NRNP 6560 FINAL EXAM SOLVED QUESTIONS AND ANSWERS 2023.

NRNP 6560 FINAL EXAM SOLVED QUESTIONS AND ANSWERS 2023. NRNP Finals 6560 2023 1. coup-contrecoup injury: Dual impacting of the brain into the skull; coup injury occurs at the point of impact; contrecoup injury occurs on the opposite side of impact, as the brain rebounds. 2. Scalp laceration: what, effect, management: Primary head injury profuse bleeding - signs of hypovolemia Apply direct pressure Suture/ staple laceration Lidocaine 1% with epi to control bleeding, not close to nose/ ears 3. Skull fracture: types, effect, management: Primary head injury Simple: no displacement of bone. Observe and protect spine Depressed: bone fragment depressing thickness of scull Surgery for debridement. Give tetanus and seizure precautions Basilar: fracture at floor of skull Raccoon eye - periorbital bruising battle's sign: mastoid bruising otorrhea/ rhinorrhea - halo sign: do not obstruct flow Give Ab's Oral intubation and oral gastric instead of nasal 4. Brain injury: types, effect, management: Primary head injury Concussion: reversible change in brain functioning loss of consciousness, amnesia Do not give opioids, admit for unconsciousness greater than 2min Contusion: bruising to surface of brain with edema Frontal and temporal region Brainstem contusion: posturing, variable temp, variable vital signs N/V, dizziness, visual changes seizure precautions 5. Hematoma - neuro: types, effect, management: Epidural hematoma: commonly temporal/ parietal region with skull fracture, causing bleeding into epidural space Loss of consciousness Rapid deterioration: obtunded, contralateral hemiparesis, ipsilateral pupil dilation CT scan (non contrast) 1 / 57 NRNP Finals 6560 2023 Treatment based on Brain trauma foundation. Surgical if greater than 30cm Subdural hematoma most common type of intracranial bleed Acute (hours): drowsy, agitated, confused, headache, pupil dilation, CT scan (noncontrast) surgery for 10mm thickness or 5mm midline shift or for worsening GCS Chronic (days): headache, memory loss, incontinence CT scan (noncontrast) Surgery: burr holes/ crani 6. Cerebral edema/ ICP elevated/ herniation: symptoms, management: decreased level of consciousness Blown pupil Cushing triad: HTN (widening pulse pressure), decreased resp rate, bradycardia (means increased intracranial pressure) 7. Neuro exam components: AVPU: awake, response to verbal stimuli, painful stimuli, unresponsive GCS: 8 or below is comatose Posturing: decorticate = arms, legs in decerebrate = arms, legs out 8. Electrolyte imbalances in brain injury: Hyponatremia: SIADH and cerebral salt wasting Hypernatremia: DI (give mannitol) 9. Management of traumatic brain injury: - Consult neurosurgery - Limit secondary injury - Prevent hypotension (syst 90) and hypoxemia (PaO2 60). May give blood to improve tissue perfusion. - Treat cerebral edema: elevate bed, sedate, paralyse, mannitol, hyperventilation (PaCO2 25-30), during first 24hrs. - sedation and analgesia: opioids to reduce ICP (Fentanyl) with propofol. Could give Nimbex or Vec. to help oxygenate/ ventilate - steroids: avoid - Give mannitol or hypertonic saline for herniation: bolus then gtt. monitor serum osmolality, sodium, and bp. - Seizure precautions: give phenytoin or keppra - DVT prophylaxis: stockings, LMWH 2 / 57 NRNP Finals 6560 2023 - head injury means spine injury until proven otherwise - hypothermia: can control ICP (89 - 91F) - decompressive crani: ICP refractory to tx - brain O2 monitoring (jugular vein O2 sats) 10. ICP monitoring: For: GCS 3-8 with abnormal CT and comatose pt's with normal CT and older than 40, posturing, hypotension. Normal value: 5-10 mmHg Recommend initiating treatment if ICP 20 mmHG. Can calculate CPP (CPP = MAP - ICP). Should be 60 11. Brain death criteria: Must have all: No spontaneous movement Absence brain stem reflexes (fixed/ dilated pupils, no corneal reflexes, absent doll's eyes, absent gag, absent vestibular response) Absence breathing drive/ apnea can't be declared brain dead when: hypothermia, drug intoxication, severe electrolyte/ acid-base imbalance EEG, CTA of brain, Cerebral angiography, transcranial doppler 12. Spinal cord trauma: cause and who: - MVA, falls, acts of violence, sports, wounds - Rapid acceleration/ deceleration causes hyperextension (fall, rear-end collision)(central cord syndrome), hyperflexion (bilateral facet dislocation), vertical column loading (compression and then shattering from falls/ dive lands on butt, at C1 from diving), whiplash - Distraction injury: from hanging - penetrating trauma: from wound - pathologic fractures (osteoporosis/ cancer) mainly cervical spine. High mortality. More common in men more common in young than old 13. Fractures and vertebrae: Cervical: C1-C7. Flexible and small diameter so many fractures Thoracic (T1-T12): connected to ribs. Not common in fractures 3 / 57 NRNP Finals 6560 2023 Lumbar: L1-L5: Very mobile, requires great force to fracture Sacral 14. Spinal cord trauma assessment: - History: mechanism of injury, pt's complaints, pre-hospital tx - Physical assessment: treat airway, breathing, circulation (ABC) first. Pulm complication common in quadriplegia. Assess respiratory status: injury above C3 is resp arrest. C5 - C6 spares diaphragm so breathing exists. - grade strengthening (0= no muscle contraction, 5 = full strength) - complete lesion: pt lacks all function below level of spinal cord damage. Poor prognosis. - incomplete lesion: parts of spinal cord intact - sensory function: start at no feeling then go to feeling - evaluate back (log-roll) 15. Motor assessment in spinal cord trauma: If unable to do, # above: Deltoids (C4): shrug shoulder Biceps (C5): flex arm and push arms away Wrist (C6): try to straighten wrist while pt tries to flex Triceps (C7): extend arm and try to bend while pt prevents that Intrinsic (C8): fan fingers and push together Hip flexion (L2 - L4): bend knee and apply pressure Knee extension (L2-L4): extend knee with hip/ knee flexed 16. key signs of spinal cord injury