Nuero Assessment
Which neurological assessment parameter is considered the most basic and critical indicator of neurologic function?
Level of consciousness (LOC).
What is the normal intracranial pressure (ICP) range in adults according to the study guide?
0–15 mmHg.
Which diagnostic test is commonly used first to identify acute intracranial bleeding after a traumatic brain injury?
Noncontrast CT scan
What type of shock is commonly associated with hypotension and bradycardia following severe cervical or upper thoracic spinal cord injury?
Neurogenic shock
During the primary trauma assessment, what does ABC stand for?
Airway, Breathing, Circulation.
A patient exhibits abnormal extension of the upper and lower extremities in response to painful stimulation. What type of posturing is this?
Decerebrate posturing.
What three components are included in the Monro–Kellie doctrine?
Brain tissue, blood, and cerebrospinal fluid (CSF).
Which blood vessel is most commonly associated with an epidural hematoma?
A. Bridging veins
B. Middle meningeal artery
C. Internal jugular vein
D. Superior vena cava
B. Middle meningeal artery.
What is the primary difference between spinal shock and neurogenic shock?
Spinal shock is temporary loss of motor, sensory, and reflex function below the injury. Neurogenic shock is cardiovascular dysfunction due to loss of sympathetic tone.
Bruising behind the ear over the mastoid process following head trauma is known as what sign, and what fracture can it indicate?
Battle sign; basilar skull fracture.
Which pupil finding is most concerning for possible uncal herniation?
A. Bilateral pupils equal and reactive
B. Unilateral dilated, nonreactive pupil
C. Pupils constricting to light
D. Pupils equal at 3 mm
B. Unilateral dilated, nonreactive pupil.
A patient has a MAP of 90 mmHg and an ICP of 22 mmHg. Calculate the cerebral perfusion pressure (CPP).
CPP = 68 mmHg
A subdural hematoma occurs between which two meningeal layers, and is the bleeding typically arterial or venous?
Between the dura mater and arachnoid mater; typically venous bleedi
Which assessment finding suggests an incomplete spinal cord injury?
A. Flaccid paralysis below the injury
B. Absent patellar reflexes
C. Preserved voluntary perianal contraction
D. Hypotension with bradycardia
Copy question
C. Preserved voluntary perianal contraction.
A trauma patient arrives with BP 78/44 mmHg, HR 132/min, and cool, clammy skin. Which type of shock should the nurse strongly suspect?
Hemorrhagic shock.
A patient opens their eyes to pain, speaks inappropriate words, and withdraws from painful stimulation. What is the Glasgow Coma Scale score?
GCS = 9 (E2 + V3 + M4).
A patient with increased ICP is lying flat with their head rotated to one side. Which positioning intervention should the nurse prioritize, assuming no contraindications?
Elevate the head of bed approximately 30 degrees and maintain the head and neck in neutral alignment.
Following a high-speed motor vehicle collision, a patient remains unconscious. The CT scan shows no large hematoma, but MRI later demonstrates small hemorrhages in deep white matter. What brain injury should the nurse suspect?
Diffuse axonal injury (DAI)
A patient with a high thoracic SCI suddenly develops BP 210/110 mmHg, a pounding headache, flushing above the injury, and bradycardia. What complication should the nurse suspect, and what is the first intervention?
Autonomic dysreflexia. Immediately sit the patient upright/elevate the HOB, monitor BP, and assess for triggers beginning with bladder distention or catheter obstruction.
An unconscious patient arrives after a motor vehicle collision with suspected cervical spine injury, facial trauma, and noisy respirations. What is the nurse's immediate priority?
Copy question
Establish and protect the airway while maintaining cervical spine stabilization.
A patient with a traumatic brain injury becomes increasingly restless and confused. Their GCS decreases from 14 to 11. The pupils remain equal and reactive. What is the nurse's priority?
Recognize and immediately report the neurological deterioration, reassess airway/oxygenation and vital signs, and initiate urgent evaluation.
A patient with severe TBI has ICP 28 mmHg, MAP 76 mmHg, and PaCO₂ 55 mmHg. Calculate CPP and explain how the PaCO₂ can affect ICP.
CPP = 48 mmHg. Elevated PaCO₂ causes cerebral vasodilation, increases cerebral blood volume, and can further increase ICP.
A patient with severe TBI develops an SpO₂ of 86%, BP 82/48 mmHg, and decreasing LOC. Which two physiologic problems must the nurse address immediately to prevent secondary brain injury?
Hypoxia and hypotension. Support the airway and oxygenation while urgently restoring adequate perfusion.
A patient with a high-level spinal cord injury develops autonomic dysreflexia. Which actions are appropriate? Select all that apply.
A. Sit the patient upright
B. Check BP frequently
C. Assess the urinary catheter for obstruction
D. Lay the patient flat
E. Evaluate for fecal impaction after bladder causes are addressed
Copy question
A, B, C, and E
A trauma patient with suspected cervical SCI has BP 80/46 mmHg, HR 42/min, warm skin, and difficulty breathing. Identify the likely shock state, explain its cause, and name two immediate nursing priorities.
Likely neurogenic shock from loss of sympathetic tone. Priorities include airway/ventilation support with cervical stabilization and urgent hemodynamic assessment and treatment to maintain perfusion.