Class 14

Question 1

Neurons are exquisitely sensitive to ______ deprivation

Answer 1

glucose

Question 2

Can neutrons store glucose?

Answer 2

no

Question 3

Increased intracranial pressure is?

Answer 3

pressure within the cranium (skull)

Question 4

ICP is dependent on the relationship between?

Answer 4

brain tissue, CSF and blood

Question 5

Is pressure in the brain normally low or high?

Answer 5

low (5-15mmHg)

Question 6

monro-kellie hypothesis

Answer 6

volume inside the cranium is fixed. Any increase in volume of one component results in the decrease of another.

Question 7

ICP occurs when?

Answer 7

compensatory mechanisms are no longer effective

Question 8

increased intracranial pressures will ______ cerebral perfusion

Answer 8

decrease

Question 9

what is the end result of increased intracranial pressure

Answer 9

brain tissue displacing

Question 10

Herniation

Answer 10

bulge and push of brain tissue down to cerebellum and around spinal cord

Question 11

Main manifestations of ICP are?

Answer 11

altered level of consciousness, pupillary alteration, changes in vital signs

Question 12

what is the earliest indicator of increased intracranial pressure

Answer 12

change in the level of consciousness

Question 13

in what stage are changes in vitals signs seen?

Answer 13

in stage 3 (beginning decompensation)

Question 14

what is the most critical index of nervous system function?

Answer 14

Level of consciousness

Question 15

How is LOC assessed?

Answer 15

using the Glasgow coma scale

Question 16

what is the highest score you can get on the GCS?

Answer 16

15/15

Question 17

What is the lowest score you can get on the GCS?

Answer 17

3/15

Question 18

what are the 3 categories of the GCS?

Answer 18

eye opening, verbal response and motor response

Question 19

If the patient being assessed for LOC does not respond to speech, what must the nurse do next?

Answer 19

elicit pain by applying pressure to nail beds or trapezius muscle

Question 20

impaired judgement or decision making and loss of ability to think rapidly and clearly

Answer 20

confusion

Question 21

If a person cannot answer time, place or self, they have?

Answer 21

disorientation

Question 22

limited spontaneous movement, easy arousal with speech or touch

Answer 22

lethargy

Question 23

mild-moderate decrease in awakeness with limited response to environment. Falls asleep unless stimulated, answers with minimal response.

Answer 23

obtundation

Question 24

deep sleep, may be aroused only by vigorous and repeated stimulation. Response is usually withdrawal or localizing.

Answer 24

stupor

Question 25

no verbal response. Noxious stimuli such as deep pain do not yield movement. GCS = 3

Answer 25

coma

Question 26

pupils will initially change on the?

Answer 26

same side as brain injury

Question 27

what is the worst type of pupil alteration to have?

Answer 27

fixed and dilated

Question 28

normal pupillary response?

Answer 28

pupils should be equal and reactive to light

Question 29

Cushing’s triad

Answer 29

1. Bradycardia
2. Widening pulse pressure
3. Irregular respirations

Question 30

Is Cushing’s triad a late or an early finding?

Answer 30

LATE finding

Question 31

What is Cushing’s triad indicative of?

Answer 31

impending herniation