NUR 333 Assessment-Vocabulary

Question 1

BE FAST

Answer 1

To determine if patient had a stroke

• Balance Difficulties
• Eyesight Changes
• Face Weakness
• Arm Weakness
• Speech Difficulties
• Time, Call 911!

Question 2

GCS

Answer 2

Glascow Coma Scale
• Objective assessment that defines the 
LOC by giving it a numeric value
• Eye opening, Motor response, Verbal 
response
• Possible score 3-15 (15 is Normal; 
Totally unresponsive = 3; a rock is a 3)
• ≤ 7-9 = Comatose
• Every brain injury is different, but 
generally, brain injury is classified as:
• Severe: GCS 8 or less
• Moderate: GCS 9-12
• Mild: GCS 13-15

Question 3

Seizure Precautions

Answer 3

• Safety is key
• Protect airway
• Pad bed rails
• Oxygen set up in room
• Suction set up in room

Question 4

CT Scan

Answer 4

Uses x-rays to produce 3 
dimensional images of organs, 
bones & tissues
Aids in determining what part of 
brain is affected
Quickly detects hemorrhage, 
bone or vascular abnormalities, 
tumors, cysts
With or without IV contrast dye

NURSING CONSIDERATIONS
• Informed consent if using contrast
• Must assess for allergies of iodine* 
• Check diet orders
• Pt. claustrophobic?
• If contrast is administered- force fluids, 
monitor for allergic reaction & monitor 
kidney function

Question 5

Expressive Aphasia

Answer 5

• Inability to name common objects or express simple ideas in words or writing
• For example, the patient understands your question but cannot express an answer
(MOTOR TYPE)

Question 6

MRI

Answer 6

• Uses computer generated radio waves & 
powerful magnetic field to produce 
detailed images
• Computer creates a 3-dimensional image 
from 2-dimensional slice
• Able to see brain, spinal cord, measure 
blood flow
• Used to dx stroke, tumors, infection, 
injury, epilepsy
• No exposure to radiation, very costly
• Contrast - gadolinium 

NURSING CONSIDERATIONS
• Obtain consent if contrast used
• Must screen for metal
• Remove all metal- glasses, telemetry, jewelry, 
dental work
• Remove all medicated patches
• Body art & permanent cosmetics may cause burns 
in MRI machine
• Loud noises- most places provide headphones and 
music
• Screen for claustrophobia
• Can take up to 90 minutes to complete

Question 7

EEG

Answer 7

Monitor brain’s electrical activity
• Helps diagnose seizures, metabolic 
disorders, inflammation, and infection
• Used to help evaluate sleep disorders
• May be used to confirm brain death
• Series of electrodes attached to skull 
using a special conducting paste
• May complete while sleeping, awake, 
or stimulated

NURSING CONSIDERATIONS
• Educate
• Check to see if HCP has ordered 
to stop sleeping aids, sedatives, 
tranquilizers
• Avoid caffeine for 8 hours
• No oils, creams, conditioner in 
hair for electrode placement 
• Provide support
• Know your patient

Question 8

Obtunded

Answer 8

• Sleeps most of the time
• Difficult to arouse- 
needs loud shout or 
vigorous shake
• Acts confused when 
aroused
• Speech mumbled or 
incoherent
• Requires constant 
stimulation to stay 
awake

Question 9

Stupor/Semi comatose

Answer 9

• Spontaneously 
unconscious
• Responds only to 
vigorous shake or pain- 
has appropriate 
response 
• Groans, mumbles

Question 10

Comatose

Answer 10

Completely unconscious.• No meaningful 
response to stimuli
• Light coma- no 
purposeful movement, 
some reflex activity
• Deep coma- no motor 
response