NUR2115 Exam 3 Questions & 100%
Correct Answers
Cerebral Perfusion Pressure (CPP)
✓ :~~ MAP-ICP
Normal CPP
✓ :~~ 80-100 mmHg
Mean Arterial Pressure (MAP)
✓ :~~ (SBP + 2DBP)/3
Normal MAP
✓ :~~ >70-80 mmHG
Normal Intracranial pressure
✓ :~~ 5-15 mmHg
Intracranial components
✓ :~~ 10% blood, 10% CSF, 80% Brain
Monro-Kellie Hypothesis
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✓ :~~ If the volume of any of the intracranial components changes, it must
be compensated for by another component. The total volume of the
intracranial compartment must remain fixed.
Neurological exam components
✓ :~~ LOC
Pupillary function
Motor function
Respiratory function
Vital signs
Arousal
✓ :~~ Evaluates lowest level of consciousness
Alert
✓ :~~ Patient responds to gently calling name
Lethargic
✓ :~~ Patient must be shouted at to gain attention
Obtunded
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✓ :~~ Patient responds to noxious, painful stimuli such as sternal rub or
trapezius pinch
Comatose
✓ :~~ Patient responds to NO stimuli
Awareness
✓ :~~ Evaluates higher level of consciousness
Orientation
✓ :~~ Determines level of awareness. Evaluate orientation to person, place,
time, and situation
Motor response
✓ :~~ Use noxious peripheral stimulation if needed to elicit a response
Spontaneous response
✓ :~~ Obeys commands
Localizes pain response
✓ :~~ Opposite extremity crosses over midline to remove stimulus
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Withdrawal response
✓ :~~ Patient presents normal flexion to avoid stimulus
Decorticate response
✓ :~~ Patient presents abnormal flexion in response to stimulus
Decerebrate response
✓ :~~ Patient presents abnormal extension in response to noxious stimuli
Flaccid response
✓ :~~ Patient does not respond at all to stimuli
PERRLA
✓ :~~ Pupils Equal Round Reactive to Light and Accommodating
Pupils oval
✓ :~~ Pupillary sign of increased ICP
Pupils constricted
✓ :~~ Pupillary sign of brain stem compression or narcotic use
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