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60 Cards in this Set
- Front
- Back
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The body temperature of an unconscious patient is never taken by which route?
Axillary Mouth Rectal Tympanic |
MOUTH
The body temperature of an unconscious patient is never taken by mouth. Rectal or tympanic (if not contraindicated) temperature measurement is preferred to the less accurate axillary temperature. |
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_________ refers to the brain’s ability to change the diameter of blood vessels to maintain cerebral blood flow
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autoregulation
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______ ______ hypothesis: because of limited space in the skull, an increase in any one of components of the skull—brain tissue, blood, and CSF—will cause a change in the volume of the others
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Monro-Kellie
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compensation to maintain a normal ICP of 10 - 20 mm Hg is normally accomplished by shifting or displacing ____.
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CSF
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when brain tissues shift through the dura it causes _______
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herniation
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Is the following statement True or False?
The earliest sign of increasing ICP is a change in LOC |
True
The earliest sign of increasing ICP is a change in LOC. Slowing of speech and delay in response to verbal suggestions are other early indicators. |
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what is the formula for CPP? what is the normal level?
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CPP = MAP - ICP
normal level 70-100 |
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CPP is closely linked to a) ICP, b) MAP, c) BP
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a) ICP
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a CPP < 50 results in a) reversible or B) permanent neurological damage
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permanent
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EARLY manifestations of IICP:
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changes in LOC, any changes in condition; increasing restlessness, confusion, drowsiness, increased respiratory effort, purposeless movements; weakness in one extremity or one side; HEADACHE--constant, increasing in intensity or aggravated by movement of straining
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LATE manifestions of IICP
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RESPIRATORY AND VASOMOTOR CHANGES
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LATE manifestions of IICP : VITAL SIGNS
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increase in SBP, widening pulse pressure, increase in temp, decrease in respirations and HR
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what are the sx of cushing's triad?
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CUSHING'S TRIAD: bradycardia, bradypnea, hypertension
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other LATE manifestations of IICP:
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projectile vomiting; further deterioration of LOC; stupor to coma; hemiplegia, decorticate, decerebrate, or flaccidity; Cheyne-Stokes respirations; loss of brainstem reflexes--pupil, gag, corneal, and swallowing
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what are the "brainstem reflexes"?
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pupil, gag, swallowing, corneal
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this location is where the transducer is calibrated for ICP monitoring (ventriculostomy)
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formen of Monro
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What is the purpose of burr holes in neurosurgical procedures?
Make a bone flap in the skull. Aspirate a brain abscess. Evacuate a hematoma. All of the above |
all of the above
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which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?
A. Cushing's response B. Monro-Kellie hypothesis C. Herniation D. Autoregulation |
C. Herniation
Monro-Kellie hypothesis is a theory that states that due to limited space for expansion within the skull, an increase in any one of the cranial contents causes a change in the volume of the others. |
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which phase of a migraine HA usually lasts less than an hour?
A. Aura B. Recovery C. Prodrome D. Headache |
A. Aura
Aura occurs in about 20% of patients any may be characterized by focal neurological symptoms. the prodrome phase occurs hours to days before a migraine; the HA phase lasts 4 - 72 hrs. During the post-HA phase, pts may sleep for extended periods. |
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Which of the following should be avoided in patients with IICP?
A. Suctioning B. Minimal environmental stimuli C. Position changes D. Enema |
D. Enema
Enemas should be avoided in pts with IICP. The Valsalva maneuver causes IICP. Suctioning should not last longer than 10 sec. If monitoring reveals that turning the pt raises ICP, rotating beds, turning sheets, and holding the pts head during turning may minimize the stimuli that cause IICP |
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A pt with neurological infection develops cerebral edema from SIADH. Which of the following is an important nursing action for this patient?
A. Restricting fluids and hydration B. Hyperoxygenation before and after tracheal suctioning C. Administering prescribed antipyretics D. Maintaining adequate hydration |
A.
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A female pt is treated for IICP. It is important for the pt to avoid hypothermia due to which of the following:
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A. Shivering in hypothermia can increase ICP
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Cerebral edema peaks at which timeframe post intracranial surgery?
48h 72h 12h 24h |
24 hours--cerebral edema tends to peak 24-36 hrs post surgery
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ICP is measured in the ______ ventricles.
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lateral
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a pt who demonstrates an obtunded LOC exhibits which of the following sx?
a. difficulty following commands, and may be agitated or irritable b. does not respond to stimuli c. sleeps almost constantly but can be aroused and can follow simple commands d. sleeps often and shows slowed speech and thought processes |
C. sleeps almost constantly but can be aroused
An obtunded pt stays awake only with persistent stimuli. rationales: A. describes a confused person B. describes a comatose person D. describes a lethargic person |
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when the nurse observes that a pt has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the pts posturing as:
A. Normal B. Flaccid C. Decerebrate D. Decorticate |
C. Decerebrate
Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate. |
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which of the following types of posturing is exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?
A. Decerebrate B. Flaccid C. Decorticate D. Normal |
C. Decorticate
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which of the following is the earliest sign of IICP?
A. Headache B. Vomiting C. Loss of consciousness D. Posturing |
C. Loss of consciousness
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the central nervous system consists of:
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the brain and spinal cord
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the peripheral nervous system consists of ____ nerves and _____ nerves.
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peripheral and cranial
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The autonomic nervous system includes the ______ and ________.
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sympathetic (adrenergic) and parasympathetic (cholinergic)
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tentorium
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extension of the dura mater--folds between the occipital lobe and cerebellum
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falx cerebri
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extension of the dura mater. folds between the two hemishperes
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the L and R hemispheres of the brain is connected by:
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corpus callosum--responsible for transmission of information from one side of teh brain to the other
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the basic functional unit of the nervous system is the _____
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neuron
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the meninges include 3 layers. what are they called?
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dura mater (outermost)
arachnoid pia mater |
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what is the main neurotransmitter of the sympathetic nervous system?
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norepinephrine
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this part of the brain controls fine movement, balance, and position (postural) sense or proprioception (awareness of where each part of the body is).
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cerebellum
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what are the major functions of the frontal lobe?
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abstract thought, memory and concentration, motor speech (Broca's area); others--personality, judgement, affect, and inhibitions
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what are the major functions of the temporal lobe?
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memory and understanding of sound and language; contains Wernicke's area (auditory receptive area)
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what are the major functions of the parietal lobe?
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interpretation of taste, pain, touch, temperature, and pressure; spatial perception; analyzes sensory information and relays the interpretation of other cortical areas; is essential to a person's awareness of body position in space, size, and shape discrimination, and right-let orientation.
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what are the components of the brain? (3)
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cerebrum, cerebellum, and brainstem
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what are the components of the brainstem?
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midbrain, pons, and medulla
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what are then functions of the brainstem?
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RR, HR, BP, coughing, swallowing, sneezing, vomiting (reflex centers)
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this part of the brain coordinates smooth muscle movement , posture, equilibrium, and muscle tone
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cerebellum
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the _____ is a relay center for sensory impulses and is part of the reticuloactivating system (RAS)
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thalamus
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the hippocampus is located in which lobe?
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temporal lobe
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what is the difference between LOC and cognition?
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LOC is the patient's wakefullness and ability to respond (alert and oriented to time, place, self, situation); cognition is ability to recall-short term to long term memory
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this is where CSF is produced, circulates, and is reabsorbed.
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ventricles
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what are the components of CSF?
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Na 135-145
K 3.3 protein 15-45 glucose 60-80 WBCs <5 water clear, colorless |
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what is the normal range of protein in CSF?
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15-45
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what is the normal range of glucose in CSF?
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60-80
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a lumbar puncture reveals elevated protein and low glucose levels in the CSF. what could this finding indicate?
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bacterial meningitis (Isolation!)
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a lumbar puncture reveals elevated protein and elevated glucose levels in the CSF. what could this finding indicate?
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viral meningitis
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the optic nerve is surrounded by CSF. what changes in vision would you expect with IICP?
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blurred vision, double vision
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which cranial nerves originate in the brainstem?
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ALL but CN 1 and 2
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The role of the _____ (cortical or subcortical) tract is higher level functioning, reasoning, impulse control, language, emotion, memory, motor/sensory functioning
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cortical
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The role of the ______ (cortical or subcortical) tract are fine motor movements (cerebellum), balance (cerebellum), coordination (cerebellum), internal regulation (BP, HR, RR)
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subcortical
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how many cervical, thoracic, lumbar, sacral, and coccygeal vertebrae are there? total?
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cervical 7
thoracic 12 lumbar 5 sacral 5 coccygeal 4 total: 33 |
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how many cervical, thoracic, lumbar, sacral, and coccygeal peripheral nerves are there? total?
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cervical 8
thoracic 12 lumbar 5 sacral 5 coccygeal 1 total: 31 |
