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NUR 254 ( LATEST 2024 / 2025 ) TEST 2 | ALL Q&AS BRAND NEW GUARANTEED A++
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NUR 254 ( LATEST 2024 / 2025 ) TEST 2 | ALL Q&AS BRAND NEW GUARANTEED A++
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NUR 254 TEST 21. Overall, as intracranial pressure increases LOC ?
Answer
Decreases
2. What assessment finding are specific to the diagnosis of Guillain-Barre Syndrome?
Answer
Mediated by an immune respinse with acute lower extremity weakness with areflexia or
diminished reflexes. An infection usually preceeds the development of GBS by about a month.
Nerve damage results in numbness/tingling, muscle weakness, paralysis, pot, respiratory comp.
3. Abnormal oculomotor eye movement where eyes follow head movement when the head is
turned side to side, producing a persistent forward gaze is know as what reflex?
Answer
"Dolls eyes" decribes the test for the oculocephalic reflex. Assesses brainstem function in a
comatose or severely lethargic patient. Normal=eyes move in the same direction the head is
moved
Abnormal=eyes gaze/fixed without any eyemovement. cant do this with cervical spine injuries
4. Abnormal posturing demonstrated with damage to the cerebrum and or midbrain. Legs are
rotated inward & upper extremities flexed?
Answer
Decorticate (flexor) poaitioinign the body moves in towarn the core.
5. How would the nurse "grade" muscle strength for a client who has full ROM against gravity,
but not full resistance?
Answer
3 out of 5
Moderate weakness, full ROM against gravity, but not resistance
, 6. A patient paralyzed from the neck down is said to have ?
Answer
Quadraplegia or tetraplegia
7. A patient with paralysis from the waist down would be documented as
?
Answer
Paraplegic
8. After performing iced calorics, what eye finding indicated brain death?
Answer
No response/No nystagmus
9. Abnormal posturing with damage to midbrain/brainstem where head is arched, legs and feed
are extended and arms extended?
Answer
Decerebrate
when a pt has problems with their midbrain or pons, pts may display decerebrate (extension),
where the arms are like E's and the legs and arms are extended
10. A pt with spinal cord injury <8hrs ago, presents with hypotension, brady- cardia, and
absent reflexes and flaccid paralysis below the level of injury. What complication is this indicative
of?
Answer
Spinal shock
11. How is cerebral perfusion pressure calculated? What is the normal value?-
Answer
MAP - ICP = CPP
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