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NURS 401 Exam 3 Critical Neuro
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NURS 401 Exam 3 Critical Neuro NURS 401 Exam 3 Critical Neuro NURS 401 Exam 3 Critical Neuro
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NURS 401 Exam 3 Critical NeuroNeuro assessment - ANS mental status, LOC, speech for articulation and voice quality, gait for balance
and symmetry, extremities for muscle strength, cranial nerves, eyes for PERRL, face for movement and
sensation
Change in LOC meANS - ANS infection, pain, meds, something is wrong!, is the earliest and most
sensitive indicator of alterations in cerebral function
Cheyne-Stokes - ANS alternating periods of apnea and hyperventilation (brainstem compression)
Central neurogenic hyperventilation - ANS sustained hyperventilation (lesions of midbrain/pons)
Small reactive pupils - ANS bilateral cerebral dysfunction
Bilaterally dilated pupils - ANS overdose of hallucinogenics or CNS stimulants; pressure in brainstem
compressing CN III bilaterally
Unilateral fixed and dilated pupil - ANS pressure on ipsilateral CN III
Glasgow coma scale - ANS assess loc using 15 pt scale, assess for best response to eye opening, motor
response, and verbal response
If talking to a pt and the pt is constantly dosing off and you are continually waking them up, what
glasgow coma score do you give them? - ANS 14
A score of 14/15 on the glasgow coma scale meANS - ANS mild dysfunction
,A score of 11-13 on the glasgow coma scale meANS - ANS moderate to severe dysfunction
A score of <10 on the glasgow coma scale meANS - ANS severe dysfunction
A score of <8 on the glasgow coma scale meANS - ANS we intubate
What is the highest score for each eye opening, verbal response and motor? - ANS 4: eye opening
5: verbal response
6: motor
Eye opening response glasgow coma scale - ANS 4: spontaneous-open with blinking at baseline
3: to verbal stimuli, command, speech
2: to pain only
1: no response
Verbal response glasgow coma scale - ANS 5: oriented
4: confused conversation, but able to answer questions
3: inappropriate words
2: incomprehensible speech
1: no response
Motor response glasgow coma scale - ANS 6: obeys commands for movement
5: purposeful movement to painful stimulus
4: withdraws in response to pain
3: flexion in response to pain (decorticate posturing)
, 2: extension response in response to pain (decerebrate posturing)
1: no response
Coma - ANS no eye opening, no ability to follow commands, no word verbalizations (3-8)
Kernigs sign - ANS flexing one leg at hip and knee then extending knee, no pain=negative kernigs sign, if
inflammation of meninges pt reports pain along vertebral column
Brudzinski's sign - ANS tested with pt supine, positive sign is when pt reports pain along vertebral
column when passively flexing hip and knee in response to head flexion
Fever and bad headache indicate - ANS meningitis
Nuchal rigidity is a sign of what - ANS meningitis (chin to chest)
LOC is assessed by - ANS orientation, memory, attention, calculation, recall, language, judgement,
insight, abstraction
Stereognosis - ANS ability to recognize objects by feeling their form, size, and weight while the eyes are
closed
AVPU - ANS Alert, Verbal, Pain (if not responding to speech, rub thumb on the bottom of the pts foot),
Unresponsive (do pain, and are still unresponsive)
Alert and Oriented x4 - ANS alert and oriented to Person, Place (what hospital), Time (month, year,
president) and Situation (why here)
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