NURS 331 FINAL Exam Questions With Verified Answers.
2 views 0 purchase
Course
NURS 331
Institution
NURS 331
o any stimulus
Glasgow Coma Scale - answeruses eye opening response, best verbal response, and best motor
response; score ranges from 3-15; score less than 14 is abnormal
Breathing patterns are controlled by - answercerebrum (pattern) and medulla (rate)
When the breathing control center is lost...
NURS 331 FINAL Exam Questions With
Verified Answers.
LOC - answer✔- The most critical clinical index of nervous system function
- Alterations indicates either improvement or deterioration of the individual's condition
- In order to be fully conscious an intact reticular activating system (RAS) is required, along with
the functioning of higher brain centers in the cerebral cortex
A person who is__________________ is considered to function at the highest level of
consciousness - answer✔alert and oriented
Components of Consciousness - answer✔1. Arousal: the state of awakeness of an individual,
mediated by Reticular Activating System (brain stem)
2. Content of thought: encompasses all cognitive functions; awareness of self, environment, &
affective states (mood)
Alterations in Consciousness - answer✔1. Confusion: loss of ability to think rapidly
2. Disorientation: to time, place, and lastly self
3. Lethargy: limited spontaneous movement or speech, will arouse when name is called or
touched
4. Obtunded: falls asleep unless stimulated verbally or tactilely
5. Stupor: vigorous and repeated stimulation needed for arousal
6. Coma: no arousal to any stimulus
Glasgow Coma Scale - answer✔uses eye opening response, best verbal response, and best motor
response; score ranges from 3-15; score less than 14 is abnormal
Breathing patterns are controlled by - answer✔cerebrum (pattern) and medulla (rate)
When the breathing control center is lost with cerebral damage, the _________ regulates the
breathing pattern by responding only to changes in the Pa____ levels. - answer✔lower brain
stem; CO2
Cheyne-Stokes - answer✔respirations cease (apnea) until carbon dioxide builds up to a certain
threshold and causes the individual to hyperventilate until carbon dioxide is removed
With breathing, damage to the brain stem causes - answer✔irregular and unpredictable patterns
of breathing
Opioid affect on breathing - answer✔Opiate overdose affects the respiratory center (medulla
oblongata) and results in a gradual decline in the breathing rate, until respiration ceases
Pupil changes that occur with brain damage - answer✔- Pinpoint pupils seen with opiates
overdose (heroin, morphine),
- Bilaterally fixed and dilated pupils (usually seen with hypoxia).
- Failing pupil response may be the first indication of impending brain herniation
- Mild dilation with sluggish or absent light response is ominous
Doll's eye phenomenon (Oculocephalic reflex) - answer✔1. Normal: eyes move with head
movement (positive)
2. Abnormal: eyes remain fixed in forward position (negative); brain stem is not intact
Cold caloric stimulation (Vestibuloocular reflex) - answer✔- cold water dropped into ear
1. Normal: eyes move symmetrically toward stimulus and pt throws up or gets nauseous
2. Abnormal: eyes are fixed forward, or only one eye moves towards stimulus and pt does not get
nauseous
Purposeful movement requires an intact ___________ system - answer✔corticospinal
Decorticate vs Decerebrate Posturing - answer✔Decorticate: brain stem intact (less severe), loss
of cerebral cortex functioning (internally rotated; hands make C shape at chest)
Decerebrate: may indicate more serious damage and results from disruption of higher brain
centers and the brainstem (externally rotated; hands make e shape by sides)
The balance between what components maintains the ICP - answer✔brain tissue, blood, and CSF
Factors influencing ICP - answer✔1. changes in brain tissue, blood, or CSF
2. changes in pressure (arterial, venous, or intra-abdominal/intrathoracic pressure, vomiting,
coughing, suctioning, seizures)
3. changes in posture, ROM, pain stimuli
4. changes in temperature
5. changes in blood gases (CO2- causes vasodilation which increases blood flow and ICP)
Normal ICP - answer✔Normal is 0-15 mmHg; ICP > 20 mmHg is a poor prognosis
Phases of ICP: Stage 1 - answer✔awake & alert, compensatory mechanisms (vasoconstriction),
ICP may not increase
Phases of ICP: Stage 2 - answer✔confusion, slight pupil and breathing changes, systemic arterial
constriction
Phases of ICP: Stage 4 - answer✔brain tissue shifts (herniates) from the compartment of greater
pressure to a compartment of lesser pressure (no fixing this)
Cushing's Triad (Late signs of ICP) - answer✔1. Systolic hypertension
2. Bradycardia
3. Bradypnea
Your client is admitted with a head injury. He complains of a headache. Can you give him a
narcotic? - answer✔NO narcotics will cause respiratory depression and increase intrancranial
pressure, causing worse injury
Cerebral death - answer✔death of the cerebral hemispheres not including the brain stem and
cerebellum (consciousness is lost); absence of awareness of self and environment and inability to
interact with others but may maintain homeostasis (respirations, CV control, yawning & reflexes
continue)
Brain Death - answer✔Irreversible cessation of function of the entire brain including the
cerebellum & brain stem
Criteria for Brain Death (2 tests 6 hrs apart) - answer✔1. Negative corneal reflex
2. Fixed and dilated pupils
3. Negative doll's eyes/cold caloric stimulation
4. Negative gag reflex
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller sirjoel. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $11.49. You're not tied to anything after your purchase.
