Exam 3 Practice

• A Glasgow Coma Scale (GCS) score of less than 8 indicates a severe traumatic brain injury (TBI) and often requires airway protection.
• Normal intracranial pressure (ICP) ranges from 7–15 mmHg.
• Oxygen is not a component of the Monro-Kellie hypothesis. The Monro-Kellie doctrine includes brain, blood, and cerebrospinal fluid (CSF).
• A late sign of increased ICP is Cushing's triad, which includes bradycardia, widened pulse pressure, and irregular respirations.
• Spinal shock is characterized by flaccid paralysis and loss of reflexes below the injury.
• Mannitol is an osmotic diuretic used to draw fluid out of brain tissue and reduce ICP.
• Multiple sclerosis (MS) causes demyelination in the central nervous system (CNS).
• Relapsing-remitting MS is the most common type, characterized by periods of remission and flare-ups.
• Transient ischemic attacks (TIAs) are transient and do not cause permanent damage.
• Cerebral Perfusion Pressure (CPP) is calculated as CPP = MAP (Mean Arterial Pressure) – ICP, representing brain blood flow.
• The main goal of a neuro assessment is to evaluate cognitive, sensory, and motor function.
• Pupil size and reactivity in neurological exams reflect brainstem pressure and the potential for brain herniation or increased ICP.
• Classic signs of autonomic dysreflexia include hypertension (HTN), bradycardia, and severe headache.
• Signs of a basilar skull fracture include Battle sign, Raccoon eyes, and CSF leakage.
• Actions expected for a patient with increased ICP include elevating the head of the bed (HOB) to 30 degrees, avoiding hypotonic fluids, and temperature control.
• Common symptoms of MS include muscle weakness and spasticity.
• Risk factors for stroke include hypertension, smoking, diabetes, and the use of oral contraceptives.
• The Glasgow Coma Scale (GCS) is used to assess consciousness by measuring eye, verbal, and motor responses.
• Cushing's triad includes widened pulse pressure, bradycardia, and irregular respirations.
• High-risk groups for TBI include infants, athletes, the elderly, and adolescents.
• A GCS score of 8 or less often requires airway support, thus the nurse's priority action is to prepare to intubate.
• An ICP greater than 20 mmHg requires intervention to prevent herniation with immediate neurosurgical consult.
• Signs of increased ICP and herniation need urgent action and the nurse would need to notify the provider.
• Sudden symptoms in MS may indicate a flare-up, so the nurse should notify the provider about a possible relapse.
• Non-contrast CT scans are performed to exclude hemorrhagic stroke before administering thrombolytics, so the nurse should order this test.

Nursing Interventions

• First priority is to reduce blood pressure (BP) and prevent stroke with a patient with suspected autonomic dysreflexia; elevate HOB immediately.
• Antihypertensives help manage cerebral pressure and bleeding in hemorrhagic stroke to reduce ICP.
• Improved LOC indicates effective ICP reduction and better cerebral perfusion after administering Mannitol.

Additional Information

• Classic signs of neurogenic shock include bradycardia and hypotension due to autonomic disruption.
• Use thickened liquids to prevent aspiration in patients with dysphagia post-stroke.
• Neurogenic shock is characterized by hypotension, bradycardia, and warm, dry skin.
• Widened pulse pressure, bradycardia, and irregular respirations indicate rising ICP, known as Cushing's triad.
• Epidural hematomas are usually arterial, and patients may deteriorate rapidly after a brief lucid interval, requiring rapid arterial bleeding requiring surgery.
• Signs of brain herniation include dilated pupils, changes in the level of consciousness (LOC), flaccidity, and vomiting.
• A CT scan without contrast, electrolyte panel, MRI, carotid ultrasound, and echocardiogram all help confirm stroke and guide treatment.
• MS progression is indicated by increased spasticity, visual changes, fatigue, and gait imbalance.
• Secondary TBI injuries include cerebral edema, hypoxia, inflammatory response, and axonal damage.
• Patients with a brain contusion, post-stroke, increased ICP, and MS flare-ups are at risk for seizures, thus require seizure precautions due to brain inflammation or injury. Hyperthyroidism is not associated with seizures.
• Transient ischemic attacks (TIAs) are warning signs, and stroke prevention strategies must be initiated, including the initiation of stroke prevention measures.
• CSF often contains glucose, differentiating it from nasal secretions, so the nurse should test for this with CSF leakage.
• A stabilized Cerebral Perfusion Pressure (CPP) indicates effective cerebral perfusion after surgical decompression.
• A return of motor function suggests reperfusion and effective stroke treatment.
• MS is chronic and incurable, though manageable, so the patient needs further education stating that their MS can be cured with the right treatment.
• Injuries above C5 can impair diaphragmatic function, making a respiratory rate of 8 the priority concern for a patient with a spinal cord injury at C4.
• Heart rate stabilizing at 80 bpm indicates autonomic recovery and resolution of neurogenic shock.
• Use a mirror for feedback during Activities of Daily Living (ADLs) to help address neglect and improve body awareness post-stroke.
• A drop of more than 2 points on the Glasgow Coma Scale (GCS) indicates significant neuro decline. For example, a nurse should be most concerned about a GCS score change from 13 to 11 in a TBI patient.
• Patient education should focus on early stroke recognition and action, emphasizing the importance of recognizing FAST (Face, Arms, Speech, Time) warning signs.
• Honest and hopeful communication is best regarding prognosis after a TBI; outcomes vary, and monitoring is essential with communication to the patient family.
• Improvement in motor symptoms indicates a positive response to receiving steroids for an MS flare-up.
• A GCS less than or equal to 8 often requires airway support, thus the nurse should prepare the patient for intubation if needed.
• Signs of increased ICP and potential herniation necessitate urgent action, requiring the nurse to immediately notify the healthcare provider.
• New or sudden symptoms in a patient with MS may indicate a flare-up, but further teaching may be required.
• Elevate the head of the bed quickly to reduce blood pressure and prevent future stroke issues..
• Administering anti-hypertensives helps manage cerebral pressure and reduce bleeding in hemorrhagic stroke, to ultimately reduce ICP.
• Classic signs of neurogenic shock due to autonomic disruption include bradycardia and low blood pressure.
• Use thickened liquids to prevent aspiration for stroke patients suffering from dysphagia, where aspiration is likely.
• Classic issues with a widening pulse pressure are the combination of bradycardia and irregular respirations, these are all indicators of rising ICP.
• A patient who deteriorated after a lucid interval likely have an epidural hematomas are usually arterial, patients may seem fine briefly then deteriorate rapidly.
• Dilated pupils, LOC change, flaccidity, and vomiting are also potential signs of brain herniation.
• CT scan without contrast Electrolyte panel, MRI, Carotid Ultrasound, Echocardiogram are tools that can help confirm a stroke type.
• MS can be marked by Spasticity, vision changes, fatigue, and poor balance.
• Secondary TBI injuries include inflammation, edema, hypoxia, and axonal damage injuries to the brain.
• TIA is often a indicator of a more severe or prolonged brain event.