Neuro Ch. 21 & 22

Cranial Nerves

100

The number of cranial nerves in the human body

12

200

The motor cranial nerve (name & number) that controls pupil size and pupillary constriction, and is assessed by instructing the patient to look up and down without moving their head

Oculomotor Nerve (CN III)

300

To assess this cranial nerve (name & number), you observe for facial symmetry by asking the patient to smile, frown, raise eyebrows, etc. 

Facial cranial nerve (CN VII)

400

The sensory cranial nerve (name & number) that controls sense of smell

Olfactory cranial nerve (CN I)

500

To test cranial nerve XI (Spinal Accessory nerve), the nurse should ask the patient to do what?

Shrug their shoulders

Intracranial Pressure

100

Normal intracranial pressure

0-15 mm Hg

200

Early signs and symptoms of increased ICP (must name at least 2)

Lethargy, decreasing consciousness, slowing of speech and delay in response to verbal cues

300

First three LATE signs of increased ICP

Cushing triad:

1. Rising systolic BP

2. Widening pulse pressure

3. Bradycardia with a full, bounding pulse

400

Treatment and nursing interventions for patients with increased ICP

Mannitol, decadron, maintaining HOB 20-30 degrees, maintaining head and neck in a midline position, strict I's & O's, hyperventilation if on a ventilator

500

Classic sign of increased ICP that can be viewed through an ophthalmascope. Shows swelling of the optic disc

Papilledema

Nursing Management

100

Bladder training includes toileting the patient how often?

Every 2 hours

200

After administering Mannitol, the nurse should monitor for what electrolyte imbalance?

Hyponatremia. Mannitol is an osmotic diuretic. 

300

Name three signs and symptoms of autonomic dysreflexia

Increased BP, severe headache, changes in pulse rate, sweating and flushing above the level of the spinal cord lesion, pallor and "goose bumps" below level of injury. 

400

Signs of a cerebrospinal fluid leakage

Halo sign on fluid from the nose or ear after a head injury. Blood will draw together in the middle of the gauze pad, leaving a yellow ring around the blood, indicating the presence of CSF

500

When performing a neurological assessment, what is the earliest indicator of the patient's neurologic status?

Level of consciousness

Nursing Management Continued

100

When grading reflexes, the nurse knows that a normal response is graded as what?

2/5=normal

0/5=absent, 1/5=weak, 2/5=normal, 3/5=exaggerated response, 4/5=hyperreflexia with clonus

200

A positive babinski reflex in an adult patient indicates what?

Brain damage. 

Never a normal (or good) sign in adult patients. 

300

PERRLA stands for what

Pupils Equal, Round, Reactive to Light and Accommodation

400

Type of posturing that involves the extension of the legs and internal rotation and adduction of the arms with the elbows bent upward that occurs with damage to the cortex

Decorticate Posturing

500

Type of posturing in which the arms are stiffly extended and held close to the body, and the wrists are flexed outward, typically means there is damage to the midbrain or brainstem

Decerebrate Posturing