NUR 265 EXAM 3 QUESTIONS AND
ANSWERS 2026 VERIFIED.
GCS Scale TBI - ANS Mild TBI (concussion): 13-15
- normal to lethargic
- LOC <30 mins
- amnesia
- dizziness/ HA/ disoriented
- irritability
Moderate TBI: 9-12
- LOC 30min- 6hrs
- lethargic to obtunded
- follows commands w/ arousal
- confused
Severe TBI: 3-8
- memory loss 24hrs
- must intubate
- not able to follow commands
Decorticate posturing - ANS
1
, Decerebrate posturing - ANS
ICP - ANS Normal 10-15
CPP= MAP-ICP (70-100)
Sxs: change in LOC, sluggish pupils, impaired eye movement, limb strength, HA, N/V, dilated
pupils
NI: LOC, neuro check, I/O, VS
Complications: Cushing triad
- HTN
- bradycardia
- wide pulse pressure
- change in RR
TBI - ANS - falls most common cause
Sxs: dec LOC, gait issues, visual issues, N/V, amnesia, drowsy, irritable
Primary Injury - ANS initial damage to the brain that results from the traumatic event
secondary injury - ANS brain damage that occurs as a response to the initial injury.
ex: hematoma, hypoxia, ICP, hemorrhage, herniation, hypotension (MAP >70), INCREASED CO2
(vasodilation)*FEVER*
Tx: Mannitol, elevate hob, inc respirations (get rid of CO2)
2
ANSWERS 2026 VERIFIED.
GCS Scale TBI - ANS Mild TBI (concussion): 13-15
- normal to lethargic
- LOC <30 mins
- amnesia
- dizziness/ HA/ disoriented
- irritability
Moderate TBI: 9-12
- LOC 30min- 6hrs
- lethargic to obtunded
- follows commands w/ arousal
- confused
Severe TBI: 3-8
- memory loss 24hrs
- must intubate
- not able to follow commands
Decorticate posturing - ANS
1
, Decerebrate posturing - ANS
ICP - ANS Normal 10-15
CPP= MAP-ICP (70-100)
Sxs: change in LOC, sluggish pupils, impaired eye movement, limb strength, HA, N/V, dilated
pupils
NI: LOC, neuro check, I/O, VS
Complications: Cushing triad
- HTN
- bradycardia
- wide pulse pressure
- change in RR
TBI - ANS - falls most common cause
Sxs: dec LOC, gait issues, visual issues, N/V, amnesia, drowsy, irritable
Primary Injury - ANS initial damage to the brain that results from the traumatic event
secondary injury - ANS brain damage that occurs as a response to the initial injury.
ex: hematoma, hypoxia, ICP, hemorrhage, herniation, hypotension (MAP >70), INCREASED CO2
(vasodilation)*FEVER*
Tx: Mannitol, elevate hob, inc respirations (get rid of CO2)
2
