NUR 4257 - Exam 1 Questions With Complete Solutions
key points with neurologic alterations
-brain does not have O2 stores...a brief interruption in blood
supply can cx significant ischemic damage (lactic acid buildup)
-without adequate BF. cell membrane integrity is lost → ECF
flows into cell → cellular edema
what happens to cerebral arteries when PaO2 is < 50 mmHg
cerebral arteries dilate and blood flow to brain increases (ICP
increases...BAD!)
neurological indications for ICU admission
-change in MS with hemodynamic instability, or extreme lab
abnormalities (hyponatremia - cerebral edema, coma, sz,
hyperkalemia, high ICP)
-any drop in CO: hypothermia, shock, cardiac arrest, dysryths,
OD, HF exacerbation
-acute NM exacerbations (GBS, MG)
-status epilepticus
-active strokes
-head/neck trauma/SCI
-post brain/spinal sx
!! neuro assessment in an ICU pt
-H&P, VS, AOx4, following commands, memory
-LOC (GCS)
!! pupil assessment (always report change to HCP)
,-CN check
-facial symmetry, dysphasia/dysphagia
-motor response to voice, touch, pain
-check strength/muscle tone (0-5)
-reflexes (2 normal)
-weakness/numbness/tremors/gait disturbances
-delirium screening (CAM)
-ICP check
-sedation/analgesic infusions
CAM
delirium screening
grading scale for motor responses
3: able to lift the extremity off the bed briefly but does not have
the strength to maintain the lift
4: some resistance
5: able to lift the extremity off the bed and maintain the position
against resistance
how would you assess orientation in an intubated pt?
-have them write
-give them choices!! nod head, squeeze hand, etc. when get to
the right answer
reflexes
1. deep tendon (DTR - with reflex hammer)
2. superficial (touching or stroking a specific area ex. corneal
reflex, !! Chvostek's sign - hypocalcemia)
,3. pathologic (Babinski - typically present at birth but goes away
with maturation of NS...pathologic is if it is still present)
what kind of reflex does Chvostek's sign test for?
superficial (touching face to check cranial nerve)
CN assessment
I olfactory (sniff test)
II optic (visual - Snellen chart)
III oculomotor (cardinal gazes, pupillary constriction, opening &
closing of the eyes - look for PEERLA, constriction)
IV trochlear (cardinal gazes, moving eyes up & down)
V trigeminal (facial/mouth sensation, mandibular, masseter, and
temporalis strength - chewing, corneal reflex)
VI abducens (cardinal gazes, lateral movement of eyes)
VII facial (puff cheeks out, smile and frown, corneal reflex)
VIII vestibulocochlear (sensory-equilibrium: Romberg
sensory-auditory: Rinne, Weber, whisper test)
!!! IX glossopharyngeal: gag reflex, swallow (sensory)
X vagus: gag/swallow reflex (motor), phonation!! vocal quality
XI accessory: shrugging shoulders, side to side mvmt -
sternocleidomastoid
XII hypoglossal: tongue mvmt and strength "light, tight,
dynamite" speech (articulation)
LOC
1. oriented
2. lethargic: not fully awake, falls off to sleep when not
stimulated, looks drowsy, responds appropriately to Q but think
, slow and fuzzy, inattentive
3. obtunded: sleeps most of time, difficult to arouse, need a loud
shout or vigorous shake, acts confused when aroused, converses
in monosyllables
4. semi-comatose: stupor, responds only to vigorous shake or
pain, withdraws to pain, only groans or mumbles
5. comatose: completely unconscious, no response to pain or
external stimuli, no purposeful mvmt, deep coma has no motor
response
6. delirium: clouding of consciousness
LOC with hepatic encephalopathy
obtunded: sleeps most of time, difficult to arouse need a loud
shout or vigorous shake, acts confused when aroused, converses
in monosyllables
common diagnostic tests r/t neurologic status
BMP: Na (hyponatremic?), glucose, BUN (uremic - obtunded,
confusion)
CBC: WBC (infection) anemic, platelets (internal bleeding?)
Coag labs: if super therapeutic INR or thrombocytopenia, great
risk of bleeding
ABG/VBGs: pH, hypoxemia, hypercapnia?
CT/MRI: CT more common (faster, don't have to screen pt)
cerebral perfusion study
carotid ultrasound (TIA, stroke)
EEG - continuous (post cardiac arrest, brain activity, status
epilepticus) or spot check EEG
uremia
key points with neurologic alterations
-brain does not have O2 stores...a brief interruption in blood
supply can cx significant ischemic damage (lactic acid buildup)
-without adequate BF. cell membrane integrity is lost → ECF
flows into cell → cellular edema
what happens to cerebral arteries when PaO2 is < 50 mmHg
cerebral arteries dilate and blood flow to brain increases (ICP
increases...BAD!)
neurological indications for ICU admission
-change in MS with hemodynamic instability, or extreme lab
abnormalities (hyponatremia - cerebral edema, coma, sz,
hyperkalemia, high ICP)
-any drop in CO: hypothermia, shock, cardiac arrest, dysryths,
OD, HF exacerbation
-acute NM exacerbations (GBS, MG)
-status epilepticus
-active strokes
-head/neck trauma/SCI
-post brain/spinal sx
!! neuro assessment in an ICU pt
-H&P, VS, AOx4, following commands, memory
-LOC (GCS)
!! pupil assessment (always report change to HCP)
,-CN check
-facial symmetry, dysphasia/dysphagia
-motor response to voice, touch, pain
-check strength/muscle tone (0-5)
-reflexes (2 normal)
-weakness/numbness/tremors/gait disturbances
-delirium screening (CAM)
-ICP check
-sedation/analgesic infusions
CAM
delirium screening
grading scale for motor responses
3: able to lift the extremity off the bed briefly but does not have
the strength to maintain the lift
4: some resistance
5: able to lift the extremity off the bed and maintain the position
against resistance
how would you assess orientation in an intubated pt?
-have them write
-give them choices!! nod head, squeeze hand, etc. when get to
the right answer
reflexes
1. deep tendon (DTR - with reflex hammer)
2. superficial (touching or stroking a specific area ex. corneal
reflex, !! Chvostek's sign - hypocalcemia)
,3. pathologic (Babinski - typically present at birth but goes away
with maturation of NS...pathologic is if it is still present)
what kind of reflex does Chvostek's sign test for?
superficial (touching face to check cranial nerve)
CN assessment
I olfactory (sniff test)
II optic (visual - Snellen chart)
III oculomotor (cardinal gazes, pupillary constriction, opening &
closing of the eyes - look for PEERLA, constriction)
IV trochlear (cardinal gazes, moving eyes up & down)
V trigeminal (facial/mouth sensation, mandibular, masseter, and
temporalis strength - chewing, corneal reflex)
VI abducens (cardinal gazes, lateral movement of eyes)
VII facial (puff cheeks out, smile and frown, corneal reflex)
VIII vestibulocochlear (sensory-equilibrium: Romberg
sensory-auditory: Rinne, Weber, whisper test)
!!! IX glossopharyngeal: gag reflex, swallow (sensory)
X vagus: gag/swallow reflex (motor), phonation!! vocal quality
XI accessory: shrugging shoulders, side to side mvmt -
sternocleidomastoid
XII hypoglossal: tongue mvmt and strength "light, tight,
dynamite" speech (articulation)
LOC
1. oriented
2. lethargic: not fully awake, falls off to sleep when not
stimulated, looks drowsy, responds appropriately to Q but think
, slow and fuzzy, inattentive
3. obtunded: sleeps most of time, difficult to arouse, need a loud
shout or vigorous shake, acts confused when aroused, converses
in monosyllables
4. semi-comatose: stupor, responds only to vigorous shake or
pain, withdraws to pain, only groans or mumbles
5. comatose: completely unconscious, no response to pain or
external stimuli, no purposeful mvmt, deep coma has no motor
response
6. delirium: clouding of consciousness
LOC with hepatic encephalopathy
obtunded: sleeps most of time, difficult to arouse need a loud
shout or vigorous shake, acts confused when aroused, converses
in monosyllables
common diagnostic tests r/t neurologic status
BMP: Na (hyponatremic?), glucose, BUN (uremic - obtunded,
confusion)
CBC: WBC (infection) anemic, platelets (internal bleeding?)
Coag labs: if super therapeutic INR or thrombocytopenia, great
risk of bleeding
ABG/VBGs: pH, hypoxemia, hypercapnia?
CT/MRI: CT more common (faster, don't have to screen pt)
cerebral perfusion study
carotid ultrasound (TIA, stroke)
EEG - continuous (post cardiac arrest, brain activity, status
epilepticus) or spot check EEG
uremia
