NUR2115 Exam 3 Questions With Complete Solutions
0 on strength scale Correct Answers Total paralysis
1 on strength scale Correct Answers Palpable/visible
contraction (muscle flicker) but without movement
2 on strength scale Correct Answers Active movement but not
against gravity
3 on strength scale Correct Answers Active movement against
gravity
300-350 mOsmL Correct Answers Target serum osmolality
post TBI. Reduces cerebral edema by pulling fluid from CSF
into vascular space.
4 on strength scale Correct Answers Active movement against
some resistance
5 on strength scale Correct Answers Active movement against
full resistance
ABCDE Correct Answers Airway
Breathing
Circulation
Disability (neuro)
Exposure/Environment
Abnormal oculocephalic reflex Correct Answers Patient's eyes
move to same side when head is turned
,Absent oculocephalic reflex Correct Answers Eyes remain
fixed when head is turned. Shows significant brain stem injury
Acoustic neuroma Correct Answers Tumor on the auditory
meatus that is slow growing and causes loss of hearing, tinnitus,
vertigo, staggering gate and needs to be treated surgically.
Activities to avoid Correct Answers PEEP >20, Coughing,
Suctioning, Valsalva maneuver
Alert Correct Answers Patient responds to gently calling name
Angiomas Correct Answers Abnormal blood vessels on the
surface of the brain that increases risk for CVA
Anterior cord syndrome causes Correct Answers Include
injury to anterior spinal artery, disc herniation, hyperflexion
injuries with dislocation or fractures.
Anterior cord syndrome characteristics Correct Answers -Loss
of pain, temperature, and motor function below level of injury
-Preserved function of light touch, position sense, and vibration
Anxiety control Correct Answers Give TBI Benzodiazepines
such as Ativan or Versed
Arousal Correct Answers Evaluates lowest level of
consciousness
, ASIA grade A Correct Answers Complete injury. No
preservation of function below level of injury. No sacral sparing.
ASIA grade B Correct Answers Incomplete injury. Sensory
but not motor function preserved below neurological level and
includes sacral segments.
ASIA grade C Correct Answers Incomplete injury. Motor
function is preserved below the neurological level and more than
half of key muscles below the neurological level have a muscle
grade less than 3.
ASIA grade D Correct Answers Incomplete injury. Motor
function is preserved below the neurological level and at least
half of key muscles below the neurological level have a muscle
grade of 3 or more.
ASIA grade E Correct Answers Normal. Motor and sensory
function are normal.
Aterial-venous malformation Correct Answers Tangle of
arteries/veins in the brain
Autonomic dysreflexia Correct Answers A life-threatening
complication that occurs due to a massive sympathetic response
to a stimulus of the sympathetic system.
Autonomic dysreflexia nursing management Correct Answers
-HOB at 90 degrees to take advantage of orthostatic hypotension
-Search for cause/treat (like immediate catheterization)
-Administer BP med
0 on strength scale Correct Answers Total paralysis
1 on strength scale Correct Answers Palpable/visible
contraction (muscle flicker) but without movement
2 on strength scale Correct Answers Active movement but not
against gravity
3 on strength scale Correct Answers Active movement against
gravity
300-350 mOsmL Correct Answers Target serum osmolality
post TBI. Reduces cerebral edema by pulling fluid from CSF
into vascular space.
4 on strength scale Correct Answers Active movement against
some resistance
5 on strength scale Correct Answers Active movement against
full resistance
ABCDE Correct Answers Airway
Breathing
Circulation
Disability (neuro)
Exposure/Environment
Abnormal oculocephalic reflex Correct Answers Patient's eyes
move to same side when head is turned
,Absent oculocephalic reflex Correct Answers Eyes remain
fixed when head is turned. Shows significant brain stem injury
Acoustic neuroma Correct Answers Tumor on the auditory
meatus that is slow growing and causes loss of hearing, tinnitus,
vertigo, staggering gate and needs to be treated surgically.
Activities to avoid Correct Answers PEEP >20, Coughing,
Suctioning, Valsalva maneuver
Alert Correct Answers Patient responds to gently calling name
Angiomas Correct Answers Abnormal blood vessels on the
surface of the brain that increases risk for CVA
Anterior cord syndrome causes Correct Answers Include
injury to anterior spinal artery, disc herniation, hyperflexion
injuries with dislocation or fractures.
Anterior cord syndrome characteristics Correct Answers -Loss
of pain, temperature, and motor function below level of injury
-Preserved function of light touch, position sense, and vibration
Anxiety control Correct Answers Give TBI Benzodiazepines
such as Ativan or Versed
Arousal Correct Answers Evaluates lowest level of
consciousness
, ASIA grade A Correct Answers Complete injury. No
preservation of function below level of injury. No sacral sparing.
ASIA grade B Correct Answers Incomplete injury. Sensory
but not motor function preserved below neurological level and
includes sacral segments.
ASIA grade C Correct Answers Incomplete injury. Motor
function is preserved below the neurological level and more than
half of key muscles below the neurological level have a muscle
grade less than 3.
ASIA grade D Correct Answers Incomplete injury. Motor
function is preserved below the neurological level and at least
half of key muscles below the neurological level have a muscle
grade of 3 or more.
ASIA grade E Correct Answers Normal. Motor and sensory
function are normal.
Aterial-venous malformation Correct Answers Tangle of
arteries/veins in the brain
Autonomic dysreflexia Correct Answers A life-threatening
complication that occurs due to a massive sympathetic response
to a stimulus of the sympathetic system.
Autonomic dysreflexia nursing management Correct Answers
-HOB at 90 degrees to take advantage of orthostatic hypotension
-Search for cause/treat (like immediate catheterization)
-Administer BP med
