NR 341 Exam Questions With Correct
Answers
What is the max GCS score? - answer15
What is the minimum GCS score? - answer3
What GCS score should you intubate? - answer8 and under
What are the limitations of the GCS? - answerage, drugs, and language
What is normal intracranial pressure (ICP)? -...
What GCS score should you intubate? - answer✔8 and under
What are the limitations of the GCS? - answer✔age, drugs, and language
What is normal intracranial pressure (ICP)? - answer✔5-15 mmHg
What are the signs and symptoms of increased ICP? - answer✔change in LOC, change in
speech, change in vital signs, seizures, headache, vomiting, eye changes, posture changes
What is the first sign of increased ICP? - answer✔changes in LOC
What is cushing's triad? - answer✔an effect of increased ICP of increased systolic BP,
decreased pulse, and cheyne-stokes respirations
What is Cheyne-Stokes respiration? - answer✔it is an abnormal rhythm of breathing with
alternation periods of hyperventilation and apnea
What is Kussmaul respiration? - answer✔deep, rapid breathing often induced by acidosis
What condition does Kussmaul respirations commonly occur with? - answer✔DKA
What posture changes occurs with increased ICP? - answer✔decerebrate, decorticate,or flaccid
What is decerebrate posturing? - answer✔Extensor response; problem with midbrain or pons
What is decorticate posturing? - answer✔Flexor response; problem with cervical spinal tract or
cerebral hemisphere
What are the eye changes that occur with increased ICP? - answer✔papilledema, pupillary
changes, impaired eye movement
What is a common cause of increased brain volume? - answer✔cerebral edema; can also be
caused by a tumor or meningitis
What causes increased cerebrospinal fluid? - answer✔hydrocephalus, blockage of normal flow,
obstruction of normal re-absorption, and excess production of CSF
What is cerebral perfusion pressure (CPP) dependent upon? - answer✔intracranial pressure
(ICP) and mean arterial pressure (MAP)
What is a normal cerebral perfusion pressure (CPP)? - answer✔50-70
What does a low cerebral perfusion pressure (CPP) result in? - answer✔loss of auto-regulation
and hypoxic insult to brain tissue
Nursing Mgmt. ICP: What is the maintenance goal of ICP? - answer✔ICP < 20 mmHg
Nursing Mgmt. ICP: What is the maintenance goal of CPP? - answer✔< 70 mmHg
Nursing Mgmt. ICP: Care should be ________ to allow rest. - answer✔spaced
Nursing Mgmt. ICP: Suctioning should be _______. - answer✔minimum/PRN
Nursing Mgmt. ICP: What should the HOB be at? - answer✔30-45 degrees (Semi-Fowler's);
keep neck in neutral position
Nursing Mgmt. ICP: Why should hyperthermia be avoided? - answer✔to help reduce metabolic
and oxygen demand
Nursing Mgmt. ICP: How should the patient be kept? - answer✔normovolemic
What is normovolemic? - answer✔normal blood volume
What electrolytes should be monitored with ICP mgmt.? - answer✔sodium --> seizures
What all should be monitored with ICP mgmt.? - answer✔ICP, electrolytes, ABG's vital signs,
daily weights, strict I&O, diabetes insipidus (DI), and SIADH
What tubes should be placed with increased ICP? - answer✔NG tube or orogastric tube
Which tube is preferred with patients who have facial fractures or skull fractures? -
answer✔orogastric tube
Nursing Mgmt. ICP: What forms of management should be given? - answer✔airway, pain and
anxiety (sedate)
Nursing Mgmt. ICP: How should the transducer be kept? - answer✔at level with the drain
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