Exam 2 Pre Quiz Flashcards
T/F During assessment of an unconscious patient, the nurse notes “fixed, dilated pupils” and understands that brain injury is at the level of the midbrain.
True
T/F The cerebral perfusion pressure (CPP) must be maintained at 50 mm Hg to ensure adequate blood flow to the brain.
False
The normal CPP is 70 to 100 mm Hg
_____ refers to the brain’s ability to change the diameter of blood vessels to maintain cerebral blood flow.
autoregulation
T/F: The first treatment priority for a patient with an altered level of consciousness is to obtain and maintain a patent airway.
True
_____ refers to abnormal flexion of the upper extremities and extension of the lower extremities as neurologic function deteriorates and the patient becomes comatose.
decortication
Using the Glasgow Coma Scale, the nurse gives a patient who is brain dead a score of ___
3
The most frequently administered hyperosmotic agent used to reduce cerebral edema before intracranial surgery is ______.
mannitol
T/F: Nursing intervention when caring for a patient with ICP is to maintain the head of the bed at 30 degrees and maintain alignment of the head.
True
T/F: The earliest sign of increasing ICP is a change in LOC.
True
______ is an abnormal episode of motor, sensory, autonomic, or psychic activity resulting from a sudden, abnormal, uncontrolled electrical discharge from cerebral neurons.
seizure
The lowest score of 3 on the Glasgow Coma Scale (GCS) indicates the ______ responsive level of consciousness.
least
T/F: Young age, male gender, and alcohol and drug use are risk factors for spinal cord injury.
TRUE
T/F: Basilar skull fractures are suspected when cerebrospinal fluid escapes from the ears and the nose
TRUE
T/F: A concussion results in any loss of consciousness lasting from seconds to minutes.
False
T/F: The person with tetraplegia or paraplegia must not remain in any position for longer than 2 hours to prevent the formation of pressure ulcers.
True
Autonomic dysreflexia occurs among patients with spinal cord lesions above thoracic vertebra ______ after spinal shock has subsided.
T6
T/F: Concussion is the condition of temporary loss of neurologic function with no apparent structural damage to the brain.
True
The three cardinal signs of brain death on clinical examination are coma, the absence of brainstem reflexes, and ______
.
apnea
The most common sites for pressure ulcers, a significant complication of spinal cord injury, are over the ischial tuberosity, the greater trochanter, the
______, and the occiput.
sacrum
The most common causes of traumatic brain injury are _____.
falls
_________ syndrome is an autoimmune attack on myelin, a complex substance that covers nerves.
Guillain–Barré: an autoimmune attack on the peripheral nerve myelin. The result is acute, rapid segmental demyelination of peripheral nerves and some cranial nerves, producing ascending weakness with dyskinesia (inability to execute voluntary movements), hyporeflexia, and paresthesias (a sensation of numbness, tingling, or a “pins and needles” sensation).
T/F: Meningeal irritation is suspected when a patient exhibits a negative, bilateral Kernig sign.
False-
it would be positive
Kernig sign. When the patient is lying with the thigh flexed on the abdomen, the leg cannot be completely extended (see Fig.64-1A). When Kernig sign is bilateral, meningeal irritation is suspected.
B. Brudzinski sign. When the patient’s neck is flexed (after ruling out cervical trauma or injury), flexion of the knees and hips is produced; when the lower extremity of one side is passively flexed, a similar movement is seen in the opposite extremity (see Fig.64-1B). Brudzinski sign is a more sensitive indicator of meningeal irritation than Kernig sign
T/F: The initial manifestation of myasthenia gravis in most patients involves the ocular muscles.
TRUE it is an autoimmune disorder affecting the myoneural junction, is characterized by varying degrees of weakness of the voluntary muscles.
T/F: Herpes simplex virus is the most common cause of acute encephalitis in the United States.
True
The most common predisposing conditions for brain abscesses among immunocompetent adults are otitis media and ________________.
rhinosinusitis
Bell palsy is caused by the unilateral inflammation of the __________ cranial nerve which results in weakness or paralysis of the facial muscles on the affected side.
seventh- facial nerve
T/F: The oral disease-modifying agent fingolimod, recently approved by the FDA, has shown to decrease relapse rates in multiple sclerosis by approximately 50%.
true
Most patients diagnosed with _______________ have a remitting-relapsing course.
multiple sclerosis
T/F: Trigeminal neuralgia (tic douloureux) is a condition of the 12th cranial nerve characterized by paroxysms of sudden pain.
FALSE
condition of the 5th cranial nerve
the 12th cranial nerve is the hypoglossal nerve and controls the muscle that moves the tongue
The primary vector in North America that is responsible for transmitting several types of viruses that cause encephalitis is the ___
mosquito 🦟
Bladder ______ is a noninvasive method of measuring urine volume in the bladder that can be performed by the nurse at the bedside.
ultrasonography
T/F: The medulla contains the nephrons, the structural and functional units of the kidney responsible for urine formation.
False
nephrons are in the lobes
T/F: When fluid intake decreases, specific gravity increases.
True
Regulation of sodium volume excretion depends on ______, a hormone synthesized and released from the adrenal cortex.
aldosterone
T/F: The angling of the ureterovesical junction is the primary factor preventing backward movement of urine from the bladder toward the kidney.
True
