11/8/24, 2:28 PM
Final Exam NR 325
WITH COMPLETE ANSWERS
Practice questions for this set
Terms in this set (81)
Conscious, locked in syndrome, persistent vegetative state (no cognition, have
Levels of consciousness sleep/wake cycles), akinetic mute syndrome (no purposeful movements, eyes open
and close refexively), Coma
Intracranial pressure must be less than ______ 40 mmHg
to still have adequate perfusion to brain
Systolic must be between _____ and ______ to 50 and 150
have adequate perfusion to the brain
If the body has increased ICP _____ will be Cushing's Reflex
triggered
What are the cardinal signs of Cushing's High BP, low HR, decreased LOC, and possibly decreased RR
Reflex?
What is the first concern when a patient A patent airway
becomes unconscious?
When a patient goes unconscious with decrease metabolic demand on brain. May use hypothermic environment. Reduce
increased ICP we want to ____ metabolic fever because of a fever's ability to increase metabolic demand
demand
1/5
, 11/8/24, 2:28 PM
How would mannitol be used with patients Mannitol is a sugar that will increase the osmotic gradient thereby pulling fluid into
with increased ICP? the vessels and will be discarded through urination
bruising of the brain with tissue injury. Often happens with an acceleration/
Contusion
decelleration event
Temporary loss of neurological function. No structural damage or bruising to the
Concussion brain. Typically no residual effects as long as enough healing time is allowed and the
concussions are not reoccurent
Usually a direct blow. Requires some type of intervention which due to its
Epidural hemorrhage
accessibility is more easily treated
Subdural hemorrhage Usually a result of trauma, can be result of aneurysm, can be acute and chronic.
Most complicated, usually inoperable, related to intracerebral aneurysm or cancer.
Intracerebral
Cannot be fixed well
Promote rest, little stimulation, elevate head of bed to decrease intracranial
pressure, give O2 (CO2 is a vasodilator), report presence of CSF from nose or ears,
Management of head injuries
provide calm environment, monitor fluid and electrolytes, provide adequate fluids to
perfuse brain, maintain safety and seizure precautions
Dilantin Drug of choice for seizure prophylaxis.
Why not give benzodyazapines to patient Benzos may help but will also alter LOC and therefore it will be hard to tell what
with head injury interventions are helping and if the patient is having a change of status
Dilantin for seizure prophylaxis. Stool softner so they are not bearing down and
Medications to give someone with a head
increases ICP. Diuretic to reduce ICP. Antihypertensives. Diprovan used to slow the
injury
activity of the CNS and relax a patient. Often used during anesthesia to relax the pt.
Fever in children, hyperthermia, tumors, malformaties, hypertension, injury, drug and
Causes of seizures
alcohol withdrawl, allergies, electrolyte imbalances
Involves both cerebral hemispheres Tonic-clonic seizure, tonic seizure, clonic
Generalized seizures
seizure, myoclonic seizure, atonic or akinetic seizure
Involves only one cerebral hemisphere. Complex partial seizure, simple partial
Partial or focal/local seizure
seizure
Begins for only a few second with a tonic episode (stiffening of the muscles) and loss
Tonic-clonic seizure
of consciousness.
Clients suddenly lose consciousness and experience sudden and increased muscle
Tonic seizure tone, loss of consciousness, and autonomic manifestations (arrhythmia, apnea,
vomiting, incontinence, salvation).
Clonic seizure Muscles contract and relax
Characterized by a few seconds in which muscle tone is lost. Frequently results in
Atonic or akinetic seizure
falling
Can cause a loss of consciousness or blackout for several minutes. Associated with
Complex partial seizure
behaviors that the client is unaware of such as lip smacking or picking at clothing.
Simple partial seizure Consciousness is maintained throughout.
Cannot drink alcohol with anti-seizure medications. Lower pt to the ground. Place on
Nursing actions during seizure side. Loosen gown. Nothing around neck. Move objects that they can hurt
themselves on. Document. Offer blow by oxygen.
Status epillepticus Seizure lasting for greater than 30 min
Valium or ativan (Benzos) IV. If we cannot gain control of status epillepticus then we
Medications during seizure
knock them out in order to prevent severe brain injury
2/5
Final Exam NR 325
WITH COMPLETE ANSWERS
Practice questions for this set
Terms in this set (81)
Conscious, locked in syndrome, persistent vegetative state (no cognition, have
Levels of consciousness sleep/wake cycles), akinetic mute syndrome (no purposeful movements, eyes open
and close refexively), Coma
Intracranial pressure must be less than ______ 40 mmHg
to still have adequate perfusion to brain
Systolic must be between _____ and ______ to 50 and 150
have adequate perfusion to the brain
If the body has increased ICP _____ will be Cushing's Reflex
triggered
What are the cardinal signs of Cushing's High BP, low HR, decreased LOC, and possibly decreased RR
Reflex?
What is the first concern when a patient A patent airway
becomes unconscious?
When a patient goes unconscious with decrease metabolic demand on brain. May use hypothermic environment. Reduce
increased ICP we want to ____ metabolic fever because of a fever's ability to increase metabolic demand
demand
1/5
, 11/8/24, 2:28 PM
How would mannitol be used with patients Mannitol is a sugar that will increase the osmotic gradient thereby pulling fluid into
with increased ICP? the vessels and will be discarded through urination
bruising of the brain with tissue injury. Often happens with an acceleration/
Contusion
decelleration event
Temporary loss of neurological function. No structural damage or bruising to the
Concussion brain. Typically no residual effects as long as enough healing time is allowed and the
concussions are not reoccurent
Usually a direct blow. Requires some type of intervention which due to its
Epidural hemorrhage
accessibility is more easily treated
Subdural hemorrhage Usually a result of trauma, can be result of aneurysm, can be acute and chronic.
Most complicated, usually inoperable, related to intracerebral aneurysm or cancer.
Intracerebral
Cannot be fixed well
Promote rest, little stimulation, elevate head of bed to decrease intracranial
pressure, give O2 (CO2 is a vasodilator), report presence of CSF from nose or ears,
Management of head injuries
provide calm environment, monitor fluid and electrolytes, provide adequate fluids to
perfuse brain, maintain safety and seizure precautions
Dilantin Drug of choice for seizure prophylaxis.
Why not give benzodyazapines to patient Benzos may help but will also alter LOC and therefore it will be hard to tell what
with head injury interventions are helping and if the patient is having a change of status
Dilantin for seizure prophylaxis. Stool softner so they are not bearing down and
Medications to give someone with a head
increases ICP. Diuretic to reduce ICP. Antihypertensives. Diprovan used to slow the
injury
activity of the CNS and relax a patient. Often used during anesthesia to relax the pt.
Fever in children, hyperthermia, tumors, malformaties, hypertension, injury, drug and
Causes of seizures
alcohol withdrawl, allergies, electrolyte imbalances
Involves both cerebral hemispheres Tonic-clonic seizure, tonic seizure, clonic
Generalized seizures
seizure, myoclonic seizure, atonic or akinetic seizure
Involves only one cerebral hemisphere. Complex partial seizure, simple partial
Partial or focal/local seizure
seizure
Begins for only a few second with a tonic episode (stiffening of the muscles) and loss
Tonic-clonic seizure
of consciousness.
Clients suddenly lose consciousness and experience sudden and increased muscle
Tonic seizure tone, loss of consciousness, and autonomic manifestations (arrhythmia, apnea,
vomiting, incontinence, salvation).
Clonic seizure Muscles contract and relax
Characterized by a few seconds in which muscle tone is lost. Frequently results in
Atonic or akinetic seizure
falling
Can cause a loss of consciousness or blackout for several minutes. Associated with
Complex partial seizure
behaviors that the client is unaware of such as lip smacking or picking at clothing.
Simple partial seizure Consciousness is maintained throughout.
Cannot drink alcohol with anti-seizure medications. Lower pt to the ground. Place on
Nursing actions during seizure side. Loosen gown. Nothing around neck. Move objects that they can hurt
themselves on. Document. Offer blow by oxygen.
Status epillepticus Seizure lasting for greater than 30 min
Valium or ativan (Benzos) IV. If we cannot gain control of status epillepticus then we
Medications during seizure
knock them out in order to prevent severe brain injury
2/5
