NUR417 Final Exam Actual study with
Questions and correct/verified Answers
S/sx of TBI - ANSWER--Unequal pupils
-Loss of consciousness
-Confusion, disorientation, laps in memory, unusual behavior, coma
-Severe headache
-Nausea and vomiting
-Amnesia
-Seizure activity following head trauma
-Weakness or numbness
-Lack of coordination, particularly on one side of the body
-Inability to wake up or stay awake
-Clear fluid (CSF) leaking from nose or ears
-Speech problems
-Balance problems
-Bruising behind the ears or around the eyes (battle signs) (racoon eyes)
How to assess brain trauma - ANSWER--LOC and GCS score
-Pupils PERRLA?
-Check for CSF leak
-Mechanism of injury?
-Motor function/strength
-Sensory assessment
-Reflexes (babinski may be present in adults with TBI)
-Changes in speech
-Cushings triad
Cushings Triad - ANSWER-three classic signs—bradycardia, hypertension w/ widened pulse pressure, and
bradypnea—seen with pressure on the medulla as a result of brain stem herniation
Glasgow Coma Scale - ANSWER-eye opening (spontaneous, to speech, to pain, or none)
verbal response (oriented x4, confused, inappropriate words, incomprehensible sounds, no response)
motor response (obeys commands, moves to pain, withdrawals from pain, decorticate posturing,
decerebrate posturing, no response)
Max- 15 pts, below 8= coma
,decorticate vs decerebrate posturing - ANSWER-decorticate has abnormal flexion, and decErebrate has
abnormal Extension
Interventions to reduce ICP - ANSWER-Maintain airway and hyperventilate; positioning HOB up to 30
degrees with head midline; avoidance of coughing, straining, and bright lights; minimizing environmental
stimuli; sedate or tx anxiety; maintain BP carefully
Monitor for DI and SIADH, monitor electrolytes
Signs of increased ICP - ANSWER-Hypertension, bradycardia, widening pulse pressures, bradypnea
(cushings triad), changes in LOC, sudden LOC, fixed unilateral pupil dilation, hemiparesis or hemiplegia,
decorticate or decerebrate posturing, severe or persistent headache, vomiting not preceded by nausea
Cerebral perfusion pressure - ANSWER-CPP = MAP - ICP.
CPP is the pressure needed to ensure blood flow to the brain. If CPP = less than 50 there is ischemia and
neuronal death, less than 30 = death
CPP application - ANSWER-Know that levels under 60 are abnormal and indicate the start of brain
perfusion problems.
MAP is managed with fluid administrations and vasopressors
ICP is managed with positioning, IV mannitol, monitoring electrolytes, ventilation, sedation, pain control,
etc
MAP and ICP must be carefully managed together to get CCP to target range and minimize risks to
patient
Spinal shock s/sx - ANSWER-Loss of deep tendon reflexes, loss of sphincter reflexes, loss of sensation,
flaccid paralysis below the level of injury, bowel and bladder dysfunction (atonic bladder/bowel and
urinary retention), hypotension, bradycardia, priapism in males, temperature regulation issues
Autonomic dysreflexia s/sx - ANSWER-•Severe rapidly occurring hypertension
•Pounding headache sudden onset
•Bradycardia
•Nasal congestion
•SOB
•Flushing/
sweating above level of injury
•Chills without fever
•Nausea
•Blurred vision
•Pale cool extremities below the level of the lesion
-feeling of impending doom
, -anxiety and nausea
Autonomic dysreflexia prevention strategies - ANSWER-Maintain regular bowel function (scheduled
bowel routine, fiber, laxatives, manual stimulation
Monitor urine output, promote regular bladder emptying, cath care, increase fluid intake
Skin care to prevent ulcers
Wear loose clothing, better fitting shoes etc
S/sx of Neurogenic Shock - ANSWER-Peripheral vasodilation, venous pooling, decreased cardiac output,
significant hypotension, bradycardia, temperature dysregulation.
Spinal cord injury effects on sexual function - ANSWER-Level and completeness of injury will determine
ability to orgasm, become erect and fertility
Treatment includes drugs, vacuum devices and surgical procedures
Men with SCI will likely have fertility struggles due to poor sperm motility,
Women usually remain fertile and will need to use contraceptives when engaging in sexual activity
Interventions for neurogenic shock - ANSWER-Spinal precautions, C-collar, vasopressors to treat
hypotension, atropine to treat bradycardia, use fluid cautiously, close monitoring and provide
O2/ventilation if needed
Peritoneal lavage - ANSWER-a diagnostic test in which rinse solution is inserted and then removed from
the peritoneal cavity to detect traumatic damage
Peritoneal lavage findings - ANSWER-grossly bloody fluid = significant abdominal bleeding
elevated WBC = infection or inflammation
Presence of bile = possible bile duct injury or perforation of GI tract
Presence of food particles or fecal matter = perforation
Elevated amylase = pancreatic injury
Elevated RBC = signifcant bleeding in the peritoneal cavity, indicates trauma to organs or vessels
Penetrating abdominal trauma intervention - ANSWER-If object is still in place, stabilize and do not
remove it.
Questions and correct/verified Answers
S/sx of TBI - ANSWER--Unequal pupils
-Loss of consciousness
-Confusion, disorientation, laps in memory, unusual behavior, coma
-Severe headache
-Nausea and vomiting
-Amnesia
-Seizure activity following head trauma
-Weakness or numbness
-Lack of coordination, particularly on one side of the body
-Inability to wake up or stay awake
-Clear fluid (CSF) leaking from nose or ears
-Speech problems
-Balance problems
-Bruising behind the ears or around the eyes (battle signs) (racoon eyes)
How to assess brain trauma - ANSWER--LOC and GCS score
-Pupils PERRLA?
-Check for CSF leak
-Mechanism of injury?
-Motor function/strength
-Sensory assessment
-Reflexes (babinski may be present in adults with TBI)
-Changes in speech
-Cushings triad
Cushings Triad - ANSWER-three classic signs—bradycardia, hypertension w/ widened pulse pressure, and
bradypnea—seen with pressure on the medulla as a result of brain stem herniation
Glasgow Coma Scale - ANSWER-eye opening (spontaneous, to speech, to pain, or none)
verbal response (oriented x4, confused, inappropriate words, incomprehensible sounds, no response)
motor response (obeys commands, moves to pain, withdrawals from pain, decorticate posturing,
decerebrate posturing, no response)
Max- 15 pts, below 8= coma
,decorticate vs decerebrate posturing - ANSWER-decorticate has abnormal flexion, and decErebrate has
abnormal Extension
Interventions to reduce ICP - ANSWER-Maintain airway and hyperventilate; positioning HOB up to 30
degrees with head midline; avoidance of coughing, straining, and bright lights; minimizing environmental
stimuli; sedate or tx anxiety; maintain BP carefully
Monitor for DI and SIADH, monitor electrolytes
Signs of increased ICP - ANSWER-Hypertension, bradycardia, widening pulse pressures, bradypnea
(cushings triad), changes in LOC, sudden LOC, fixed unilateral pupil dilation, hemiparesis or hemiplegia,
decorticate or decerebrate posturing, severe or persistent headache, vomiting not preceded by nausea
Cerebral perfusion pressure - ANSWER-CPP = MAP - ICP.
CPP is the pressure needed to ensure blood flow to the brain. If CPP = less than 50 there is ischemia and
neuronal death, less than 30 = death
CPP application - ANSWER-Know that levels under 60 are abnormal and indicate the start of brain
perfusion problems.
MAP is managed with fluid administrations and vasopressors
ICP is managed with positioning, IV mannitol, monitoring electrolytes, ventilation, sedation, pain control,
etc
MAP and ICP must be carefully managed together to get CCP to target range and minimize risks to
patient
Spinal shock s/sx - ANSWER-Loss of deep tendon reflexes, loss of sphincter reflexes, loss of sensation,
flaccid paralysis below the level of injury, bowel and bladder dysfunction (atonic bladder/bowel and
urinary retention), hypotension, bradycardia, priapism in males, temperature regulation issues
Autonomic dysreflexia s/sx - ANSWER-•Severe rapidly occurring hypertension
•Pounding headache sudden onset
•Bradycardia
•Nasal congestion
•SOB
•Flushing/
sweating above level of injury
•Chills without fever
•Nausea
•Blurred vision
•Pale cool extremities below the level of the lesion
-feeling of impending doom
, -anxiety and nausea
Autonomic dysreflexia prevention strategies - ANSWER-Maintain regular bowel function (scheduled
bowel routine, fiber, laxatives, manual stimulation
Monitor urine output, promote regular bladder emptying, cath care, increase fluid intake
Skin care to prevent ulcers
Wear loose clothing, better fitting shoes etc
S/sx of Neurogenic Shock - ANSWER-Peripheral vasodilation, venous pooling, decreased cardiac output,
significant hypotension, bradycardia, temperature dysregulation.
Spinal cord injury effects on sexual function - ANSWER-Level and completeness of injury will determine
ability to orgasm, become erect and fertility
Treatment includes drugs, vacuum devices and surgical procedures
Men with SCI will likely have fertility struggles due to poor sperm motility,
Women usually remain fertile and will need to use contraceptives when engaging in sexual activity
Interventions for neurogenic shock - ANSWER-Spinal precautions, C-collar, vasopressors to treat
hypotension, atropine to treat bradycardia, use fluid cautiously, close monitoring and provide
O2/ventilation if needed
Peritoneal lavage - ANSWER-a diagnostic test in which rinse solution is inserted and then removed from
the peritoneal cavity to detect traumatic damage
Peritoneal lavage findings - ANSWER-grossly bloody fluid = significant abdominal bleeding
elevated WBC = infection or inflammation
Presence of bile = possible bile duct injury or perforation of GI tract
Presence of food particles or fecal matter = perforation
Elevated amylase = pancreatic injury
Elevated RBC = signifcant bleeding in the peritoneal cavity, indicates trauma to organs or vessels
Penetrating abdominal trauma intervention - ANSWER-If object is still in place, stabilize and do not
remove it.
