NUR 265 Exam 3 Practice Questions and Answers (latest Update), 100% Correct

NUR 265 Exam 3 Practice Questions and Answers (latest Update), 100% Correct  Assessment Findings o Changes in LOC – First sign of IICP is declining LOC & includes restlessness or confusion to Stuporous  W/o glucose & 02, brain shuts down. Ex. Pt knew who you were in am & now don’t remember o Headache – Quite environment may have photophobia so keep room lights very low. o Change in speech pattern – Aphasia, Slurred Speech o Changes in pupil size – 2 cm change in either direction is significant, dilated or constricted, Notify Dr  Normal is 6 mm. Getting better if going back toward normal from dilated or constricted  Uneven pupils tx as IICP until proven otherwise; pinpoint - brain stem (pons) dysfunction o Abnormal Posturing – Decorticate (flexion) or Decerebrate (extensor)  Decorticate – arms drawn to core, legs straight  Decerebrate – arms straight and stiff, pts rarely survive o Hyperthermia – followed later by hypothermia  When hypothermic – BE CONCERNED, pressure on hypothalamus located next to brain stem o Cardiac & respiratory rate/rhythm changes  Tachy first – Increased HR & RR before brady HR & RR o N/V – Common in IICP o Cushing’s Triad – Severe HTN, Widened Pulse Pressure, Bradycardia  Late response & indicates severe IICP w/loss of autoregulation, Imminent death  Systolic BP increases bc decreased blood flow to brain  Pressure on Vagus nerve and brainstem = bradycardia