NURS 331 FINAL Exam Questions With Verified Answers.
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NURS 331
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NURS 331
o any stimulus
Glasgow Coma Scale - answeruses eye opening response, best verbal response, and best motor
response; score ranges from 3-15; score less than 14 is abnormal
Breathing patterns are controlled by - answercerebrum (pattern) and medulla (rate)
When the breathing control center is lost...
NURS 331 FINAL Exam Questions With
Verified Answers.
LOC - answer✔- The most critical clinical index of nervous system function
- Alterations indicates either improvement or deterioration of the individual's condition
- In order to be fully conscious an intact reticular activating system (RAS) is required, along with
the functioning of higher brain centers in the cerebral cortex
A person who is__________________ is considered to function at the highest level of
consciousness - answer✔alert and oriented
Components of Consciousness - answer✔1. Arousal: the state of awakeness of an individual,
mediated by Reticular Activating System (brain stem)
2. Content of thought: encompasses all cognitive functions; awareness of self, environment, &
affective states (mood)
Alterations in Consciousness - answer✔1. Confusion: loss of ability to think rapidly
2. Disorientation: to time, place, and lastly self
3. Lethargy: limited spontaneous movement or speech, will arouse when name is called or
touched
4. Obtunded: falls asleep unless stimulated verbally or tactilely
5. Stupor: vigorous and repeated stimulation needed for arousal
6. Coma: no arousal to any stimulus
Glasgow Coma Scale - answer✔uses eye opening response, best verbal response, and best motor
response; score ranges from 3-15; score less than 14 is abnormal
Breathing patterns are controlled by - answer✔cerebrum (pattern) and medulla (rate)
When the breathing control center is lost with cerebral damage, the _________ regulates the
breathing pattern by responding only to changes in the Pa____ levels. - answer✔lower brain
stem; CO2
Cheyne-Stokes - answer✔respirations cease (apnea) until carbon dioxide builds up to a certain
threshold and causes the individual to hyperventilate until carbon dioxide is removed
With breathing, damage to the brain stem causes - answer✔irregular and unpredictable patterns
of breathing
Opioid affect on breathing - answer✔Opiate overdose affects the respiratory center (medulla
oblongata) and results in a gradual decline in the breathing rate, until respiration ceases
Pupil changes that occur with brain damage - answer✔- Pinpoint pupils seen with opiates
overdose (heroin, morphine),
- Bilaterally fixed and dilated pupils (usually seen with hypoxia).
- Failing pupil response may be the first indication of impending brain herniation
- Mild dilation with sluggish or absent light response is ominous
Doll's eye phenomenon (Oculocephalic reflex) - answer✔1. Normal: eyes move with head
movement (positive)
2. Abnormal: eyes remain fixed in forward position (negative); brain stem is not intact
Cold caloric stimulation (Vestibuloocular reflex) - answer✔- cold water dropped into ear
1. Normal: eyes move symmetrically toward stimulus and pt throws up or gets nauseous
2. Abnormal: eyes are fixed forward, or only one eye moves towards stimulus and pt does not get
nauseous
Purposeful movement requires an intact ___________ system - answer✔corticospinal
Decorticate vs Decerebrate Posturing - answer✔Decorticate: brain stem intact (less severe), loss
of cerebral cortex functioning (internally rotated; hands make C shape at chest)
Decerebrate: may indicate more serious damage and results from disruption of higher brain
centers and the brainstem (externally rotated; hands make e shape by sides)
The balance between what components maintains the ICP - answer✔brain tissue, blood, and CSF
Factors influencing ICP - answer✔1. changes in brain tissue, blood, or CSF
2. changes in pressure (arterial, venous, or intra-abdominal/intrathoracic pressure, vomiting,
coughing, suctioning, seizures)
3. changes in posture, ROM, pain stimuli
4. changes in temperature
5. changes in blood gases (CO2- causes vasodilation which increases blood flow and ICP)
Normal ICP - answer✔Normal is 0-15 mmHg; ICP > 20 mmHg is a poor prognosis
Phases of ICP: Stage 1 - answer✔awake & alert, compensatory mechanisms (vasoconstriction),
ICP may not increase
Phases of ICP: Stage 2 - answer✔confusion, slight pupil and breathing changes, systemic arterial
constriction
Phases of ICP: Stage 4 - answer✔brain tissue shifts (herniates) from the compartment of greater
pressure to a compartment of lesser pressure (no fixing this)
Cushing's Triad (Late signs of ICP) - answer✔1. Systolic hypertension
2. Bradycardia
3. Bradypnea
Your client is admitted with a head injury. He complains of a headache. Can you give him a
narcotic? - answer✔NO narcotics will cause respiratory depression and increase intrancranial
pressure, causing worse injury
Cerebral death - answer✔death of the cerebral hemispheres not including the brain stem and
cerebellum (consciousness is lost); absence of awareness of self and environment and inability to
interact with others but may maintain homeostasis (respirations, CV control, yawning & reflexes
continue)
Brain Death - answer✔Irreversible cessation of function of the entire brain including the
cerebellum & brain stem
Criteria for Brain Death (2 tests 6 hrs apart) - answer✔1. Negative corneal reflex
2. Fixed and dilated pupils
3. Negative doll's eyes/cold caloric stimulation
4. Negative gag reflex
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