
Fowler's); keep neck in neutral position
Nursing Mgmt. ICP: Why should hyperthermia be avoided? - Answer- to help reduce
metabolic and oxygen demand
Nursing Mgmt. ICP: How should the patient be kept? - Answer- normovolemic
What is normovolemic? - Answer- normal blood volume
What electrolytes should be monitored with ICP mgmt.? - Answer- sodium --> seizures
What all should be monitored with ICP mgmt.? - Answer- ICP, electrolytes, ABG's vital
signs, daily weights, strict I&O, diabetes insipidus (DI), and SIADH
What tubes should be placed with increased ICP? - Answer- NG tube or orogastric tube
Which tube is preferred with patients who have facial fractures or skull fractures? -
Answer- orogastric tube
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