NURS 244 EXAM 4 QUESTIONS WITH 100%
CORRECT ANSWERS
What is a ventriculostomy system? - ANSWER Monitoring system used for ICP by
insertion of a fine bore catheter into a lateral ventricle
What other purpose can a ventriculostomy system be used for? - ANSWER 1. Draining of
CSP during acute increases in pressure
2. Access for intraventricular medication administration
What signs are seen in a patient with Cushing triad? - ANSWER 1. Increase in systolic
blood pressure
2. Widening of pulse pressure
3. Bradycardia
(Change in respiratory status as well)
What causes the Cushings response? - ANSWER Cerebral blood flow decreases,
sympathetic triggers take over causing the response
What is decorticate posturing? - ANSWER Flexion of the arm and legs pulled toward the
core of the body. Remember the core.
What is decerebrate posturing? - ANSWER Abnormal body posture involves the arms
and legs being extended straight out, the total is being pointed downward, and the head
and neck being arched backwards.
What is mannitol given for? - ANSWER cerebral edema
ICP
How does mannitol treat IICP? - ANSWER It is an osmotic diuretic that excels fluid from
the body decreasing the ICP
What are the lowest and highest possible scores on the GCS? - ANSWER 3 is lowest and
15 is highest
How is the eye opening response scored? - ANSWER 4: spontaneous
3: to voice
2: to pain
1: none
, How is the verbal response scored? - ANSWER 5: oriented
4: confused
3: inappropriate words
2: incomprehensible sounds
1: none
How is the motor response scored? - ANSWER 6: obeys commands
5: localized pain
4: withdraws
3: flexion
2: extension
1: none
What nursing interventions can be done to increase cerebral tissue perfusion? -
ANSWER -HOB at 30 with head at midline
-promote fluid balance
What is cerebral spinal fluid? - ANSWER CSF is a clear liquid that aids in protecting the
brain, spinal cord and meninges
How can you determine if it is cerebral spinal fluid? - ANSWER Check the glucose
When is CSF seen? - ANSWER Fractures that cause an exposure of the fluid cavities
creating a leakage of the fluid
What are signs of a concussion? - ANSWER Loss of consciousness, disorientation,
Incoherent speech, confusion, memory loss, dazed or vacant stare.
What discharge instructions are given to a patient with a concussion? - ANSWER
Monitor neurologic responses, if symptoms worsen return tot he ER, do not allow patient
to be alone
What is an epidural hematoma? - ANSWER Results when a collection of blood forms
between the skull and the dura mater.
What are symptoms of a epidural hematoma? - ANSWER Initial loss of consciousness,
followed by lucid interval, then rapid deterioration
How is a epidural hematoma treated? - ANSWER Emergency surgery to relieve pressure
What is increased intracranial pressure? - ANSWER a raised level of pressure within the
skull above the normal and healthy level
CORRECT ANSWERS
What is a ventriculostomy system? - ANSWER Monitoring system used for ICP by
insertion of a fine bore catheter into a lateral ventricle
What other purpose can a ventriculostomy system be used for? - ANSWER 1. Draining of
CSP during acute increases in pressure
2. Access for intraventricular medication administration
What signs are seen in a patient with Cushing triad? - ANSWER 1. Increase in systolic
blood pressure
2. Widening of pulse pressure
3. Bradycardia
(Change in respiratory status as well)
What causes the Cushings response? - ANSWER Cerebral blood flow decreases,
sympathetic triggers take over causing the response
What is decorticate posturing? - ANSWER Flexion of the arm and legs pulled toward the
core of the body. Remember the core.
What is decerebrate posturing? - ANSWER Abnormal body posture involves the arms
and legs being extended straight out, the total is being pointed downward, and the head
and neck being arched backwards.
What is mannitol given for? - ANSWER cerebral edema
ICP
How does mannitol treat IICP? - ANSWER It is an osmotic diuretic that excels fluid from
the body decreasing the ICP
What are the lowest and highest possible scores on the GCS? - ANSWER 3 is lowest and
15 is highest
How is the eye opening response scored? - ANSWER 4: spontaneous
3: to voice
2: to pain
1: none
, How is the verbal response scored? - ANSWER 5: oriented
4: confused
3: inappropriate words
2: incomprehensible sounds
1: none
How is the motor response scored? - ANSWER 6: obeys commands
5: localized pain
4: withdraws
3: flexion
2: extension
1: none
What nursing interventions can be done to increase cerebral tissue perfusion? -
ANSWER -HOB at 30 with head at midline
-promote fluid balance
What is cerebral spinal fluid? - ANSWER CSF is a clear liquid that aids in protecting the
brain, spinal cord and meninges
How can you determine if it is cerebral spinal fluid? - ANSWER Check the glucose
When is CSF seen? - ANSWER Fractures that cause an exposure of the fluid cavities
creating a leakage of the fluid
What are signs of a concussion? - ANSWER Loss of consciousness, disorientation,
Incoherent speech, confusion, memory loss, dazed or vacant stare.
What discharge instructions are given to a patient with a concussion? - ANSWER
Monitor neurologic responses, if symptoms worsen return tot he ER, do not allow patient
to be alone
What is an epidural hematoma? - ANSWER Results when a collection of blood forms
between the skull and the dura mater.
What are symptoms of a epidural hematoma? - ANSWER Initial loss of consciousness,
followed by lucid interval, then rapid deterioration
How is a epidural hematoma treated? - ANSWER Emergency surgery to relieve pressure
What is increased intracranial pressure? - ANSWER a raised level of pressure within the
skull above the normal and healthy level
