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NR 341 Neuro – Questions And Verified Answers (Rated A+)
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NR 341 Neuro – Questions And Verified Answers (Rated A+)
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NR 341 Neuro – Questions And Verified Answers(Rated A+)
What is the max GCS score? Right Ans - 15
What is the minimum GCS score? Right Ans - 3
What GCS score should you intubate? Right Ans - 8 and under
What are the limitations of the GCS? Right Ans - age, drugs, and language
What is normal intracranial pressure (ICP)? Right Ans - 5-15 mmHg
What are the signs and symptoms of increased ICP? Right Ans - 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? Right Ans - changes in LOC
What is cushing's triad? Right Ans - an effect of increased ICP of increased
systolic BP, decreased pulse, and cheyne-stokes respirations
What is Cheyne-Stokes respiration? Right Ans - it is an abnormal rhythm of
breathing with alternation periods of hyperventilation and apnea
What is Kussmaul respiration? Right Ans - deep, rapid breathing often
induced by acidosis
What condition does Kussmaul respirations commonly occur with? Right
Ans - DKA
What posture changes occurs with increased ICP? Right Ans - decerebrate,
decorticate,or flaccid
What is decerebrate posturing? Right Ans - Extensor response; problem
with midbrain or pons
, What is decorticate posturing? Right Ans - Flexor response; problem with
cervical spinal tract or cerebral hemisphere
What are the eye changes that occur with increased ICP? Right Ans -
papilledema, pupillary changes, impaired eye movement
What is a common cause of increased brain volume? Right Ans - cerebral
edema; can also be caused by a tumor or meningitis
What causes increased blood volume? Right Ans - loss of auto-regulation,
decreased oxygenation, hypercapnia, increased metabolic demands, and
obstruction of venous outflow
What causes increased cerebrospinal fluid? Right Ans - hydrocephalus,
blockage of normal flow, obstruction of normal re-absorption, and excess
production of CSF
What is cerebral perfusion pressure (CPP) dependent upon? Right Ans -
intracranial pressure (ICP) and mean arterial pressure (MAP)
What is a normal cerebral perfusion pressure (CPP)? Right Ans - 50-70
What does a low cerebral perfusion pressure (CPP) result in? Right Ans -
loss of auto-regulation and hypoxic insult to brain tissue
Nursing Mgmt. ICP: What is the maintenance goal of ICP? Right Ans - ICP <
20 mmHg
Nursing Mgmt. ICP: What is the maintenance goal of CPP? Right Ans - < 70
mmHg
Nursing Mgmt. ICP: Care should be ________ to allow rest. Right Ans - spaced
Nursing Mgmt. ICP: Suctioning should be _______. Right Ans - minimum/PRN
Nursing Mgmt. ICP: What should the HOB be at? Right Ans - 30-45 degrees
(Semi-Fowler's); keep neck in neutral position
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