MED SURG II FINAL STUDY GUIDE EXAM QUESTIONS WITH CORRECT VERIFIED ANSWERS | 100% PASS (A+ CERTIFIED)

1. ICP Answer intracranial pressure - 10% CSF - 12% blood - 78% brain tissue - any changes in ANY volume will cause changes in pressure in the brain -- if one component increases, another must decrease to maintain normal - ability to compensate is limited 2. normal ICP range Answer 5-15 mHg - elevated if 20 mmHg sustained 3. ICP sx Answer change in LOC: PRIORITY - Cushing's Triad - ocular signs - compression of oculomotor nerve: unilateral pupil dialation, sluggish or no response to light, inability to move eye upward, eyelid ptosis - diplopia, blurred vision, EOM changes - decrease in motor function: hemiparesis/hemiplegia, decerebrate posturing, decorticate posturing - headache that is continuous and worse in the AM - projectile vomiting with no nausea beforehand 4. CPP equation Answer MAP-ICP - normal is 60-100 - MAP: SBP+2(DBP)/3 5. ngt/ogt related to head injuries Answer avoid gastric dilation - prevent aspiration - start nutritional supplement early 6. ventriculostomy purpose Answer tx interstitial cerebral edema - monitoring ICP, brain perfusion - tube drains the excess fluid -- if indicated, can be intermittent or continuously 7. ventriculostomy management Answer evaluate pt condition - ensure no leaks, kinks, blocks, differences in height, incorrect height, bubbles, and air - carefully monitor the volume drained - prevent infection 8. ICP and hyponatremia Answer hyponatremia can increase ICP with cerebral edema -- osmotically driven movement of water into the brain - manage fluid and electrolyte balance -- IV hypertonic saline - monitor for DI or SIADH 9. improving cerebral perfusion Answer maintain head in midline position, prevent extreme neck flexion - HOB elevated, not 30 degrees - turn slowly - avoid coughing, straining, valsalva -- increases intrathoracic pressure contributes to increased ICP by impending the venous return - avoid hip flexion: decrease the risk of raising the intra-abdomnial pressure, which increase ICP 10. mannitol Answer plasma expander - osmotic diuretic - monitor fluid and electrolyte status - decreases cerebral edema - used to treat h/a associated w increased ICP 11. concussion D/C teaching Answer report: headache that worsens or doesnt go away, nausea, uncontrolled vomiting, increased confusion, change of personality, drowsiness/inability to wake up, slurred speech, weakness, numbness, seizures, loss of consciousness, - ensure rest then gradually return to regular activities - ibuprofen or acetaminophen for headaches 12. subdural hematoma sx Answer sx can show like increased ICP - decreased LOC - headache - ipsilateral pupil dialtion or fixed pupil with severe 13. blood thinners with head injuries Answer ensure assessment of if pt is on anticoags - contusions can have an increased risk of hemorrhage if on anticoags 14. battle's sign Answer sign of head injury (basilar skull fracture) - postauricular ecchymosis (bruising behind the ear) - may mean that there is a significant internal injury to the brain 15. racoon eyes Answer sign of head injury - bruising around the eyes (periorbital ecchymosis) - can be a sign of skull or facial fracture (very classic sign of basilar skull fracture) - can also be a sign of subgaleal hematoma 16. emergent interventions of epidural hematomas & s/sx Answer sx: unconsciousness, brief lucid interval, followed by decrease in LOC, HA, N/V, focal findings - rapid evacuation: craniotomy if swelling is extreme, burr-holes 17. measure for leaking CSF Answer HOB elevated - loose collection pad under nose/over ear - no sneezing or blowing nose - no NG tube - no nasotracheal suctioning - monitor for with battles sign and racoon eyes 18. how to verify the presence of CSF Answer Dextrostix or Tes-Tape strip: test leaking fluid using a strip to determine whether glucose is present (cerebral spinal fluid gives a positive reading; do not test with blood if in the fluid bc blood carries glucose) - Halo or ring sign (if blood present in leakage): allow leaking fluid to drip onto a white gauze pad and observe the drainage (blood coalesces into the center and a yellowish ring encircles the blood if CSF is present)