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CCRN CRITICAL CARE REGISTERED NURSE EXAM 3
LATEST 2024/2025 QUESTIONS AND 100% CORRECT
ANSWERS TEST BANK
What is the first thing assessed if a patient has a suspected TBI? - (answers)Level
of consciousness
What are the 5 levels of LOC and what are the characteristics of each one? -
(answers)1. Alert = Awake and easily aroused
2. Lethargic = Drowsy, drifts asleep when not stimulated.
3. Obtunded = Sleeps most times, difficult to arouse, stimulated with loud noise,
shaking, or non-painful touch
4. Stuporous = Need persistent/continuous loud noise or pain for arousal;
responds to stimuli
5. Comatose = No response to any stimulation
What is hyperarousal in LOC? - (answers)An agitated/delusional state
What is noxious stimulation and what are 4 examples? - (answers)Painful
stimulation
1. Sternal rub = rubbing fist on its sternum
2. Supraorbital = putting pressure above its eyes
3. Trapezius pinch = pinch btw neck and shoulders
4. Mandibular pressure = pushing at the angle of jaw
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What are the 4 H's that negate/invalidate the neuro exam? - (answers)1.
Hypotension
2. Hypoxia
3. Hypoglycemia
4. Hypothermia
What is the Glasgow Coma Scale (GCS) used for? - (answers)To assess patients
with altered levels of consciousness
What are the 3 things assessed for in the GCS? What are the ranges for mild,
moderate, and severe? - (answers)3 things = eyes, verbal, and motor function
1. Mild = 13-15
2. Moderate = 9-12
3. Severe = <8
When assessing a pts motor functioning in a neuro assessment what are the 5
things that are looked at? - (answers)1. Noxious stimulation
2. Strenght (scale 1-5)
3. Lateral comparison
4. Withdrawal & Localization
5. Posturing
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What is posturing in a motor assessment? - (answers)Motor responses of upper
extremities and how they respond to painful stimuli
What are the 4 types of posturing in a motor assessment? - (answers)1.
Localization = moving extremities towards the stimulation
2. Decorticate = abnormal flexion, arm curled and flexed
3. Decerebrate = abnormal extension, arm extended & straight (internal rotation
of shoulder)
4. No response to stimuli
What is the difference between contralateral and ipsilateral affect? -
(answers)Contralateral = Responses that affect the opposite side of the brain:
motor
Ipsilateral = Responses that affect the same side of the brain: pupils
What 3 things are looked at about the eyes/pupils in an neuro assessment? -
(answers)1. Size
2. Reaction
3. Equality
What are the 2 best assessment indicators of neurologic status? - (answers)#1 =
LOC
#2 = Eyes/pupils
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What is the Doll's eyes assessment test and which cranial nerve is this? -
(answers)Turning head & looking for motor movements of eyes. Used for ruling
out brain death
Cranial nerve 3: occulomotor reflex
What is the normal & abnormal findings of a Doll's eye assessment? -
(answers)Normal = eyes move when head turned & brain stem is intact (positive
finding)
Abnormal = eyes stay fixated when head turned & need to continue brain death
assessment (negative finding)
What does Cushing's triad indicate? What are 3 effects on the vital signs? -
(answers)Late sign of increased ICP on brain stem
1. Increased systolic BP
2. Decreased HR
3. Decreased RR
What are 4 common physical assessment findings that rule out brain death? -
(answers)1. Gag reflex
2. Breathing over vent
3. Opening eyes
4. Responding to stimuli
What is a TCD and what is it used for? - (answers)Transcranial Doppler
CCRN CRITICAL CARE REGISTERED NURSE EXAM 3
LATEST 2024/2025 QUESTIONS AND 100% CORRECT
ANSWERS TEST BANK
What is the first thing assessed if a patient has a suspected TBI? - (answers)Level
of consciousness
What are the 5 levels of LOC and what are the characteristics of each one? -
(answers)1. Alert = Awake and easily aroused
2. Lethargic = Drowsy, drifts asleep when not stimulated.
3. Obtunded = Sleeps most times, difficult to arouse, stimulated with loud noise,
shaking, or non-painful touch
4. Stuporous = Need persistent/continuous loud noise or pain for arousal;
responds to stimuli
5. Comatose = No response to any stimulation
What is hyperarousal in LOC? - (answers)An agitated/delusional state
What is noxious stimulation and what are 4 examples? - (answers)Painful
stimulation
1. Sternal rub = rubbing fist on its sternum
2. Supraorbital = putting pressure above its eyes
3. Trapezius pinch = pinch btw neck and shoulders
4. Mandibular pressure = pushing at the angle of jaw
,2|Page
What are the 4 H's that negate/invalidate the neuro exam? - (answers)1.
Hypotension
2. Hypoxia
3. Hypoglycemia
4. Hypothermia
What is the Glasgow Coma Scale (GCS) used for? - (answers)To assess patients
with altered levels of consciousness
What are the 3 things assessed for in the GCS? What are the ranges for mild,
moderate, and severe? - (answers)3 things = eyes, verbal, and motor function
1. Mild = 13-15
2. Moderate = 9-12
3. Severe = <8
When assessing a pts motor functioning in a neuro assessment what are the 5
things that are looked at? - (answers)1. Noxious stimulation
2. Strenght (scale 1-5)
3. Lateral comparison
4. Withdrawal & Localization
5. Posturing
,3|Page
What is posturing in a motor assessment? - (answers)Motor responses of upper
extremities and how they respond to painful stimuli
What are the 4 types of posturing in a motor assessment? - (answers)1.
Localization = moving extremities towards the stimulation
2. Decorticate = abnormal flexion, arm curled and flexed
3. Decerebrate = abnormal extension, arm extended & straight (internal rotation
of shoulder)
4. No response to stimuli
What is the difference between contralateral and ipsilateral affect? -
(answers)Contralateral = Responses that affect the opposite side of the brain:
motor
Ipsilateral = Responses that affect the same side of the brain: pupils
What 3 things are looked at about the eyes/pupils in an neuro assessment? -
(answers)1. Size
2. Reaction
3. Equality
What are the 2 best assessment indicators of neurologic status? - (answers)#1 =
LOC
#2 = Eyes/pupils
, 4|Page
What is the Doll's eyes assessment test and which cranial nerve is this? -
(answers)Turning head & looking for motor movements of eyes. Used for ruling
out brain death
Cranial nerve 3: occulomotor reflex
What is the normal & abnormal findings of a Doll's eye assessment? -
(answers)Normal = eyes move when head turned & brain stem is intact (positive
finding)
Abnormal = eyes stay fixated when head turned & need to continue brain death
assessment (negative finding)
What does Cushing's triad indicate? What are 3 effects on the vital signs? -
(answers)Late sign of increased ICP on brain stem
1. Increased systolic BP
2. Decreased HR
3. Decreased RR
What are 4 common physical assessment findings that rule out brain death? -
(answers)1. Gag reflex
2. Breathing over vent
3. Opening eyes
4. Responding to stimuli
What is a TCD and what is it used for? - (answers)Transcranial Doppler
