Critical Care Exam #4: Neuro
Assessment, CVA, ICP,
Seizures, Head/Brain Injury,
Spinal Cord Injury, Trauma,
Burns, Code Meds Questions
With Correct Answers
,when does the neurological assessment begin? - Correct Answer: ★ upon entering the patient's
room
describe the Glasgow coma scale. - Correct Answer: an assessment tool that gives a reliable,
consistent way to determine the neurological state/functioning of a patient.
★ based on: eye-opening, motor response, and verbal responses to stimuli.
the Glasgow coma scale is based on which (3) parameters ? - Correct Answer: ★ eye-opening
★ verbal response to stimuli
★ motor response to stimuli
how is the Glasgow coma scale scored? - Correct Answer: ★ severe brain injury: LESS THAN
<8
★ moderate brain injury: 9-12
★ mild brain injury: 13-15
★the LOWER the score the LOWER the neuro function★
★ GCS LESS THAN<9 needs ICP monitoring
True or False: A patient with a "high" (13-15) Glasgow coma scale score has LOW levels of
neurological functioning. - Correct Answer: ★ FALSE
-a score of LESS THAN <8 indicates severe brain injury.
★the LOWER the score the LOWER the neuro function★
how often is the Glasgow coma scale completed? - Correct Answer: ★ q1-2h
a "motor exam" is always completed _____________. - Correct Answer: -bilaterally
,-zero to 5 scale
what three (3) parameters are tested during a "motor exam" ? - Correct Answer: ★ hand grasps
★ pedal pushes AND pulls
★ ability to lift head off the bed
how is a "motor exam" scored? - Correct Answer: ★ rate strength bilaterally on a 0-5 scale.
5= full strength against resistance
4= moves against gravity and resistance weakly
3= moves against gravity, not resistance
2= moves with gravity eliminated
1= flicker of voluntary muscle contraction
0= no muscle contraction
★ the HIGHER the score, the HIGHER the pt motor function!
True or False: A HIGH "motor exam score" indicates HIGH motor function. - Correct Answer:
★ TRUE
★ the HIGHER the score, the HIGHER the pt motor function!
vital signs are taken within __________ minutes of meeting the patient. - Correct Answer: 10
minutes.
what is the most important indicator of neurological function? - Correct Answer: ★ level of
consciousness
, describe an "unconscious" patient. - Correct Answer: unresponsive to loud, verbal stimuli OR
deep tactile stimuli.
what are the 4 main "protective reflexes" ? - Correct Answer: ★ cough
★ gag
★ blink
★ corneals **ONLY tested if the "blink reflex" is NOT PRESENT !!**
the "corneal reflex" is ONLY tested when...? - Correct Answer: ★ the "blink reflex" is NOT
PRESENT!
-use sterile 2x2 gauze!
the "protective reflexes" will be ______________ if there is
impaired neuro function. - Correct Answer: ★ depressed
INTACT oculovestibular reflexes indicate a ____________ ___________ ? - Correct Answer: ★
INTACT brainstem
in order to evaluate brainstem function in an unconscious patient, which test will be performed? -
Correct Answer: ★ "cold caloric" testing
- "non-invasive"
describe "cold caloric" testing. - Correct Answer: -cold water is poured into the ear.
-sitting position
-HOB elevated 30-40 degrees
-tympanic membrane needs to be intact "prior"
if a patient has a "normal brainstem" (INTACT oculovestibular reflex), what will occur during
"cold caloric" testing? - Correct Answer: ★ patient eyes will deviate TOWARDS the cold water!
Assessment, CVA, ICP,
Seizures, Head/Brain Injury,
Spinal Cord Injury, Trauma,
Burns, Code Meds Questions
With Correct Answers
,when does the neurological assessment begin? - Correct Answer: ★ upon entering the patient's
room
describe the Glasgow coma scale. - Correct Answer: an assessment tool that gives a reliable,
consistent way to determine the neurological state/functioning of a patient.
★ based on: eye-opening, motor response, and verbal responses to stimuli.
the Glasgow coma scale is based on which (3) parameters ? - Correct Answer: ★ eye-opening
★ verbal response to stimuli
★ motor response to stimuli
how is the Glasgow coma scale scored? - Correct Answer: ★ severe brain injury: LESS THAN
<8
★ moderate brain injury: 9-12
★ mild brain injury: 13-15
★the LOWER the score the LOWER the neuro function★
★ GCS LESS THAN<9 needs ICP monitoring
True or False: A patient with a "high" (13-15) Glasgow coma scale score has LOW levels of
neurological functioning. - Correct Answer: ★ FALSE
-a score of LESS THAN <8 indicates severe brain injury.
★the LOWER the score the LOWER the neuro function★
how often is the Glasgow coma scale completed? - Correct Answer: ★ q1-2h
a "motor exam" is always completed _____________. - Correct Answer: -bilaterally
,-zero to 5 scale
what three (3) parameters are tested during a "motor exam" ? - Correct Answer: ★ hand grasps
★ pedal pushes AND pulls
★ ability to lift head off the bed
how is a "motor exam" scored? - Correct Answer: ★ rate strength bilaterally on a 0-5 scale.
5= full strength against resistance
4= moves against gravity and resistance weakly
3= moves against gravity, not resistance
2= moves with gravity eliminated
1= flicker of voluntary muscle contraction
0= no muscle contraction
★ the HIGHER the score, the HIGHER the pt motor function!
True or False: A HIGH "motor exam score" indicates HIGH motor function. - Correct Answer:
★ TRUE
★ the HIGHER the score, the HIGHER the pt motor function!
vital signs are taken within __________ minutes of meeting the patient. - Correct Answer: 10
minutes.
what is the most important indicator of neurological function? - Correct Answer: ★ level of
consciousness
, describe an "unconscious" patient. - Correct Answer: unresponsive to loud, verbal stimuli OR
deep tactile stimuli.
what are the 4 main "protective reflexes" ? - Correct Answer: ★ cough
★ gag
★ blink
★ corneals **ONLY tested if the "blink reflex" is NOT PRESENT !!**
the "corneal reflex" is ONLY tested when...? - Correct Answer: ★ the "blink reflex" is NOT
PRESENT!
-use sterile 2x2 gauze!
the "protective reflexes" will be ______________ if there is
impaired neuro function. - Correct Answer: ★ depressed
INTACT oculovestibular reflexes indicate a ____________ ___________ ? - Correct Answer: ★
INTACT brainstem
in order to evaluate brainstem function in an unconscious patient, which test will be performed? -
Correct Answer: ★ "cold caloric" testing
- "non-invasive"
describe "cold caloric" testing. - Correct Answer: -cold water is poured into the ear.
-sitting position
-HOB elevated 30-40 degrees
-tympanic membrane needs to be intact "prior"
if a patient has a "normal brainstem" (INTACT oculovestibular reflex), what will occur during
"cold caloric" testing? - Correct Answer: ★ patient eyes will deviate TOWARDS the cold water!
