NUR 426 Exam 4 Study Guide Exam
Questions And All Correct Answers.
functions of the autonomic nervous system - Answer component of the peripheral nervous system that
regulates involuntary physiologic processes such as heart rate, blood pressure, respirations, and
digestion
normal range ICP - Answer 10-15 mmHg in adults
causes of elevation in ICP - Answer hemorrhagic or ischemic stroke, increased cerebrospinal fluid from
blockages (such as brain tumor), encephalitis, meningitis, hydrocephalus, hypertension, hepatic
encephalopathy
early signs and symptoms of increased ICP - Answer headache, blurred vision, lethargy, vomiting,
altered mental status, weakness (off balance, trouble with speech or vision), larger than normal head
circumference, increased temperature, dysarthria, aphasia, ataxia, cranial nerve dysfunction
Late signs and symptoms of increased ICP - Answer blown pupils, brain "shift" seen in imaging,
cushings triad, hypertension with widening pulse pressure, bradycardia, abnormal respiration
cushings triade - Answer -hypertension with widening pulse pressure
-bradycardia
-abnormal respirations
- there is concern for impending herniation of the brain
nursing implications and management of increased ICP - Answer airway is number one priority
diagnostics - extensive and serial neuro checks, lumbar puncture, CT scan is gold standard, MRI for more
precise pictures
Treatment - medications for sedation, decreasing ICP, and pain; if initial medication mgmt does not work,
may use barbiturate coma, hypothermia, and decompressive craniotomy
,hypothermia protocol - Answer goal core temp is 89.6-93.2 F for 24-48 hours to preserve brain function
medications for increased ICP - Answer mannitol - osmotic diuretic; must use a filter to administer
hypertonic saline 3% - contraindicated in hyponatremia
Lasix - given as adjunct, increases effects of mannitol
fentanyl - helps with pain, less effect on BP and HR than morphine
propofol or versed - sedative to help keep pt calm, no analgesic effect
lidocaine - suppresses cough
side effects of mannitol - Answer extravasation of IV site can cause compartment syndrome
hypervolemia
electrolyte disturbances
nephrotoxicity
side effects of hypertonic saline 3% - Answer hemolysis - give with D5W/NaCl 0.2% or NaCl 0.45%
sodium toxicity can occur is rate of correction is too fast (can lead to seizures, then death)
side effects of lasix - Answer hypokalemia, hypomagnesemia, hypocalcemia, hyponatremia, headache,
dizziness (low bp)
side effects of fentanyl - Answer Decreased respiratory rate and depth (respiratory depression)
constricted pupils
dizziness
urinary retention
side effects of propofol or versed - Answer orthostatic hypotension
blurred vision
fast, slow, or irregular heartbeat
headache
, side effects of lidocaine - Answer drowsiness, dizziness, hypotension, bradycardia, bradypnea
nursing interventions for increased ICP - Answer -keep HOB at 30-45 degrees and head and spine in
alignment
-assess for fluid overload
-assess neuro status q 1 hr and prn including pupil response
-teach pt to avoid cough, blowing nose, valsalva maneuvers
-seizure precautions
-frequent temp checks, temp can increase
-assess for babinski reflex and posturing
-avoid CNS depression meds in beginning (can alter mental status)
-strict I and O
-monitor electrolytes (Na can increase w meds, increases seizure potential)
-decrease stimuli in room (quiet environment, low lights)
-avoid clustering care, do one thing then let rest
-hyperoxygenate prior to suctioning and monitor airway to prevent unnecessary coughing, keep sat at 95
and up
difference between decorticate and decerebrate posturing - Answer decorticate has hands up,
decerebrate has hands at sides
hemorrhagic stroke - Answer bleeding
ischemic stroke - Answer clot - approximately 87% of strokes
TIA (transient ischemia stroke) - Answer mini stroke - treat the same as a ischemic stroke, but outside
of TPA window; looks like a stroke but gets better on its own
