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NR 341 Exam 3 – Questions With Solutions (Verified By Experts)
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NR 341 Exam 3 – Questions With Solutions (Verified By Experts)
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NR 341 Exam 3 – Questions With Solutions (Verified ByExperts)
Normal ICP Right Ans - - 0-15
- >20 you're concerned
What does Increased ICP do to CPP? Right Ans - - Cerebral Perfusion
Pressure decreases
- leads to cerebral ischemia and then brain death
Normal CPP Right Ans - 60-100 (<55 patient will die)
How do you calculate CPP? Right Ans - MAP - ICP = CPP
Monroe Kelly Doctrine Right Ans - only so much space in the brain, brain
will start to compensate
What makes up the brain? Right Ans - - brain tissue 80%
- CSF 10%
- Blood 10%
Intraventricular Device (Ventriculostomy) Right Ans - - infection is
possible
- can reduce CSF
- aseptic technique
- turn off when moving patient
- possible to drain too much
- monitor wave form
Increased ICP Causes Right Ans - - trauma - need craniotomy
- tumors - remove
- cerebral edema - cymedrol or mannatol (can cause fluid overload)
Too Much CSF Right Ans - - hydrocephalic
- get a VP shunt
- put in IV device
Too much blood Right Ans - - caused by trauma
, - aneurysm (stop the bleeding)
- hematoma
Subdural Hematoma Right Ans - - venous bleeding
- quick bleeding
- look for midline shift
Epidural Hematoma Right Ans - - arterial bleed
- surgery asap
- fast bleeding
Early S/S of ICP Right Ans - - altered LOC or loss of consciousness
- increased irritability
Increased ICP Interventions Right Ans - - HOB elevated
- minimize suctioning
- decrease stimulation, minimize visitors
- do not cluster care!
Late signs of ICP Right Ans - Cushing's Triad
- widening pulses, increased SBP
- bradycardia
- irregular respirations
Brain Dead Right Ans - complete irreversible cessation of brain and brain
stem function
Glasgow Coma Scale Right Ans - - 3-15
- 15 is good
- <8 intubate
- 3 = dead
Hyperventilation Right Ans - may hyperventilate increased ICP patients to
decreased ICP
Dolls Eyes Right Ans - - normal response
- turn head, eyes go in opposite direction
- occulocephalic
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