Test Bank Critical Care
Nursing
• anticonvulsants such as phenytoin (Dilantin) to prevent seizures
• respiratory support, including mechanical ventilation and ET intubation for patients with
respiratory failure from brain stem involvement
• prophylactic antibiotics to prevent the onset of meningitis from CSF leakage
associated with skull fractures.
Considerations
• Observe the patient closely for signs of hypoxia or increased ICP, such as headache,
dizziness, irritability, anxiety, and changes in behavior such as agitation.
• Monitor elderly patients especially closely because they may have brain atrophy and,
therefore, more space for cerebral edema.
This means ICP may increase without showing signs.
Concussion (closed head injury) - CORRECT ANSWER-• Blow to the head hard
enough to make the brain hit the skull, but not hard enough to cause a cerebral
contusion; causes *temporary neural dysfunction.*
• Recovery is usually complete within 24 to 48 hours.
Contusion (bruising of brain tissue) - CORRECT ANSWER-• Most result from arterial
bleeding.
• Blood commonly accumulates between skull and dura. Injury to middle meningeal
artery in parietotemporal area is most common and is typically accompanied by linear
skull fractures in temporal region over middle meningeal artery.
• It less commonly arises from dural venous sinuses.
Epidural Hematoma - CORRECT ANSWER-• Acceleration-deceleration or coup-
contrecoup injuries disrupt normal nerve functions in bruised
area.
• Injury is directly beneath the site of impact when the brain rebounds against the skull
from the force of a blow (a beating with a blunt instrument, for example), when the force
,of the blow drives the brain against the opposite side of the skull, or when the head is
hurled forward and stopped abruptly (as in an automobile crash when a driver's head
strikes the windshield).
• Brain continues moving and slaps against the skull (acceleration), then rebounds
(deceleration).
Brain may strike bony prominences inside the skull (especially the sphenoidal ridges),
causing intracranial hemorrhage or hematoma that may result in tentorial herniation.
Epidural Hematoma S/S & Test - CORRECT ANSWER-S/S
• Brief period of unconsciousness after injury reflecting the concussive effects of head
trauma, followed by a lucid interval varying from 10-15 minutes to hours or, rarely, days
• Anterograde and retrograde amnesia (patient can't recall events immediately after the
injury or events that led up to the traumatic incident)
• CT shows lens shape d/t dural adhesions to coronal and lambdoid sutures
Dermatomes - CORRECT ANSWER-• C6 - T1 arms
•
help family members solve problems by: - CORRECT ANSWER-• verbalize the
immediate problem
• identify support systems
• recall how they handled stress in the past
*Such assistance helps family members to focus on the present
issue. It also allows them to solve problems and regain a sense of
control over their lives.*
Medical futility - CORRECT ANSWER-*treatment that's hopeless* or interventions
that aren't likely to benefit the patient even though they may appear to be effective
H&H Q's - CORRECT ANSWER-• Do you have headaches? How often do you have
them?
What precipitates them?
• Do you ever feel dizzy? How often do you feel this
way? What seems to precipitate the episodes?
• Do you ever feel a tingling or prickling sensation or numbness?
If so, where?
• Have you ever had seizures or tremors? Have you ever had
weakness or paralysis in your arms or legs?
• Do you have trouble urinating, walking, speaking, understanding
others, reading, or writing?
• How's your memory and ability to concentrate?
Mental Status Q's - CORRECT ANSWER-What's your name? *person*
What's your mother's name? *other ppl*
What year is it? *time*
Where are you now? *place*
, How old are you? *memory*
Where were you born? *remote memory*
What did you have for breakfast? *recent memory*
Who's Pres of the U.S. now? *general knowledge*
Can you count backward from 20 to 1? *Attn span &*
*calculation skills*
Steps to arousal - CORRECT ANSWER-1. auditory
2. tactile
3. painful
Assess for dysarthria - CORRECT ANSWER-(=diff forming words)
Ask pt to repeat "no ifs, ands, or buts"
CN I Assess - CORRECT ANSWER-Check the patency of each nostril. Then instruct
the patient to close his eyes. Occlude one nostril, and hold a familiar, pungent-smelling
substance under the patient's nose and ask him to identify it.
Repeat this with the other nostril.
CN II Assess - CORRECT ANSWER-Do this by asking the patient to read a newspaper,
starting with large headlines and moving to small print.
CN III, IV, VI Assess - CORRECT ANSWER-Check pupil size, pupil shape, and
pupillary response to light. When assessing pupil size, look for trends, such as a
gradual increase in the size of one pupil or appearance of unequal pupils.
Ask the patient to follow your finger through six cardinal positions of gaze. (assess the
patient for nystagmus, or involuntary eye movement,
and the ability to hold gaze in that particular position.)
CN V Assess - CORRECT ANSWER-Gently touch the right and left sides of the
patient's forehead with a cotton ball while his eyes are closed. Instruct him to tell you the
moment the cotton touches each area. Compare the patient's responses on both sides.
Repeat the technique on the right and left cheek and on the right and left jaw.
Next, repeat the entire procedure using a sharp object, such as the tip of a safety pin.
Ask the patient to describe and compare both sensations.
To assess the motor function, ask the patient to clench his teeth while you palpate his
temporal and masseter muscles.
Corneal reflex.
CN VII Assess - CORRECT ANSWER-Ask pt to:
• wrinkle his forehead
• raise and lower his eyebrows
Nursing
• anticonvulsants such as phenytoin (Dilantin) to prevent seizures
• respiratory support, including mechanical ventilation and ET intubation for patients with
respiratory failure from brain stem involvement
• prophylactic antibiotics to prevent the onset of meningitis from CSF leakage
associated with skull fractures.
Considerations
• Observe the patient closely for signs of hypoxia or increased ICP, such as headache,
dizziness, irritability, anxiety, and changes in behavior such as agitation.
• Monitor elderly patients especially closely because they may have brain atrophy and,
therefore, more space for cerebral edema.
This means ICP may increase without showing signs.
Concussion (closed head injury) - CORRECT ANSWER-• Blow to the head hard
enough to make the brain hit the skull, but not hard enough to cause a cerebral
contusion; causes *temporary neural dysfunction.*
• Recovery is usually complete within 24 to 48 hours.
Contusion (bruising of brain tissue) - CORRECT ANSWER-• Most result from arterial
bleeding.
• Blood commonly accumulates between skull and dura. Injury to middle meningeal
artery in parietotemporal area is most common and is typically accompanied by linear
skull fractures in temporal region over middle meningeal artery.
• It less commonly arises from dural venous sinuses.
Epidural Hematoma - CORRECT ANSWER-• Acceleration-deceleration or coup-
contrecoup injuries disrupt normal nerve functions in bruised
area.
• Injury is directly beneath the site of impact when the brain rebounds against the skull
from the force of a blow (a beating with a blunt instrument, for example), when the force
,of the blow drives the brain against the opposite side of the skull, or when the head is
hurled forward and stopped abruptly (as in an automobile crash when a driver's head
strikes the windshield).
• Brain continues moving and slaps against the skull (acceleration), then rebounds
(deceleration).
Brain may strike bony prominences inside the skull (especially the sphenoidal ridges),
causing intracranial hemorrhage or hematoma that may result in tentorial herniation.
Epidural Hematoma S/S & Test - CORRECT ANSWER-S/S
• Brief period of unconsciousness after injury reflecting the concussive effects of head
trauma, followed by a lucid interval varying from 10-15 minutes to hours or, rarely, days
• Anterograde and retrograde amnesia (patient can't recall events immediately after the
injury or events that led up to the traumatic incident)
• CT shows lens shape d/t dural adhesions to coronal and lambdoid sutures
Dermatomes - CORRECT ANSWER-• C6 - T1 arms
•
help family members solve problems by: - CORRECT ANSWER-• verbalize the
immediate problem
• identify support systems
• recall how they handled stress in the past
*Such assistance helps family members to focus on the present
issue. It also allows them to solve problems and regain a sense of
control over their lives.*
Medical futility - CORRECT ANSWER-*treatment that's hopeless* or interventions
that aren't likely to benefit the patient even though they may appear to be effective
H&H Q's - CORRECT ANSWER-• Do you have headaches? How often do you have
them?
What precipitates them?
• Do you ever feel dizzy? How often do you feel this
way? What seems to precipitate the episodes?
• Do you ever feel a tingling or prickling sensation or numbness?
If so, where?
• Have you ever had seizures or tremors? Have you ever had
weakness or paralysis in your arms or legs?
• Do you have trouble urinating, walking, speaking, understanding
others, reading, or writing?
• How's your memory and ability to concentrate?
Mental Status Q's - CORRECT ANSWER-What's your name? *person*
What's your mother's name? *other ppl*
What year is it? *time*
Where are you now? *place*
, How old are you? *memory*
Where were you born? *remote memory*
What did you have for breakfast? *recent memory*
Who's Pres of the U.S. now? *general knowledge*
Can you count backward from 20 to 1? *Attn span &*
*calculation skills*
Steps to arousal - CORRECT ANSWER-1. auditory
2. tactile
3. painful
Assess for dysarthria - CORRECT ANSWER-(=diff forming words)
Ask pt to repeat "no ifs, ands, or buts"
CN I Assess - CORRECT ANSWER-Check the patency of each nostril. Then instruct
the patient to close his eyes. Occlude one nostril, and hold a familiar, pungent-smelling
substance under the patient's nose and ask him to identify it.
Repeat this with the other nostril.
CN II Assess - CORRECT ANSWER-Do this by asking the patient to read a newspaper,
starting with large headlines and moving to small print.
CN III, IV, VI Assess - CORRECT ANSWER-Check pupil size, pupil shape, and
pupillary response to light. When assessing pupil size, look for trends, such as a
gradual increase in the size of one pupil or appearance of unequal pupils.
Ask the patient to follow your finger through six cardinal positions of gaze. (assess the
patient for nystagmus, or involuntary eye movement,
and the ability to hold gaze in that particular position.)
CN V Assess - CORRECT ANSWER-Gently touch the right and left sides of the
patient's forehead with a cotton ball while his eyes are closed. Instruct him to tell you the
moment the cotton touches each area. Compare the patient's responses on both sides.
Repeat the technique on the right and left cheek and on the right and left jaw.
Next, repeat the entire procedure using a sharp object, such as the tip of a safety pin.
Ask the patient to describe and compare both sensations.
To assess the motor function, ask the patient to clench his teeth while you palpate his
temporal and masseter muscles.
Corneal reflex.
CN VII Assess - CORRECT ANSWER-Ask pt to:
• wrinkle his forehead
• raise and lower his eyebrows
