NUR2115 Exam 3 Questions and
Correct Answers | Latest Update
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
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Monro-Kellie Hypothesis
✓ ~:- 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
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Obtunded
✓ ~:- 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
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✓ ~:- Opposite extremity crosses over midline to remove stimulus
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
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