Page |1
NSG 4100 Final Exam Latest Test Bank
Questions With Correct Verified Answers|
Graded A+ ( )
Question:
Early s/s of increased ICP ?
Answer:
- change in LOC - earliest
- disorientation, restlessness, increased respiratory effort (Kussmals), purposeless movements,
mental confusion,
- pupillary changes and impaired extraocular movements
-
Question:
late s/s of increased ICP (vital sign changes) ?
Answer:
- Cushing's Triad
- bradycardia, bradypnea, widen pulse pressure (increased systolic, decreased diastolic_
- increased BP and temp
Question:
Late signs of increased ICP ?
Answer:
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- patient becomes erratic
- GCS score <8
- LOC continues to deteriorate
- Chain-stokes (rhythmic waxing and waning of ate and depth with brief episodes of apnea
- Ataxic breathing - irregular breathing with random deep and shallow breath
- projectile vomiting
- hemiplegia
- decorticate
- decerebrate
- flaccidity before death
- loss of brain stem reflexes: pupillary, corneal, gag, and swallowing reflexes are not present
(signs of approaching death)
Question:
Normal ICP pressure ?
Answer:
5-15 mmHg
Question:
Normal CPP ?
Answer:
70-100 mmHg
Question:
an ICP >25 indicates? ?
Answer:
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worsening if pressure does not return within 5 minutes
Question:
a CPP <50mmHg indicates ?
Answer:
No blood glow and irreversible damage
Question:
What is the goal for a Craniotomy post op? ?
Answer:
- aimed at detecting and reducing cerebral edema, relieve ing pain, preventing seizures,
monitoring ICP, and neurological status
Question:
Plan of care post op for a craniotomy? ?
Answer:
- reduce cerebral edema by giving: mannitol, IV dexamethasone, and taper off when
discontinuing
- relieve pain and decrease temp with:
- acetaminophen (mild)
- codeine and morphine - for intense pain
- prophylactic anticonvulsants: phenytoin and levetiracetam
- remove the ICP monitor as soon as ICP is regulated and is stable
Question:
what would require immediate intervention for a patient with head trauma? ?
Answer:
- CSF drainage: meningitis infection can occur
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- A depressed fracture - require surgery within 24 hrs
- A battle sign (bruising over the mastoid bone)
- Pts who pees ALOT - indicate dilute urine --> DI
- GCS - score <8
- Decorticate and Decerebrate posturing
- Changes in pupils
Question:
What would require immediate intervention for a patient with TBIs? ?
Answer:
- Dolls eyes (dilation of eyes), fixation of pupils, paralysis of extremity ---> indicate herniation
- When Turing pt head to one side, and if eyes turn into the same direction = bad response
- opposite direction = normal response
Question:
Clinical manifestations that require immediate intervention for acute SDH? ?
Answer:
- Coma, increase BP, decreased HR, slow RR
Question:
What emergency procedure would be preformed for a patient with a epidural hematoma? ?
Answer:
Burr holes - release blood accumulated in the between the skull and dura bc it can cause
neurological deficits and respiratory arrest
NSG 4100 Final Exam Latest Test Bank
Questions With Correct Verified Answers|
Graded A+ ( )
Question:
Early s/s of increased ICP ?
Answer:
- change in LOC - earliest
- disorientation, restlessness, increased respiratory effort (Kussmals), purposeless movements,
mental confusion,
- pupillary changes and impaired extraocular movements
-
Question:
late s/s of increased ICP (vital sign changes) ?
Answer:
- Cushing's Triad
- bradycardia, bradypnea, widen pulse pressure (increased systolic, decreased diastolic_
- increased BP and temp
Question:
Late signs of increased ICP ?
Answer:
, Page |2
- patient becomes erratic
- GCS score <8
- LOC continues to deteriorate
- Chain-stokes (rhythmic waxing and waning of ate and depth with brief episodes of apnea
- Ataxic breathing - irregular breathing with random deep and shallow breath
- projectile vomiting
- hemiplegia
- decorticate
- decerebrate
- flaccidity before death
- loss of brain stem reflexes: pupillary, corneal, gag, and swallowing reflexes are not present
(signs of approaching death)
Question:
Normal ICP pressure ?
Answer:
5-15 mmHg
Question:
Normal CPP ?
Answer:
70-100 mmHg
Question:
an ICP >25 indicates? ?
Answer:
, Page |3
worsening if pressure does not return within 5 minutes
Question:
a CPP <50mmHg indicates ?
Answer:
No blood glow and irreversible damage
Question:
What is the goal for a Craniotomy post op? ?
Answer:
- aimed at detecting and reducing cerebral edema, relieve ing pain, preventing seizures,
monitoring ICP, and neurological status
Question:
Plan of care post op for a craniotomy? ?
Answer:
- reduce cerebral edema by giving: mannitol, IV dexamethasone, and taper off when
discontinuing
- relieve pain and decrease temp with:
- acetaminophen (mild)
- codeine and morphine - for intense pain
- prophylactic anticonvulsants: phenytoin and levetiracetam
- remove the ICP monitor as soon as ICP is regulated and is stable
Question:
what would require immediate intervention for a patient with head trauma? ?
Answer:
- CSF drainage: meningitis infection can occur
, Page |4
- A depressed fracture - require surgery within 24 hrs
- A battle sign (bruising over the mastoid bone)
- Pts who pees ALOT - indicate dilute urine --> DI
- GCS - score <8
- Decorticate and Decerebrate posturing
- Changes in pupils
Question:
What would require immediate intervention for a patient with TBIs? ?
Answer:
- Dolls eyes (dilation of eyes), fixation of pupils, paralysis of extremity ---> indicate herniation
- When Turing pt head to one side, and if eyes turn into the same direction = bad response
- opposite direction = normal response
Question:
Clinical manifestations that require immediate intervention for acute SDH? ?
Answer:
- Coma, increase BP, decreased HR, slow RR
Question:
What emergency procedure would be preformed for a patient with a epidural hematoma? ?
Answer:
Burr holes - release blood accumulated in the between the skull and dura bc it can cause
neurological deficits and respiratory arrest
