NSGD 2256: AHA Final (Pace FA24) Questions With
Complete Solutions
3 main components within the skull:
Brain tissue, blood vessels and CSF.
Munro-Killie doctrine:
If there is an increase in one component of the brain there will
be a decrease in the other two components.
Protective mechanisms of the brain:
- Skull
- Meninges
- Cerebrospinal fluid
- Blood brain barrier
Meninges consist of 3 layers of tough membrane that protects
the brain and spinal cord:
- Dura mater
- Arachnoid mater
- Pia mater
Dura mater:
Tough outer layer
Arachnoid mater:
Middle layer
Pia mater:
,Thin delicate layer over the brain tissue.
Subdural space:
Lies between the dura mater and the arachnoid mater.
Cerebrospinal fluid:
Clear fluid that acts as a shock barrier. Provides nutrients and
removes waste, maintains homeostasis.
Blood brain barrier:
Physiological barrier between blood capillaries and brain tissue,
protects from neurotoxic substances, may become damaged by
trauma.
The visual system includes:
eyes, optic muscles, cranial nerves II, III, IV, V and VI.
The external eye includes the eyelid, conjunctiva, lacrimal
gland, and eye muscles:
Regulate visual input, protect the eye, and tear production.
The internal eye consists of three layers:
The outer layer, middle layer and the inner layer (sclera/ cornea,
choroid/ciliary body/iris, retina.
Cranial nerve I transports the stimulus to the brain to produce:
Smell
Pt symptoms when ICP increases:
,Headache, altered LOC, vomiting. Followed by pupil changes.
Late findings include widened pulse pressure, bradycardia, and
irregular breathing patterns.
Cushing Triad:
Widened pulse pressure, bradycardia, irregular breathing
pattern.
What is a major cause of traumatic brain injury:
Motor vehicle accident
Modify assessment to a focuses neurological assessment
depending on abnormal findings:
Always follow up with a neurological recheck at specific
intervals depending on the patients status and agency protocols.
Changes in vital signs are a ________ finding of increased ICP.
Late
Glasgow Coma Scale assesses for which 3 components?
Eye opening, best verbal response, and best motor response.
Alteration of LOC is a ________ sign of increasing ICP.
Early
Unilateral dilated pupil with may or may not react to light is a
________ sign of increasing ICP.
Early
, How do we assess for Cranial Nerve II (Optic Nerve)?
Provide lighting and ask the patient to read material from 36cm
away. Read with each each and then both eyes.
How do we assess for Cranial Nerves III, IV & VI (Oculomotor,
Trochlear, & Abducens)?
Assess pupils bilat for size, shape, reaction. Ask the patient to
point at an object far and then near, hold penlight 30cm away
and do an H pattern asking the patient to keep their head in a
neutral position and follow the penlight.
How do we assess Cranial Nerve V (Trigeminal Nerve)?
Have client look upwards and lightly touch lateral sclera to elicit
blink reflex, test light sensation by having pt close eyes, wipe a
wisp of cotton over pts forehead.
How do we assess for Cranial Nerve VII (Facial Nerve)?
Ask pt to smile, raise eyebrows, frown, and puff out cheeks,
close eyes tightly.
How do we assess Cranial Nerve VIII (Acoustic Nerve)?
Assess hearing through conversation, lip-reading or leaning
forward.
How to assess Cranial Nerve IX and X (Glossopharyngeal &
Vagus Nerve)?
Have pt say 'ah' observing soft palate, elicit gag reflex, ask pt to
speak and swallow.
Complete Solutions
3 main components within the skull:
Brain tissue, blood vessels and CSF.
Munro-Killie doctrine:
If there is an increase in one component of the brain there will
be a decrease in the other two components.
Protective mechanisms of the brain:
- Skull
- Meninges
- Cerebrospinal fluid
- Blood brain barrier
Meninges consist of 3 layers of tough membrane that protects
the brain and spinal cord:
- Dura mater
- Arachnoid mater
- Pia mater
Dura mater:
Tough outer layer
Arachnoid mater:
Middle layer
Pia mater:
,Thin delicate layer over the brain tissue.
Subdural space:
Lies between the dura mater and the arachnoid mater.
Cerebrospinal fluid:
Clear fluid that acts as a shock barrier. Provides nutrients and
removes waste, maintains homeostasis.
Blood brain barrier:
Physiological barrier between blood capillaries and brain tissue,
protects from neurotoxic substances, may become damaged by
trauma.
The visual system includes:
eyes, optic muscles, cranial nerves II, III, IV, V and VI.
The external eye includes the eyelid, conjunctiva, lacrimal
gland, and eye muscles:
Regulate visual input, protect the eye, and tear production.
The internal eye consists of three layers:
The outer layer, middle layer and the inner layer (sclera/ cornea,
choroid/ciliary body/iris, retina.
Cranial nerve I transports the stimulus to the brain to produce:
Smell
Pt symptoms when ICP increases:
,Headache, altered LOC, vomiting. Followed by pupil changes.
Late findings include widened pulse pressure, bradycardia, and
irregular breathing patterns.
Cushing Triad:
Widened pulse pressure, bradycardia, irregular breathing
pattern.
What is a major cause of traumatic brain injury:
Motor vehicle accident
Modify assessment to a focuses neurological assessment
depending on abnormal findings:
Always follow up with a neurological recheck at specific
intervals depending on the patients status and agency protocols.
Changes in vital signs are a ________ finding of increased ICP.
Late
Glasgow Coma Scale assesses for which 3 components?
Eye opening, best verbal response, and best motor response.
Alteration of LOC is a ________ sign of increasing ICP.
Early
Unilateral dilated pupil with may or may not react to light is a
________ sign of increasing ICP.
Early
, How do we assess for Cranial Nerve II (Optic Nerve)?
Provide lighting and ask the patient to read material from 36cm
away. Read with each each and then both eyes.
How do we assess for Cranial Nerves III, IV & VI (Oculomotor,
Trochlear, & Abducens)?
Assess pupils bilat for size, shape, reaction. Ask the patient to
point at an object far and then near, hold penlight 30cm away
and do an H pattern asking the patient to keep their head in a
neutral position and follow the penlight.
How do we assess Cranial Nerve V (Trigeminal Nerve)?
Have client look upwards and lightly touch lateral sclera to elicit
blink reflex, test light sensation by having pt close eyes, wipe a
wisp of cotton over pts forehead.
How do we assess for Cranial Nerve VII (Facial Nerve)?
Ask pt to smile, raise eyebrows, frown, and puff out cheeks,
close eyes tightly.
How do we assess Cranial Nerve VIII (Acoustic Nerve)?
Assess hearing through conversation, lip-reading or leaning
forward.
How to assess Cranial Nerve IX and X (Glossopharyngeal &
Vagus Nerve)?
Have pt say 'ah' observing soft palate, elicit gag reflex, ask pt to
speak and swallow.
