Nur 265 Exam 3 Review Neuro & Shock Management Notes With
Complete Solutions Latest Update 2026/2027
UNIT 7 : Neuro
Increased Intracranial Pressure (ICP) Vital Sign Changes:
BP - HR – Widened Pulse Pressure
Normal ICP Range = 10 – 15 mmHg Abnormal Posturing (D’s)
Cushing Triad = EMERGENCY!
Earliest Indication of Increase ICP = Change in LOC
Positioning :
Signs of Increased ICP = Headache, Vomiting & Altered LOC
o Mid-line – Neutral Position
o HOB 30 -45
o Avoid Flexion
Monitor : Nasal or Ear Drainage Leaking CSF (Positive Glucose + Halo Sign)
Treatment & Interventions :
o Medications
Mannitol – Hypertonic Fluids – Furosemide
o Interventions
Oxygen (<95%)
No cluster care – avoid overstimulating patient
Keep patient warm & control fevers shivering will increase ICP TBI is at risk
for developing
Traumatic Brain Injury (TBI)
Basilar (Open) Skull Fracture :
Assessment Headache with Mild TBI = Take Tylenol
o Raccoon Eyes
o Battle’s Sign (behind ears)
o Ecchymosis (Bruising)
o Increased Risk for
Bleeding/Hemorrhage
Mild TBI aka “Concussion” :
Symptoms
o Temporary Confusion
o Headache
o Dizzy
o Nausea & Vomiting
o Visual Changes
o Sleeping Problems
, Risk Factors for TBI : ormalities o
Pla Hypotension o
yin Change in GCS score
g
con
tac
t
spo
rt –
foo
tba
ll
Old
er
Ad
ults
wit
h
fre
qu
ent
fall
s
Treatment & Interventions :
o Mannitol – Hypertonic Fluids –
Lasix
o Report GCS change of 2 or more
o Spine Precautions – NO Flexion
o Suctioning – Oxygen before & after
o Seizure Precautions
Critical Findings = Respiratory
Insufficiency & Poor Cerebral
Perfusion
o Decreased LOC
o Changes in breathing patterns
oP
u
p
i
l
a
b
n
Complete Solutions Latest Update 2026/2027
UNIT 7 : Neuro
Increased Intracranial Pressure (ICP) Vital Sign Changes:
BP - HR – Widened Pulse Pressure
Normal ICP Range = 10 – 15 mmHg Abnormal Posturing (D’s)
Cushing Triad = EMERGENCY!
Earliest Indication of Increase ICP = Change in LOC
Positioning :
Signs of Increased ICP = Headache, Vomiting & Altered LOC
o Mid-line – Neutral Position
o HOB 30 -45
o Avoid Flexion
Monitor : Nasal or Ear Drainage Leaking CSF (Positive Glucose + Halo Sign)
Treatment & Interventions :
o Medications
Mannitol – Hypertonic Fluids – Furosemide
o Interventions
Oxygen (<95%)
No cluster care – avoid overstimulating patient
Keep patient warm & control fevers shivering will increase ICP TBI is at risk
for developing
Traumatic Brain Injury (TBI)
Basilar (Open) Skull Fracture :
Assessment Headache with Mild TBI = Take Tylenol
o Raccoon Eyes
o Battle’s Sign (behind ears)
o Ecchymosis (Bruising)
o Increased Risk for
Bleeding/Hemorrhage
Mild TBI aka “Concussion” :
Symptoms
o Temporary Confusion
o Headache
o Dizzy
o Nausea & Vomiting
o Visual Changes
o Sleeping Problems
, Risk Factors for TBI : ormalities o
Pla Hypotension o
yin Change in GCS score
g
con
tac
t
spo
rt –
foo
tba
ll
Old
er
Ad
ults
wit
h
fre
qu
ent
fall
s
Treatment & Interventions :
o Mannitol – Hypertonic Fluids –
Lasix
o Report GCS change of 2 or more
o Spine Precautions – NO Flexion
o Suctioning – Oxygen before & after
o Seizure Precautions
Critical Findings = Respiratory
Insufficiency & Poor Cerebral
Perfusion
o Decreased LOC
o Changes in breathing patterns
oP
u
p
i
l
a
b
n
