NURS 331 FINAL EXAM QUESTIONS AND VERIFIED
DETAILED ANSWERS
LOC - ANSWER - The most significant clinical indicator of nervous system functioning
- Changes reflect either an improvement or decline of the patient's status
- To be alert, fully conscious an intact reticular activating system (RAS) must exist along
with proper functioning of higher centers of brain in the cerebral cortex
An individual who is ____________________ is judged to be working at the highest state of
alertness - ANSWER - alert and oriented
Components of Consciousness - ANSWER 1. Arousal: the state of awakeness of a
person, mediated by Reticular Activating System (brain stem)
2. Content of thought: involves all cognitive functions; awareness of self, environment, &
affective states (mood)
Alterations in Consciousness - ANSWER 1. Confusion: loss of ability to think quickly
2. Disorientation: to time, place, and lastly self
3. Lethargy: limited spontaneous movement or speech, will arouse when name is called
or touched
4. Obtunded: falls asleep unless stimulated verbally or tactilely
5. Stupor: vigorous and repeated stimulation needed for arousal
6. Coma: no arousal to any stimulus
Glasgow Coma Scale - ANSWER uses eye opening response, best verbal response, and
best motor response; score ranges from 3-15; score less than 14 is abnormal
Breathing patterns are controlled by - ANSWER cerebrum (pattern) and medulla (rate)
,When the breathing control center is lost with cerebral damage, the _________ regulates
the breathing pattern by responding only to changes in the Pa____ levels. - ANSWER
lower brain stem; CO2
Cheyne-Stokes - ANSWER respirations cease (apnea) until carbon dioxide builds up to a
certain threshold and causes the individual to hyperventilate until carbon dioxide is
removed
With respiration, brain stem damage leads to - ANSWER erratic and unpredictable
respirations
Opioid effect on respiration - ANSWER Opiate overdose impacts the respiratory
center/medulla oblongata and leads to a gradual slowing of the respiration rate until
breathing stops
Pupil changes that accompany brain injury - ANSWER - Constricted pupils associated
with opiates overdose (heroin, morphine),
Fixed and dilated pupils bilaterally-usually with hypoxia
A failing pupil response may be the first indication of impending brain herniation
Mild dilation with sluggish or absent light response is ominous
Doll's eye phenomenon (Oculocephalic reflex)- ANSWER 1. Normal: eyes move with
head movement (positive)
2. Abnormal: eyes remain fixed in forward position (negative); brain stem is not intact
Cold caloric stimulation (Vestibuloocular reflex) - ANSWER - cold water dropped into ear
1. Normal: eyes move symmetrically toward stimulus and pt throws up or gets nauseous
2. Abnormal: eyes are fixed forward, or only one eye moves towards stimulus and pt
does not get nauseous
, Purposeful movement requires an intact ___________ system - ANSWER corticospinal
Decorticate vs Decerebrate Posturing - ANSWER Decorticate: brain stem intact-less
severe, loss of cerebral cortex functioning-internally rotated; hands make C shape at
chest
Decerebrate: may indicate more serious damage and results from disruption of higher
brain centers and the brainstem-externally rotated; hands make e shape by sides
The balance between what components maintains the ICP - ANSWER brain tissue,
blood, and CSF
Factors that influence ICP - ANSWER 1. Changes in brain tissue, blood, or CSF
2. Pressure changes (arterial, venous, or intra-abdominal/intrathoracic pressure,
vomiting, coughing, suctioning, seizures)
3. Posture changes, ROM, pain stimuli
4. Temperature changes
5. Blood gases changes (CO2- causes vasodilation which increases blood flow and ICP)
Normal ICP - ANSWER Normal is 0-15 mmHg; ICP > 20 mmHg is a poor prognosis
Stages of ICP Stage 1-ANSWER alert and awake, compensatory mechanisms
(vasoconstriction), ICP may not rise
Stages of ICP Stage 2-ANSWER confusion, slight changes in pupils and breathing,
constriction of systemic arteries
Stages of ICP Stage 3-ANSWER decreased LOC, hyperventilation, bradycardia, wide
pulse pressure, ICP approaches BP, brain hypoxia
DETAILED ANSWERS
LOC - ANSWER - The most significant clinical indicator of nervous system functioning
- Changes reflect either an improvement or decline of the patient's status
- To be alert, fully conscious an intact reticular activating system (RAS) must exist along
with proper functioning of higher centers of brain in the cerebral cortex
An individual who is ____________________ is judged to be working at the highest state of
alertness - ANSWER - alert and oriented
Components of Consciousness - ANSWER 1. Arousal: the state of awakeness of a
person, mediated by Reticular Activating System (brain stem)
2. Content of thought: involves all cognitive functions; awareness of self, environment, &
affective states (mood)
Alterations in Consciousness - ANSWER 1. Confusion: loss of ability to think quickly
2. Disorientation: to time, place, and lastly self
3. Lethargy: limited spontaneous movement or speech, will arouse when name is called
or touched
4. Obtunded: falls asleep unless stimulated verbally or tactilely
5. Stupor: vigorous and repeated stimulation needed for arousal
6. Coma: no arousal to any stimulus
Glasgow Coma Scale - ANSWER uses eye opening response, best verbal response, and
best motor response; score ranges from 3-15; score less than 14 is abnormal
Breathing patterns are controlled by - ANSWER cerebrum (pattern) and medulla (rate)
,When the breathing control center is lost with cerebral damage, the _________ regulates
the breathing pattern by responding only to changes in the Pa____ levels. - ANSWER
lower brain stem; CO2
Cheyne-Stokes - ANSWER respirations cease (apnea) until carbon dioxide builds up to a
certain threshold and causes the individual to hyperventilate until carbon dioxide is
removed
With respiration, brain stem damage leads to - ANSWER erratic and unpredictable
respirations
Opioid effect on respiration - ANSWER Opiate overdose impacts the respiratory
center/medulla oblongata and leads to a gradual slowing of the respiration rate until
breathing stops
Pupil changes that accompany brain injury - ANSWER - Constricted pupils associated
with opiates overdose (heroin, morphine),
Fixed and dilated pupils bilaterally-usually with hypoxia
A failing pupil response may be the first indication of impending brain herniation
Mild dilation with sluggish or absent light response is ominous
Doll's eye phenomenon (Oculocephalic reflex)- ANSWER 1. Normal: eyes move with
head movement (positive)
2. Abnormal: eyes remain fixed in forward position (negative); brain stem is not intact
Cold caloric stimulation (Vestibuloocular reflex) - ANSWER - cold water dropped into ear
1. Normal: eyes move symmetrically toward stimulus and pt throws up or gets nauseous
2. Abnormal: eyes are fixed forward, or only one eye moves towards stimulus and pt
does not get nauseous
, Purposeful movement requires an intact ___________ system - ANSWER corticospinal
Decorticate vs Decerebrate Posturing - ANSWER Decorticate: brain stem intact-less
severe, loss of cerebral cortex functioning-internally rotated; hands make C shape at
chest
Decerebrate: may indicate more serious damage and results from disruption of higher
brain centers and the brainstem-externally rotated; hands make e shape by sides
The balance between what components maintains the ICP - ANSWER brain tissue,
blood, and CSF
Factors that influence ICP - ANSWER 1. Changes in brain tissue, blood, or CSF
2. Pressure changes (arterial, venous, or intra-abdominal/intrathoracic pressure,
vomiting, coughing, suctioning, seizures)
3. Posture changes, ROM, pain stimuli
4. Temperature changes
5. Blood gases changes (CO2- causes vasodilation which increases blood flow and ICP)
Normal ICP - ANSWER Normal is 0-15 mmHg; ICP > 20 mmHg is a poor prognosis
Stages of ICP Stage 1-ANSWER alert and awake, compensatory mechanisms
(vasoconstriction), ICP may not rise
Stages of ICP Stage 2-ANSWER confusion, slight changes in pupils and breathing,
constriction of systemic arteries
Stages of ICP Stage 3-ANSWER decreased LOC, hyperventilation, bradycardia, wide
pulse pressure, ICP approaches BP, brain hypoxia
