Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Complex Care > Week 5 THURS > Flashcards

Week 5 THURS Flashcards

adult neuro

1
Q

What is a priority nursing intervention for a pt who is unconscious?

A

maintain pt airway

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

During an active seizure the nurse should?

A

place client on their side, remove dangerous objects, and protect their head

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What intervention should the nurse implement to prevent increases in ICP?

A

Elevate HOB 30 degrees

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is the earliest sign of increased ICP?

A

Change in LOC

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

A client is sitting in a chair and begins having a tonic-clonic seizure. What is the most appropriate nursing response?

A
  • carefully move client to a flat surface and turn them on their side
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

A client has an altered LOC due to blunt force trauma to the head. The nurse should first gauge the clients LOC on the result of what diagnostic tool?

A

Glasgow Coma Scale

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What score indicates severe impairment of neurologic function on the GCS?

A

3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Assessing a clients pupils, what reaction would confirm increasing ICP?

A
  • fixed and dilated
  • unequal response
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

the cranial vault contains three components which are……

A
  • blood 10-12%
  • CSF 8-10%
  • brain tissue 80%
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

T or F CSF is the most easily displaced fluid in the cranial vault

A

TRUE!

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

The pressure that soft contents of cranial vault against the rigid cranial bones

A

Intracranial pressure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is normal Intracranial pressure?

A

0-15mm HG
- anything above 20 for five minutes or more needs to be treated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

2 Factors that impact neurological status

A
  • intracranial pressure
  • cerebral perfusion pressure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

the amount of pressure required to provide blood flow to the brain

A

cerebral perfusion pressure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

MAP-ICP=?

A

CPP> cerebral perfusion pressure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Normal adult range for CPP?

A

70-100

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

If any one component increases, 1 or 2 of the other components need to decrease— failure to maintain balance (greater than 100% or less than 100%) = higher ICP or lower ICP

A

Monroe Kellie hypothesis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Increased intracranial pressure has 3 factors that are increased

A
  1. increased brain volume
  2. increased cerebral blood volume
  3. increased CSF
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What happens if CPP falls too low?

A

the brain and brian tissue are not perfused

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

ICP= 30, BP=120/80, MAP= 93
what is the CPP?

A

120+2(80)/3
CPP=93-30= 57

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

If ICP is HIGH then CPP is LOW
and if MAP is LOW then CPP is LOW .Tor F

A

True!
this is the rule of thumb for relationships

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Interventions for low CPP

A

Raise HOB, Head alignment, limit stimulation, Mannitol(osmotic diuretic), fluid restriction, avoid any vasopressors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Interventions for high CPP

A

Fluid Bolus, vasopressors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

HIGH CBV and CBF s/s

A

High systemic BP, avoid systemic acifosis, high metabolic rate (fever, pain), high cerebral edema

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

LOW CBV and CBF s/s

A

Hypotension, systemic alkalosis, cerebral edema, low CO, cerebral vasoconstriction, low metabolic rate (sedation, hypothermia, paralysis)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Early S/S of HIGH ICP

A

HA, visual disturbances, N/V - Seizures, decreased LOC
Dizziness, small change in VS - posturing, fixed/ dilated pupils
Changes in PERRLA> sluggish - Cushing Triad:
restlesness/ irritability - decorticate/ decerebrate posturing
Vomiting w/out nausea
Peds: sunset eye, bulging fontanels
Wide suture lines, high pitched cry

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Late S/S of HIGH ICP

A

Seizures, decreased LOC
posturing, fixed/ dilated pupils
Cushing Triad:
decorticate/ decerebrate posturing

28
Q

A decrease in ADH leads to increase urine out put and polyuria, polydipsia, etc describes what complication of IICP

A
  • neurogenic diabetes insipidus
    “dry inside”
  • can’t keep enough fluid in body before it is flushed out
29
Q

too much ADH prevents production of urine and leads to retention of excess water in the body describes what complication of IICP

A

Syndrome of inappropriate antidiuretic hormone
“ soaked inside”
- can’t urinate> fluid volume overload

30
Q

Inadequate cerebral perfusion can lead to …..

A

Ischemia> brain tissue dies

31
Q

1 sign of increased ICP is….

A

Decreased LOC

32
Q

assessment of cerebral perfusion (neuro) includes

A
  • LOC
  • pupillary reaction
  • Vital signs
  • Cranial nerve reflexes
  • ICP monitoring
  • observation of pt
33
Q

Glasgow coma scale

A
  • scale to assess LOC
  • measures eyes, motor, and speech
  • < 8, intubate
34
Q

factors that influence changes in LOC

A
  • cerebral blood flow
  • decreased cerebral perfusion pressure
  • increased intracranial pressure
35
Q

Fixed and dilated pupils means…

A

severe ischemia
- calling code if you see this

36
Q

Unequal pupils means…

A
  • lesion or herniation
  • make sure to know pts baseline prior
37
Q

Pinpoint pupils mean…

A
  • lesion or pt just took opioids
  • lots of pain meds cause pinpoint pupils
38
Q

Any trauma to scalp, skull or brain caused by an external physical force

A

Traumatic Brain injury(TBI)

39
Q

What are the 3 points in time when death from a head injury may occur

A
  • immediately: primary injury
  • several hours after primary injury: secondary injury
  • about 3 weeks after injury> multi system failure
40
Q

Classifications of TBI

A
  • focal> localized
  • diffuse> generalized
41
Q

Bruising of the brain tissue caused by blunt force trauma, falls, mva, penetrating wounds

A

contusion

42
Q

The Meninges> layer of skin

A

Dura matter, arachnoid matter, pia mater> PAD(brain to skull)

43
Q

Injury causes bleeding thats collected between the dura mater and inner aspect of the skull

A

epidural hematoma
- above dura!

44
Q

Blood between the dura and arachnoid layers. bleeding from bridging veins that connect the cerebral venous sinuses to the superficial veins of the skul

A

Subdural hematoma
- acute, subacute, and chronic

45
Q

Medical management for hematomas

A
  • surgical evacuations> burr holes, craniotomy, ICP monitor placement
  • frequent neuro checks
  • proper head position; HOB > 30 degrees
46
Q

Diffuse brain injuries

A
  • concussion and diffuse axonal injury
47
Q

sudden, temporary, mechanical injury with disruption of neutral activity and change in LOC
- blow to the head, neck, face

A

concussions

48
Q

1 goal in immediate care for pts with TBI

A
  • prevent further injury!
49
Q

Widespread damage to axons in white matter of cerebral hemispheres, basal ganglia, thalamus, and brainstem
- shearing forces may disrupt the structure of neurons and blood vessels

A

Diffuse axonal injury
- sympoms appear 12-24 hrs after injury

50
Q

A temporary(transient) episode of neurological dysfunction
- treat as a medical emergency!

A

Transient Ischemic Attack (TIA)

51
Q

What should you assess when a pt has a tbi or head trauma

A
  • LOC
  • presence of carotid bruit
  • palpate carotid artery
  • check if jugular is distened
  • health hx
  • ct scan
  • ekg
  • cerebral carotid angiogram
52
Q

Nonmodifiable risks for TIA and stroke

A
  • age
  • gender
  • race/ethnicity
  • heredity
53
Q

Modifiable risk for TIA and stroke

A
  • HTN
  • alcohol
  • smoking
  • obesity
  • oral contraceptives
  • cardiac disease
  • cardiac stenosis
  • cocaine use
  • sleep apnea
54
Q

An acute neurologic deficit that occurs when impaired blood flow to localized area of the brain results in injury to the brain tissues

A

Stroke

55
Q

Ischemic stroke

A
  • blood clot causes stroke
  • blood supply to part of the brain is suddenly interupted
56
Q

hemorrhagic stroke

A
  • occurs when there is a bleeing into the brain tissue or cranial vault
57
Q

Causes of stroke in adults

A
  • HTN
  • SMOKING
  • Alcohol
  • A fib
  • blood vessel abnormalities
  • high cholesterol levels
58
Q

Warning signs of a stroke

A

BEFAST
- balance
- eyes
- face
- arms
- speech
- time to call 911

59
Q

Medical management for an ischemic stroke

A
  • tPA> clot buster
  • heparin
  • mechanical thrombectomy
60
Q

What should you avoid giving to a pt with an ischemic stroke

A
  • avoid giving glucose-containing IV fluids> stroke may convert to hemorrhagic w/ glucose
61
Q

Medical management for a hemorrhagic stroke

A
  • coiling/ stenting/ clipping
  • craniotomy/ burr hole
  • reverse clotting factors
62
Q

Blood in space between the brain and the arachnoid membrane

A

subarachnoid hemorrhage

63
Q

The consequences of a ruptured aneurysm

A
  • blood into subarachnoid space
  • inflammatory response cause IICP
64
Q

T or F tPA should be given to a patient with a hemorrhagic stroke

A

FALSE!!
- tPA should never be given! Can increase bleeding

65
Q
A

Complex Care (26 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions