NUR 405 Exam 1 UPDATED Questions and
CORRECT Answers
List the layers in the head starting from the skull and ending with brain tissue - CORRECT ANSWER -skull >
epidural space > dura > subdural space > arachnoid > subarachnoid space > pia mater > brain tissue
What is the normal ICP? - CORRECT ANSWER -5-15
Define MAP - CORRECT ANSWER -The average pressure in the arteries during one cardiac cycle; reflects overall
tissue perfusion
What is the normal range for MAP? - CORRECT ANSWER ->60
What is the math equation to calculate a patients MAP? - CORRECT ANSWER -SBP + 2(DBP) /3 = MAP
Define CPP - CORRECT ANSWER -The amount of pressure driving blood flow to the brain
What is a normal CPP? - CORRECT ANSWER -70-80
How do you calculate a patients CPP? - CORRECT ANSWER -MAP - ICP = CPP
If the CPP is below 50, what will you see? - CORRECT ANSWER -Ischemia
If the CPP is below 30, what will you see? - CORRECT ANSWER -Brain tissue death
*The higher the ICP, the higher the MAP needs to be to maintain CPP* - CORRECT ANSWER -*The higher the
ICP, the higher the MAP needs to be to maintain CPP*
List 4 factors that impair intracranial regulation and examples of each - CORRECT ANSWER -Impaired perfusion
= HF, COPD, shock
Compromised neurotransmission = ALS, cerebral palsy
Pathology = hydrocephalus, meningitis
Glucose regulation = hypoglycemia will see AMS
Define the monro-kellie hypothesis - CORRECT ANSWER -Any increase in the volume of one of the components
requires compensatory decrease in another to maintain a constant intracranial pressure; otherwise ICP will rise, potential
leading to brain damage
List the patho in order of what happens when ICP is increase - CORRECT ANSWER -Increased ICP > decreased
cerebral perfusion > edema of the brain > brain shift > herniation [can see bulging eyes]
List factors that can increase ICP - CORRECT ANSWER -Can be managed by nursing:
- temperature
- arterial and venous pressure
- O2 and CO2
- position
- abdominal and thoracic pressure
Managed by medical interventions
- cerebral edema
- bleeds
- tumors
- trauma
- hydrocephalus
- aneurysms
What is the BI-FORM? - CORRECT ANSWER -Helps anticipate brain deficits patients may have
,What are some psychosocial impacts on health from an increased ICP? - CORRECT ANSWER -- social cognition
- challenges to inhibitory control [When ICP rises, the brain struggles to regulate (inhibit) excessive blood flow and
pressure — this impairs autoregulation, leading to worsening swelling, ischemia, and further ↑ICP.]
- worsening executive function
What are some impacts on a patients diet when they have increased ICP? - CORRECT ANSWER -- at risk for
malnutrition
- give them high protein diets
- they have an increased metabolic demand
- they have ebb and flow phases
What is cushings triad? - CORRECT ANSWER -- increased SBP
- decreased HR
- decreased RR
*the bigger the pulse pressure the worse it is*
What are early clinical manifestations of increased ICP? - CORRECT ANSWER -- change in mental status [often
the first sign]
- headache
- n/v
- visual changes [blurred/double]
What are late clinical manifestations of increased ICP? - CORRECT ANSWER -- cushings triad
- pupils fixed and dilated
- difference in respirations [example: cheyne stokes/ataxic]
- posturing [decorticate (IN) and decerebrate (OUT)]
- coma
List diagnostic tests for increased ICP - CORRECT ANSWER -- physical assessment
- GCS!!!!!!!
- CT
- monitoring via invasive [use more frequ. with a drain] or non-invasive
What 3 categories does the GCS test? - CORRECT ANSWER -- eye opening response
- verbal response
- motor response
List the responses for "eye opening" in the GCS - CORRECT ANSWER -4. spontaneously
3. to speech
2. to pain
1. no response
List the responses for "verbal response" in the GCS - CORRECT ANSWER -5. oriented to time, person place
4. confused
3. inappropriate words
2. incomprehensible words
1. no response
List the responses for "motor response" in the GCS - CORRECT ANSWER -6. obeys commands
5. moves to localized pain [touch their right shoulder and left hand crosses midline]
4. flex to withdraw from pain [they purposefully take their hand away]
3. abnormal flexion [decorticate]
2. abnormal extension [decerebrate]
1. no response
Define lethargic - CORRECT ANSWER -Oriented when awake but will sleep if left alone; requires verbal or
gentle touch to initiate response but is easily arouseable
, Define somnolent - CORRECT ANSWER -Awakens to simple stimuli [voice/touch] and follows commands but
requires sustained stimulation to stay awake
Define obtunded - CORRECT ANSWER -Requires repeated moderate stimulation to maintain attention, responds
slow and goes back to sleep
Define stupor - CORRECT ANSWER -Aroused by vigorous stimuli, decreased reaction to external stimuli
List the treatments and therapies for a patient with increased ICP - CORRECT ANSWER -Nursing measures to
decrease stimulation at all times
Oxygen
- hypoxia causes vasodilation and causes ischemia > give o2 to treat
RR (acidosis/alkalosis)
- CO2 is a potent vasodilator, hyperventilate is appropriate to treat
Maintain CPP
- cardiac output and BP management via fluids/pressors
Decrease metabolic rate
- control temp
Monitor
- VS, neuro, ICP, fluid balance, level of consciousness
- UO: >200 mL/hr for 2 consecutive hours is a concern for DI!
Good oral care
- mouth is inspected for dryness, inflammation, crusting
- risk of parotitis if not kept clean
- thin coating of petrolatum on lips for drying
- if ET tube, move it side to side to prevent breakdown
- clean with chlorhexidine and keep HOB elevated to decrease VAP
Pharmacological
- anticonvulsants, sedation, barbituates, neuromusuclar blocking agents, osmotic diuretics, glucose management
List the 4 types of surgical management for a patient with increased ICP - CORRECT ANSWER --
hemicraniectomy
- burr holes
- bolts
- *ventriculostomy [has the drain]*
For a patient with increase ICP, how do you want them positioned in bed? - CORRECT ANSWER -- HOB >30 deg
- head and neck midline
- knees straight > NOT BENT
How can temperature affect ICP? - CORRECT ANSWER -Hyperthermia: causes vasodilation and increases ICP
Hypothermia: causes shivering and increases ICP
How do we treat cerebral edema? - CORRECT ANSWER -Mannitol and/or 3% NS
Why are we cautious with lumbar punctures in a patient with increased ICP? - CORRECT ANSWER -Can pull
down brain into herniation when pulling from lumbar puncture
List interventions for hypoxia - CORRECT ANSWER -- maintain O2
- monitor ABGs
- suction PRN
- maintain airway
CORRECT Answers
List the layers in the head starting from the skull and ending with brain tissue - CORRECT ANSWER -skull >
epidural space > dura > subdural space > arachnoid > subarachnoid space > pia mater > brain tissue
What is the normal ICP? - CORRECT ANSWER -5-15
Define MAP - CORRECT ANSWER -The average pressure in the arteries during one cardiac cycle; reflects overall
tissue perfusion
What is the normal range for MAP? - CORRECT ANSWER ->60
What is the math equation to calculate a patients MAP? - CORRECT ANSWER -SBP + 2(DBP) /3 = MAP
Define CPP - CORRECT ANSWER -The amount of pressure driving blood flow to the brain
What is a normal CPP? - CORRECT ANSWER -70-80
How do you calculate a patients CPP? - CORRECT ANSWER -MAP - ICP = CPP
If the CPP is below 50, what will you see? - CORRECT ANSWER -Ischemia
If the CPP is below 30, what will you see? - CORRECT ANSWER -Brain tissue death
*The higher the ICP, the higher the MAP needs to be to maintain CPP* - CORRECT ANSWER -*The higher the
ICP, the higher the MAP needs to be to maintain CPP*
List 4 factors that impair intracranial regulation and examples of each - CORRECT ANSWER -Impaired perfusion
= HF, COPD, shock
Compromised neurotransmission = ALS, cerebral palsy
Pathology = hydrocephalus, meningitis
Glucose regulation = hypoglycemia will see AMS
Define the monro-kellie hypothesis - CORRECT ANSWER -Any increase in the volume of one of the components
requires compensatory decrease in another to maintain a constant intracranial pressure; otherwise ICP will rise, potential
leading to brain damage
List the patho in order of what happens when ICP is increase - CORRECT ANSWER -Increased ICP > decreased
cerebral perfusion > edema of the brain > brain shift > herniation [can see bulging eyes]
List factors that can increase ICP - CORRECT ANSWER -Can be managed by nursing:
- temperature
- arterial and venous pressure
- O2 and CO2
- position
- abdominal and thoracic pressure
Managed by medical interventions
- cerebral edema
- bleeds
- tumors
- trauma
- hydrocephalus
- aneurysms
What is the BI-FORM? - CORRECT ANSWER -Helps anticipate brain deficits patients may have
,What are some psychosocial impacts on health from an increased ICP? - CORRECT ANSWER -- social cognition
- challenges to inhibitory control [When ICP rises, the brain struggles to regulate (inhibit) excessive blood flow and
pressure — this impairs autoregulation, leading to worsening swelling, ischemia, and further ↑ICP.]
- worsening executive function
What are some impacts on a patients diet when they have increased ICP? - CORRECT ANSWER -- at risk for
malnutrition
- give them high protein diets
- they have an increased metabolic demand
- they have ebb and flow phases
What is cushings triad? - CORRECT ANSWER -- increased SBP
- decreased HR
- decreased RR
*the bigger the pulse pressure the worse it is*
What are early clinical manifestations of increased ICP? - CORRECT ANSWER -- change in mental status [often
the first sign]
- headache
- n/v
- visual changes [blurred/double]
What are late clinical manifestations of increased ICP? - CORRECT ANSWER -- cushings triad
- pupils fixed and dilated
- difference in respirations [example: cheyne stokes/ataxic]
- posturing [decorticate (IN) and decerebrate (OUT)]
- coma
List diagnostic tests for increased ICP - CORRECT ANSWER -- physical assessment
- GCS!!!!!!!
- CT
- monitoring via invasive [use more frequ. with a drain] or non-invasive
What 3 categories does the GCS test? - CORRECT ANSWER -- eye opening response
- verbal response
- motor response
List the responses for "eye opening" in the GCS - CORRECT ANSWER -4. spontaneously
3. to speech
2. to pain
1. no response
List the responses for "verbal response" in the GCS - CORRECT ANSWER -5. oriented to time, person place
4. confused
3. inappropriate words
2. incomprehensible words
1. no response
List the responses for "motor response" in the GCS - CORRECT ANSWER -6. obeys commands
5. moves to localized pain [touch their right shoulder and left hand crosses midline]
4. flex to withdraw from pain [they purposefully take their hand away]
3. abnormal flexion [decorticate]
2. abnormal extension [decerebrate]
1. no response
Define lethargic - CORRECT ANSWER -Oriented when awake but will sleep if left alone; requires verbal or
gentle touch to initiate response but is easily arouseable
, Define somnolent - CORRECT ANSWER -Awakens to simple stimuli [voice/touch] and follows commands but
requires sustained stimulation to stay awake
Define obtunded - CORRECT ANSWER -Requires repeated moderate stimulation to maintain attention, responds
slow and goes back to sleep
Define stupor - CORRECT ANSWER -Aroused by vigorous stimuli, decreased reaction to external stimuli
List the treatments and therapies for a patient with increased ICP - CORRECT ANSWER -Nursing measures to
decrease stimulation at all times
Oxygen
- hypoxia causes vasodilation and causes ischemia > give o2 to treat
RR (acidosis/alkalosis)
- CO2 is a potent vasodilator, hyperventilate is appropriate to treat
Maintain CPP
- cardiac output and BP management via fluids/pressors
Decrease metabolic rate
- control temp
Monitor
- VS, neuro, ICP, fluid balance, level of consciousness
- UO: >200 mL/hr for 2 consecutive hours is a concern for DI!
Good oral care
- mouth is inspected for dryness, inflammation, crusting
- risk of parotitis if not kept clean
- thin coating of petrolatum on lips for drying
- if ET tube, move it side to side to prevent breakdown
- clean with chlorhexidine and keep HOB elevated to decrease VAP
Pharmacological
- anticonvulsants, sedation, barbituates, neuromusuclar blocking agents, osmotic diuretics, glucose management
List the 4 types of surgical management for a patient with increased ICP - CORRECT ANSWER --
hemicraniectomy
- burr holes
- bolts
- *ventriculostomy [has the drain]*
For a patient with increase ICP, how do you want them positioned in bed? - CORRECT ANSWER -- HOB >30 deg
- head and neck midline
- knees straight > NOT BENT
How can temperature affect ICP? - CORRECT ANSWER -Hyperthermia: causes vasodilation and increases ICP
Hypothermia: causes shivering and increases ICP
How do we treat cerebral edema? - CORRECT ANSWER -Mannitol and/or 3% NS
Why are we cautious with lumbar punctures in a patient with increased ICP? - CORRECT ANSWER -Can pull
down brain into herniation when pulling from lumbar puncture
List interventions for hypoxia - CORRECT ANSWER -- maintain O2
- monitor ABGs
- suction PRN
- maintain airway
