FCCN 2 ACTUAL EXAMS SCRIPT QUESTIONS AND
ANSWERS SURE A+
✔✔HHNS - ✔✔hyperglycemia in Type 2 which is really just dehydration
✔✔cerebral perfusion pressure - ✔✔MAP-ICP
adult normal 50-100
✔✔ICP - ✔✔0-15 mmHg
✔✔early signs of increased ICP - ✔✔-AMS
-headache
-vomiting
-papilloedema
-seizures
-focal neuro signs
✔✔late signs of increased ICP - ✔✔-stupor, coma
-changes in pupil size or reaction
-seizures
-hemiplegia, paralysis
-cushing's triad (decrease HR, widening pulse pressure, respiratory irregularities)
✔✔interventions to decrease ICP - ✔✔-semi fowlers
-control bp
-quiet room
-osmotic diuretics
-hypertonic saline
-corticosteroids
-anticonvulsants
, -antihypertensives
-analgesics
-sedatives
-surgery (mass removal, bone flap removal, burr holes, EVD)
✔✔ICP nursing management - ✔✔-don't cluster cares
-neuro assessments
-facilitate venous return to heart
-neck positioning
-I&Os
-bowel care
-reduce environmental stimuli
-monitor fluid/lytes
-reduce metabolic needs, cool them off
✔✔things that increase ICP - ✔✔-PEEP
-agitation/stimulation
-suctioning
✔✔things that decrease ICP - ✔✔-mannitol
-hypothermia
-quiet room
-good body alignment/posturing
-CSF draining
✔✔decorticate posturing - ✔✔characterized by upper extremities flexed at the elbows
and held closely to the body and lower extremities that are externally rotated and
extended. occurs when the brainstem is not inhibited by the motor function of the
cerebral cortex
✔✔deceribrate posturing - ✔✔WORSE!! arms and legs extended. ominous sign of
cerebral hemispheric or brain stem injury
✔✔ischemic stroke - ✔✔a type of stroke that occurs when the flow of blood to the brain
is blocked, by thrombus or embolus
✔✔hemorrhagic stroke - ✔✔occurs when a blood vessel in the brain leaks or ruptures
aneurysm or vessel rupture or hypertensive crisis
✔✔stroke interventions - ✔✔-assess/monitor ABCs
-call stroke team
-monitor sats
-obtain CT/MRI
-position head in midline
ANSWERS SURE A+
✔✔HHNS - ✔✔hyperglycemia in Type 2 which is really just dehydration
✔✔cerebral perfusion pressure - ✔✔MAP-ICP
adult normal 50-100
✔✔ICP - ✔✔0-15 mmHg
✔✔early signs of increased ICP - ✔✔-AMS
-headache
-vomiting
-papilloedema
-seizures
-focal neuro signs
✔✔late signs of increased ICP - ✔✔-stupor, coma
-changes in pupil size or reaction
-seizures
-hemiplegia, paralysis
-cushing's triad (decrease HR, widening pulse pressure, respiratory irregularities)
✔✔interventions to decrease ICP - ✔✔-semi fowlers
-control bp
-quiet room
-osmotic diuretics
-hypertonic saline
-corticosteroids
-anticonvulsants
, -antihypertensives
-analgesics
-sedatives
-surgery (mass removal, bone flap removal, burr holes, EVD)
✔✔ICP nursing management - ✔✔-don't cluster cares
-neuro assessments
-facilitate venous return to heart
-neck positioning
-I&Os
-bowel care
-reduce environmental stimuli
-monitor fluid/lytes
-reduce metabolic needs, cool them off
✔✔things that increase ICP - ✔✔-PEEP
-agitation/stimulation
-suctioning
✔✔things that decrease ICP - ✔✔-mannitol
-hypothermia
-quiet room
-good body alignment/posturing
-CSF draining
✔✔decorticate posturing - ✔✔characterized by upper extremities flexed at the elbows
and held closely to the body and lower extremities that are externally rotated and
extended. occurs when the brainstem is not inhibited by the motor function of the
cerebral cortex
✔✔deceribrate posturing - ✔✔WORSE!! arms and legs extended. ominous sign of
cerebral hemispheric or brain stem injury
✔✔ischemic stroke - ✔✔a type of stroke that occurs when the flow of blood to the brain
is blocked, by thrombus or embolus
✔✔hemorrhagic stroke - ✔✔occurs when a blood vessel in the brain leaks or ruptures
aneurysm or vessel rupture or hypertensive crisis
✔✔stroke interventions - ✔✔-assess/monitor ABCs
-call stroke team
-monitor sats
-obtain CT/MRI
-position head in midline
