Study your flashcards anywhere!

Download the official Cram app for free >

  • Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/60

Click to flip

60 Cards in this Set

  • Front
  • Back
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.
_________ refers to the brain’s ability to change the diameter of blood vessels to maintain cerebral blood flow
autoregulation
______ ______ 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
Monro-Kellie
compensation to maintain a normal ICP of 10 - 20 mm Hg is normally accomplished by shifting or displacing ____.
CSF
when brain tissues shift through the dura it causes _______
herniation
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.
what is the formula for CPP? what is the normal level?
CPP = MAP - ICP
normal level 70-100
CPP is closely linked to a) ICP, b) MAP, c) BP
a) ICP
a CPP < 50 results in a) reversible or B) permanent neurological damage
permanent
EARLY manifestations of IICP:
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
LATE manifestions of IICP
RESPIRATORY AND VASOMOTOR CHANGES
LATE manifestions of IICP : VITAL SIGNS
increase in SBP, widening pulse pressure, increase in temp, decrease in respirations and HR
what are the sx of cushing's triad?
CUSHING'S TRIAD: bradycardia, bradypnea, hypertension
other LATE manifestations of IICP:
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
what are the "brainstem reflexes"?
pupil, gag, swallowing, corneal
this location is where the transducer is calibrated for ICP monitoring (ventriculostomy)
formen of Monro
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
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.
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.
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
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.
A female pt is treated for IICP. It is important for the pt to avoid hypothermia due to which of the following:
A. Shivering in hypothermia can increase ICP
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
ICP is measured in the ______ ventricles.
lateral
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
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.
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
which of the following is the earliest sign of IICP?
A. Headache
B. Vomiting
C. Loss of consciousness
D. Posturing
C. Loss of consciousness
the central nervous system consists of:
the brain and spinal cord
the peripheral nervous system consists of ____ nerves and _____ nerves.
peripheral and cranial
The autonomic nervous system includes the ______ and ________.
sympathetic (adrenergic) and parasympathetic (cholinergic)
tentorium
extension of the dura mater--folds between the occipital lobe and cerebellum
falx cerebri
extension of the dura mater. folds between the two hemishperes
the L and R hemispheres of the brain is connected by:
corpus callosum--responsible for transmission of information from one side of teh brain to the other
the basic functional unit of the nervous system is the _____
neuron
the meninges include 3 layers. what are they called?
dura mater (outermost)
arachnoid
pia mater
what is the main neurotransmitter of the sympathetic nervous system?
norepinephrine
this part of the brain controls fine movement, balance, and position (postural) sense or proprioception (awareness of where each part of the body is).
cerebellum
what are the major functions of the frontal lobe?
abstract thought, memory and concentration, motor speech (Broca's area); others--personality, judgement, affect, and inhibitions
what are the major functions of the temporal lobe?
memory and understanding of sound and language; contains Wernicke's area (auditory receptive area)
what are the major functions of the parietal lobe?
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.
what are the components of the brain? (3)
cerebrum, cerebellum, and brainstem
what are the components of the brainstem?
midbrain, pons, and medulla
what are then functions of the brainstem?
RR, HR, BP, coughing, swallowing, sneezing, vomiting (reflex centers)
this part of the brain coordinates smooth muscle movement , posture, equilibrium, and muscle tone
cerebellum
the _____ is a relay center for sensory impulses and is part of the reticuloactivating system (RAS)
thalamus
the hippocampus is located in which lobe?
temporal lobe
what is the difference between LOC and cognition?
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
this is where CSF is produced, circulates, and is reabsorbed.
ventricles
what are the components of CSF?
Na 135-145
K 3.3
protein 15-45
glucose 60-80
WBCs <5
water
clear, colorless
what is the normal range of protein in CSF?
15-45
what is the normal range of glucose in CSF?
60-80
a lumbar puncture reveals elevated protein and low glucose levels in the CSF. what could this finding indicate?
bacterial meningitis (Isolation!)
a lumbar puncture reveals elevated protein and elevated glucose levels in the CSF. what could this finding indicate?
viral meningitis
the optic nerve is surrounded by CSF. what changes in vision would you expect with IICP?
blurred vision, double vision
which cranial nerves originate in the brainstem?
ALL but CN 1 and 2
The role of the _____ (cortical or subcortical) tract is higher level functioning, reasoning, impulse control, language, emotion, memory, motor/sensory functioning
cortical
The role of the ______ (cortical or subcortical) tract are fine motor movements (cerebellum), balance (cerebellum), coordination (cerebellum), internal regulation (BP, HR, RR)
subcortical
how many cervical, thoracic, lumbar, sacral, and coccygeal vertebrae are there? total?
cervical 7
thoracic 12
lumbar 5
sacral 5
coccygeal 4
total: 33
how many cervical, thoracic, lumbar, sacral, and coccygeal peripheral nerves are there? total?
cervical 8
thoracic 12
lumbar 5
sacral 5
coccygeal 1
total: 31