Test 3 - Extra Focus

Question 1

MAP Equation

Answer 1

[(2 x diastolic) + systolic] / 3 = MAP

Question 2

CPP Normal

Answer 2

60 - 80

Question 3

CPP Equation

Answer 3

MAP - ICP = CPP

Question 4

Sodium max level

Answer 4

160

Question 5

ABG CO2

Answer 5

35 - 38

Question 6

End Tidal CO2

Answer 6

30 - 35

Question 7

Thrombolytic Exclusion Labs

Answer 7

• Plt <100,000
• INR >1.7
• High PTT

Question 8

ALT

Answer 8

10 - 130

Question 9

AST

Answer 9

10 - 34

Question 10

Autonomic Dysreflexia: S/S

Answer 10

• HA, flushing, warmth
• HTN
• Bradycardia
• Anxiety
• Skin cool below LOI

Question 11

Autonomic Dysreflexia: Interventions

Answer 11

• Elevate HOB
• Remove stimulus
• V/S checks q2-5 minutes
• IV meds (if BP remains elevated)

Question 12

Vasospasm: Nursing Responsibilities

Answer 12

-Monitor for S/S (LOC changes -> assess with GCS)
     Day 4-14 post op
-Transcranial doppler
-Hemodynamic augmentation
     Vasopressors (Dopamine and Nor-Epi)

Question 13

Basilar Skull Fracture: S/S

Answer 13

• CSF leak
• Facial Palsy
• Facial numbness
• Deafness
• Hemotympanum
• Battle’s Sign
• Raccoon Sign
• Nystagmus

Question 14

Basilar Skull Fracture: Nursing Care

Answer 14

• Assess vision, smell, hearing
• Nothing in the nose
• HOB 30 degrees
• Avoid strain/cough/sneeze
• Watch for meningitis s/s
• Administer abx

Surgery needed is CSF leak >1 week

Question 15

Basilar Artery Syndrome

Answer 15

Affects the brainstem; 95% fatality

S/S:

• Dizziness
• Ataxia
• Tinnitus
• Nausea/Vomiting
• One sided weakness

Testing: pt. touch nose, touch RN finger, repeat

Question 16

Possible Activity with Injury to: C4 and higher

Answer 16

None

Question 17

Possible Activity with Injury to: C5

Answer 17

May be able to feed/dress self with assistive devices

Question 18

Possible Activity with Injury to: C6 - C8

Answer 18

Specialized motorized wheelchair and/or car use possible

Question 19

Possible Activity with Injury to: T1 - T10

Answer 19

Independent self-care, manual wheelchair

Question 20

Possible Activity with Injury to: T11 - L5

Answer 20

Can walk short distances with braces

Question 21

Possible Activity with Injury to: S1 - S5

Answer 21

Free roaming - may use braces

Question 22

Motor Assessment: C4 and C5

Answer 22

Shrug shoulders

Question 23

Motor Assessment: C5 and C6

Answer 23

Pull up arms

Question 24

Motor Assessment: C8

Answer 24

Form a fist, grab an object

Question 25

Motor Assessment: L5

Answer 25

Apply resistance with dorsiflexion of feet

Question 26

Brain Tumor: S/S

Answer 26

• Headache (worse in the am)
• Vomiting
• Personality changes
• Aphasia (loss of speech/language comprehension)
• Ataxia (impaired coordination)

Question 27

Increased ICP: S/S

Answer 27

• LOC change
• Pupil changes (ipsilateral; bilateral is worsened)
• Papilledema
• Motor changes
• HA
• Projectile vomiting
• Cushing’s Triad

Question 28

GCS: Motor

Answer 28

6 - Obeys commands
5 - Moves to localized pain
4 - Flexion withdrawal from pain
3 - Abnormal flexion (decorticate)
2 - Abnormal extension (decerebrate)
1 - No response

Question 29

GCS: Eye Opening

Answer 29

4 - Spontaneous
3 - To speech
2 - To pain
1 - No response

Question 30

GCS: Verbal Response

Answer 30

5 - Oriented to time, place, and person
4 - Confused
3 - Inappropriate words
2 - Incomprehensible sounds 
1 - No response