MDC4 FINAL EXAM -RASMUSSEN -
250+ PRACTICE QUESTIONS AND
CORRECT ANSWERS
What is increased ICP made of?
CSF, blood, brain
what causes increased ICP
infection, trauma, increased CSF, hemorrhage, tumors
s/s of increased ICP
MIND CRUSH
M: mental status change (early sign) = decreased LOC, irritable, confusion
I: irregular breathing (late sighn) = Cheyene Stokes
N: nerve damage to eye = pupil changes
D: decerebrate (limbs out) and decorticate (limbs to core) posturing
C: cushing's triad (late) = HTN + brady + wide pule pressure
R: reflux - N/V
U: unconscious
S: seizures
H: headaches
,Nursing care for Increased ICP
PRESS
P: position HOB @ 30 degrees and make sure body's midline (no flexion of
neck or hips)
R: respiratory we want to prevent hypercapnia by hyperventilating (limit
suctioning)
E: elevated temp - prevent it!
S: system checks = neuro checks
S: straining things - avoid it (no lifting, blowing nose, cough/sneeze)
Additional Nursing care measures for ICP
- turn down the lights
- no TV or noise
- put sign on door telling visitors to see nurse first
What do you NOT do when someone has increased ICP?
Lumbar Puncture
What is the Glasgow Coma Scale?
-A brain injury severity scale that assesses depth
and duration of impaired consciousness and coma.
,what 3 areas make up the Glasgow coma scale?
- eyes score 1-4
- verbal score 1-5
- motor score 1-6
Total score 3-15 **lower the score = more severe injury/status
Eyes for Glasgow Coma Scale
ESPN
E - eyes open spontaneously (4)
S - sound (3)
P - pain (2)
N - not open (1)
Verbal for Glasgow coma scale
Our Country WIN
O: oriented (5)
C: confusion (4)
W: words are inappropriate (3)
I: incomprehensible sounds (2)
N: nothing (1)
, Motor for Glasgow coma scale
Can't Live Without FANs
C: commands followed (6)
L: localize to pain (5)
W: withdrawal from pain (4)
F: flexion - decorticate posturing (3)
A: abnormal extension-decerebrate (2)
N: nothing (1)
what are seizure
abnormal and increase in firing of neurons
what is epilepsy
chronic seizures
what triggers seizures
stress, fatigue, coffee
what are risk factors for seizures
infection, trauma, fever, withdrawal, imbalances
250+ PRACTICE QUESTIONS AND
CORRECT ANSWERS
What is increased ICP made of?
CSF, blood, brain
what causes increased ICP
infection, trauma, increased CSF, hemorrhage, tumors
s/s of increased ICP
MIND CRUSH
M: mental status change (early sign) = decreased LOC, irritable, confusion
I: irregular breathing (late sighn) = Cheyene Stokes
N: nerve damage to eye = pupil changes
D: decerebrate (limbs out) and decorticate (limbs to core) posturing
C: cushing's triad (late) = HTN + brady + wide pule pressure
R: reflux - N/V
U: unconscious
S: seizures
H: headaches
,Nursing care for Increased ICP
PRESS
P: position HOB @ 30 degrees and make sure body's midline (no flexion of
neck or hips)
R: respiratory we want to prevent hypercapnia by hyperventilating (limit
suctioning)
E: elevated temp - prevent it!
S: system checks = neuro checks
S: straining things - avoid it (no lifting, blowing nose, cough/sneeze)
Additional Nursing care measures for ICP
- turn down the lights
- no TV or noise
- put sign on door telling visitors to see nurse first
What do you NOT do when someone has increased ICP?
Lumbar Puncture
What is the Glasgow Coma Scale?
-A brain injury severity scale that assesses depth
and duration of impaired consciousness and coma.
,what 3 areas make up the Glasgow coma scale?
- eyes score 1-4
- verbal score 1-5
- motor score 1-6
Total score 3-15 **lower the score = more severe injury/status
Eyes for Glasgow Coma Scale
ESPN
E - eyes open spontaneously (4)
S - sound (3)
P - pain (2)
N - not open (1)
Verbal for Glasgow coma scale
Our Country WIN
O: oriented (5)
C: confusion (4)
W: words are inappropriate (3)
I: incomprehensible sounds (2)
N: nothing (1)
, Motor for Glasgow coma scale
Can't Live Without FANs
C: commands followed (6)
L: localize to pain (5)
W: withdrawal from pain (4)
F: flexion - decorticate posturing (3)
A: abnormal extension-decerebrate (2)
N: nothing (1)
what are seizure
abnormal and increase in firing of neurons
what is epilepsy
chronic seizures
what triggers seizures
stress, fatigue, coffee
what are risk factors for seizures
infection, trauma, fever, withdrawal, imbalances
