NURS 480 Advanced Medical Surgical Nursing
Assessment 2 | Questions and correct detailed
Answers | 2026 Updates | 100% correct
What condition is caused by prolonged pressure above 15 mmHg? - ANSWER- -Increased
Intracranial Pressure
What is the normal range for intracranial pressure? - ANSWER- -10-15 mmHg
What can happen if ICP is left untreated? - ANSWER- -Cessation of breathing and cardiac
function
Arterial pressure, venous pressure, intraabdominal & intrathoracic pressure, posture,
temperature, ABGs (PaCO2 in particular) are factors that can affect - ANSWER- -ICP
What are the common causes of increased ICP? - ANSWER- -Mass (tumor, hematoma,
abscess)
Cerebral edema (contusion, meningitis)
What are the 3 factors that autoregulate in the skull if there is an increase in one or the other? -
ANSWER- -Brain, blood & CSF
What is the net pressure gradient that drives oxygen delivery to cerebral tissue (blood flow to
the brain) mL's passing through 100g of brain tissue in 1 minute - ANSWER- -Cerebral Blood
Flow (CBF)
What is the pressure needed to ensure blood flow to the brain called? - ANSWER- -Cerebral
perfusion pressure (CPP)
,What is the normal range for CCP? - ANSWER- -60-100 mmHg
Ischemia and neuronal death is associated with a CPP < ? - ANSWER- -50 mmHg
ischemia and incompatible with life are associated with a CPP <? - ANSWER- -30 mmHg
How do you calculate CPP? - ANSWER- -MAP-ICP
MAP=SBP+DBP(x2)/3
Example:
BP - 205/120/ICP - 22
205 + 240 ÷ 3
MAP= 148
CPP 126
What are the early signs of increased ICP? - ANSWER- -Decreased consciousness (most
significant sign)
Excruciating, constant headache
Nuchal rigidity (stiff neck)
Vomiting / nausea
What assessment concentrates on neurologic function and is useful to determine the level of
consciousness and monitor response to treatment? - ANSWER- -Glasgow Coma Scale
GCS eye opening response - ANSWER- -4 = spontaneous
, 3 = to speech
2 = to pain
1 = none
GCS verbal response - ANSWER- -5-Oriented
4-Confused conversation
3-Inappropriate words
2-Incomprehensible sounds
1-None
GCS motor response - ANSWER- -6-Obeys commands
5-Localizes
4-Withdraws
3-Abnormal flexion (decorticate)
2-Extension response (decerebrate)
1-None
What breathing pattern has cycles of hyperventilation and apnea? - ANSWER- -Cheyne-
Stokes
What breathing pattern is sustained, regular, rapid and deep breathing? - ANSWER- -Central
neurogenic hyperventilation
What breathing pattern has a prolonged inspiratory phase or pauses alternation with expiratory
pauses? - ANSWER- -Apneustic breathing
Assessment 2 | Questions and correct detailed
Answers | 2026 Updates | 100% correct
What condition is caused by prolonged pressure above 15 mmHg? - ANSWER- -Increased
Intracranial Pressure
What is the normal range for intracranial pressure? - ANSWER- -10-15 mmHg
What can happen if ICP is left untreated? - ANSWER- -Cessation of breathing and cardiac
function
Arterial pressure, venous pressure, intraabdominal & intrathoracic pressure, posture,
temperature, ABGs (PaCO2 in particular) are factors that can affect - ANSWER- -ICP
What are the common causes of increased ICP? - ANSWER- -Mass (tumor, hematoma,
abscess)
Cerebral edema (contusion, meningitis)
What are the 3 factors that autoregulate in the skull if there is an increase in one or the other? -
ANSWER- -Brain, blood & CSF
What is the net pressure gradient that drives oxygen delivery to cerebral tissue (blood flow to
the brain) mL's passing through 100g of brain tissue in 1 minute - ANSWER- -Cerebral Blood
Flow (CBF)
What is the pressure needed to ensure blood flow to the brain called? - ANSWER- -Cerebral
perfusion pressure (CPP)
,What is the normal range for CCP? - ANSWER- -60-100 mmHg
Ischemia and neuronal death is associated with a CPP < ? - ANSWER- -50 mmHg
ischemia and incompatible with life are associated with a CPP <? - ANSWER- -30 mmHg
How do you calculate CPP? - ANSWER- -MAP-ICP
MAP=SBP+DBP(x2)/3
Example:
BP - 205/120/ICP - 22
205 + 240 ÷ 3
MAP= 148
CPP 126
What are the early signs of increased ICP? - ANSWER- -Decreased consciousness (most
significant sign)
Excruciating, constant headache
Nuchal rigidity (stiff neck)
Vomiting / nausea
What assessment concentrates on neurologic function and is useful to determine the level of
consciousness and monitor response to treatment? - ANSWER- -Glasgow Coma Scale
GCS eye opening response - ANSWER- -4 = spontaneous
, 3 = to speech
2 = to pain
1 = none
GCS verbal response - ANSWER- -5-Oriented
4-Confused conversation
3-Inappropriate words
2-Incomprehensible sounds
1-None
GCS motor response - ANSWER- -6-Obeys commands
5-Localizes
4-Withdraws
3-Abnormal flexion (decorticate)
2-Extension response (decerebrate)
1-None
What breathing pattern has cycles of hyperventilation and apnea? - ANSWER- -Cheyne-
Stokes
What breathing pattern is sustained, regular, rapid and deep breathing? - ANSWER- -Central
neurogenic hyperventilation
What breathing pattern has a prolonged inspiratory phase or pauses alternation with expiratory
pauses? - ANSWER- -Apneustic breathing
