Neuro Assessment

Question 1

What are the 3 signs/components of Cushing’s triad?

Answer 1

1) bradycardia (slow and bounding)
2) increased SBP and widening pulse pressure
3) irregular and decreased respirations

Question 2

What is the significance of Cushing’s triad?

Answer 2

it is a LATE sign of increased ICP

Question 3

Describe decorticate and decerebrate posturing and which areas of the brain are likely affected.

Answer 3

Decorticate: flexed upper extremities and extended lower extremities
- injury of corticospinal tract (above brainstem)
Decerebrate: rigid extension, arms pronated; wrists, fingers, and jaw flexed; back arched with lower extremities extended and feet plantarflexed
- injury between midbrain and brainstem

Question 4

What are the 3 sections that make up the Glasgow Coma Scale (GCS)?

Answer 4

1) Eye opening response /4
2) Motor response /6
3) Verbal response /5
Total score out of 15

Question 5

What score on the GCS indicates a coma?

Answer 5

less than 8

Question 6

Match the lobes of the brain:
Frontal
Temporal
Parietal
Occipital

with the brain functions:
vision
judgment, problem solving, insight
sensory, proprioception
auditory, speech, taste

Answer 6

Frontal: judgment, problem solving, insight
Temporal: auditory, speech, taste
Parietal: sensory, proprioception
Occipital: vision

Question 7

Explain the difference between injury of upper motor neurons (UMN) vs. lower motor neurons (LMN)

Answer 7

UMN lesions: spasticity, hyperreflexia

LMN lesions: weakness, paralysis, areflexia, flaccidity

Question 8

Describe the 5 grades of muscle strength

Answer 8

0 - no contraction
1 - slight contraction
2 - full PROM
3 - full ROM
4 - full ROM against some resistance
5 - full ROM against full resistance

Question 9

Describe the assessment for the following cranial nerves:
I
II
III, IV, VI
V
VII
VIII
IX
X
XI
XII

Answer 9

I - smell
II - vision
III, IV, VI - pupil response
V - chewing
VII - facial symmetry
VIII - hearing
IX - swallow
X - speech
XI - shoulder shrug
XII - tongue movement

Question 10

What are the classifications and subtypes of stroke

Answer 10

Ischemic stroke - thrombotic and embolic

Hemorrhagic stroke - intracerebral or subarachnoid

Question 11

What is the best treatment for hemorrhagic stroke?

Answer 11

evacuate the hematoma if possible, to limit injury and damage
in subarachnoid hemorrhage, vasospasm is controlled with nimodipine (calcium channel blocker)

Question 12

What is the best treatment for ischemic stroke?

Answer 12

tPA if given within 3 hours of stroke symptom onset

Question 13

What medications are given for prophylaxis and treatment of ischemic stroke?

Answer 13

Aspirin
Clopidogrel (Plavix)
Aspirin-dipyridamole (Aggrenox)
Warfarin - reserved for patient at risk for thromboembolic strokes due to AFib, coagulation disorders, or other cardiogenic sources

Question 14

What nursing interventions should be started to treat ICP that occurs with occlusion of cerebral arteries?

Answer 14

treat hypoxia, hypercarbia and hyperthermia
elevate HOB to 30 degrees to promote drainage
osmotic diuretics

Question 15

What parameters for blood glucose and BP should be monitored before starting treatment?

Answer 15

BP: do not treat unless DBP > 120 or SBP > 220
BG: treat hyperglycemia with IV insulin when > 200 mg/dL

Question 16

What is the pneumonic for the cranial nerves - names and functions?

Answer 16

Names: Oh, Oh, Oh, To Touch And Feel Very Green Vegetables - AH!
Some Say Marry Money But My Brother Says Big Brains Matter Most

Question 17

What are 4 indications for neurological assessment?

Answer 17

1) on admission
2) after surgery
3) after medical interventions
4) changes in patient status and condition

Question 18

Which part of the GCS includes pupillary response?

Answer 18

Eye opening

Question 19

What are the 5 levels of consciousness?

Answer 19

“FLOSC”
Full - alert, attentive, and follows commands
Lethargy: drowsy but awakens, answers questions and follows commands, does slowly and inattentively
Obtunded: difficult to rouse and needs constant stimulation to follow a simple command; may respond verbally with 1-2 words but will drift back to sleep between stimulation
Stupor: patient rouses to vigorous and continuous stimulation; usually painful stimulus is required; may moan briefly but does not follow commands
Coma: patient does not respond to continuous or painful stimuli; does not move except possibly reflexively; does not make any verbal sounds

Question 20

What is the sequence of neurological deterioration?

Answer 20

1) Loss of consciousness - orientation is lost first –> patient becomes difficult to rouse, needs increased stimulation
2) Changes in motor function: strong –> moderate
3) pupillary changes
- pupils become unequal and reaction changes from brisk to sluggish to fixed and dilated
4) vital signs - Cushing’s triad