NURS 487 EXAM 2 QUESTIONS WITH COMPLETE
SOLUTIONS
3 Essential Components of the cranial vault Correct Answer
brain, blood, CSF; Overall volume must remain constant; if not,
increased ICP occurs
A pt diagnosed with brain death who develops a coagulopathy
may receive which therapy to counteract this problem? Correct
Answer Fresh frozen plasma
Abnormal Posturing Correct Answer - Decorticate Posturing
(abnormal flexion): cerebral hemisphere dysfunction
- Decerebrate Posturing (abnormal extension): brainstem
dysfunction—worse
Anti-diuretic hormone (ADH) Correct Answer - Helps
maintain water balance in body (water retention)
- Excreted by posterior pituitary gland
- Normally secreted to prevent diuresis and loss of urine during
physiologic stress
- Loss of ADH secretion results in diuresis
As a nurse caring for a patient with brain injury, you must do
your best to avoid situations that will lead to... Correct Answer
cerebral hypoxia or hypotension (makes ischemia worse)
Assessment of a Stroke Correct Answer - Time responding to
event is incredibly important; assess the speed of onset and rate
of progression of neurological deficits
- Evaluate for facial droop, arm drift, and speech (FAST)
,- Neurological Exam (NIH Stroke Scale) tool that measures the
severity of neurological dysfunction (examines visual, motor,
sensory, cerebellar, inattention, language, and LOC)
- Pt. HX: recent medical, surgical, trauma or TIA events
- Cardiac evaluation: irregular heart rhythm could indicate atrial
fibrillation (monitor vitals, O2, and BG)
- Assessment of medications and adherence
Assessment of Arousal State: GCS Correct Answer - Tool to
identify changes in arousal
- Lowest score 3, highest score 15 (7 =coma)
- Determine what stimulus arouses pt: Trapezius pinch, Sternal
rub, Supraorbital pressure
Basilar Skull Fx Correct Answer - Fracture of one of the bones
that make up the base of the skull caused by a high impact head
injury
- S/S: periorbital ecchymosis - "raccoon eyes", mastoid
ecchymosis - "Battle's sign", otorrhea, rhinorrhea, facial nerve
paralysis
- Test drainage from nose and ears to detect presence of cerebral
spinal fluid (CSF); indicates that the meninges are torn; clear
drainage that tests positive for glucose indicates CSF; bloody
drainage with yellow halo on gauze is CSF
- Medical Interventions: allow CSF to drain and dura to close on
its own; if injury doesn't heal itself after 1-2 weeks, surgical
repair may be necessary
- Nursing Interventions: neuro assessment, pain mgmt, look for
s/s of infection, aseptic dressing changes, sterile cotton gauze in
ear/nose
, Blood Brain Barrier Correct Answer - Controls brain volume
(mainly water found intracellularly) and contents by controlling
permeability
- Most drugs do not cross the BBB
- Disruption results in increased brain volume
- Permeable to: water, oxygen, lipid-soluble compounds, and
carbon dioxide (slightly permeable to electrolytes)
Brain Attack Mnemonic—Assessment and Nursing Care of
Acute Stroke Pt Correct Answer - B: Blood Pressure—if
ischemic stroke, Tx given in emergency only
- R: Respiration—if O2 sats < 95%, provide O2
- A: Airway—monitor consciousness level, GCS <9, consider
intubation
- I: Imaging—CT brain scan; determine type of stroke
- N: Normoglycemia—monitor BG, avoid dextrose infusions
first 48 hours post-stroke; consider insulin infusion if BG>200
- A: Aspirin—325mg for ischemic stroke
- T: Temperature-99.5F, treat, obtain blood cultures
- T: Thrombolysis (tPA)
- A: Assess swallow, nutrition, and hydration—perform swallow
screen
- C: Continence
- K: Keep up with patient positioning (HOB 30)
Brain Death Correct Answer - No evidence of brainstem
function for up to 24 hours
- Normal temperature
- No depressant drugs or ETOH
SOLUTIONS
3 Essential Components of the cranial vault Correct Answer
brain, blood, CSF; Overall volume must remain constant; if not,
increased ICP occurs
A pt diagnosed with brain death who develops a coagulopathy
may receive which therapy to counteract this problem? Correct
Answer Fresh frozen plasma
Abnormal Posturing Correct Answer - Decorticate Posturing
(abnormal flexion): cerebral hemisphere dysfunction
- Decerebrate Posturing (abnormal extension): brainstem
dysfunction—worse
Anti-diuretic hormone (ADH) Correct Answer - Helps
maintain water balance in body (water retention)
- Excreted by posterior pituitary gland
- Normally secreted to prevent diuresis and loss of urine during
physiologic stress
- Loss of ADH secretion results in diuresis
As a nurse caring for a patient with brain injury, you must do
your best to avoid situations that will lead to... Correct Answer
cerebral hypoxia or hypotension (makes ischemia worse)
Assessment of a Stroke Correct Answer - Time responding to
event is incredibly important; assess the speed of onset and rate
of progression of neurological deficits
- Evaluate for facial droop, arm drift, and speech (FAST)
,- Neurological Exam (NIH Stroke Scale) tool that measures the
severity of neurological dysfunction (examines visual, motor,
sensory, cerebellar, inattention, language, and LOC)
- Pt. HX: recent medical, surgical, trauma or TIA events
- Cardiac evaluation: irregular heart rhythm could indicate atrial
fibrillation (monitor vitals, O2, and BG)
- Assessment of medications and adherence
Assessment of Arousal State: GCS Correct Answer - Tool to
identify changes in arousal
- Lowest score 3, highest score 15 (7 =coma)
- Determine what stimulus arouses pt: Trapezius pinch, Sternal
rub, Supraorbital pressure
Basilar Skull Fx Correct Answer - Fracture of one of the bones
that make up the base of the skull caused by a high impact head
injury
- S/S: periorbital ecchymosis - "raccoon eyes", mastoid
ecchymosis - "Battle's sign", otorrhea, rhinorrhea, facial nerve
paralysis
- Test drainage from nose and ears to detect presence of cerebral
spinal fluid (CSF); indicates that the meninges are torn; clear
drainage that tests positive for glucose indicates CSF; bloody
drainage with yellow halo on gauze is CSF
- Medical Interventions: allow CSF to drain and dura to close on
its own; if injury doesn't heal itself after 1-2 weeks, surgical
repair may be necessary
- Nursing Interventions: neuro assessment, pain mgmt, look for
s/s of infection, aseptic dressing changes, sterile cotton gauze in
ear/nose
, Blood Brain Barrier Correct Answer - Controls brain volume
(mainly water found intracellularly) and contents by controlling
permeability
- Most drugs do not cross the BBB
- Disruption results in increased brain volume
- Permeable to: water, oxygen, lipid-soluble compounds, and
carbon dioxide (slightly permeable to electrolytes)
Brain Attack Mnemonic—Assessment and Nursing Care of
Acute Stroke Pt Correct Answer - B: Blood Pressure—if
ischemic stroke, Tx given in emergency only
- R: Respiration—if O2 sats < 95%, provide O2
- A: Airway—monitor consciousness level, GCS <9, consider
intubation
- I: Imaging—CT brain scan; determine type of stroke
- N: Normoglycemia—monitor BG, avoid dextrose infusions
first 48 hours post-stroke; consider insulin infusion if BG>200
- A: Aspirin—325mg for ischemic stroke
- T: Temperature-99.5F, treat, obtain blood cultures
- T: Thrombolysis (tPA)
- A: Assess swallow, nutrition, and hydration—perform swallow
screen
- C: Continence
- K: Keep up with patient positioning (HOB 30)
Brain Death Correct Answer - No evidence of brainstem
function for up to 24 hours
- Normal temperature
- No depressant drugs or ETOH
