Final Exam: NR574/ NR 574 (2023/2024 Latest Update) Acute Care Practicum Review | Week 5-8 | Questions and Verified Answers| 100% Correct- Chamberlain

Final Exam: NR574/ NR 574 (2023/2024

Latest Update) Acute Care Practicum Review

| Week 5-8 | Questions and Verified Answers|

100% Correct- Chamberlain

Q: Glascow Coma Scale (GCS)

Answer:

Neurologic assessment of a patie response, eye opening, and motor function.

Q: Calculate the GCS for Aasan.

Aasan, an elderly client, was brought to the emergency department by EMS following a fall.

There is a large laceration on his occiput with profuse bleeding. He opens his eyes when you

speak to him, but his responses are incompre- hensible. He responds to localized painful stimuli.

Aasan's GCS is 10.

Answer:

Ratio- nale: Aasan's GCS score is

Q: He opens his eyes to voice (3), incomprehensible speech (2), responds to localized pain (5).

Q: Roy has a suspected head injury. Which of the following clinical findings increases

suspicion for a basilar skull fracture?

a. Periorbital ecchymosis (Correct answer)

b. A large, gaping forehead laceration with profuse bleeding c. Palpable bony step-off on the top

of the skull

d. Motor and sensory loss distal to the shoulders

Answer:

a. Periorbital ecchymosis

Rationale: Periorbital ecchymosis (raccoon's eyes), battle's sign, hemotympanum, and

rhinorrhea/otorrhea are clinical signs of a basilar skull fracture. Motor and sensory loss distal to

the shoulders is more consistent with a cervical spine injury. A basilar skull fracture occurs at the

base of the skull, therefore a palpable step-off at the top of the head or a large forehead laceration

should not increase suspicion for the presence of a basilar skull fracture.

Q: GCS Eye Response Grading

Answer:

Eye Opening (4)

1 - No eye opening.

2 - Eye opening to pain.

3 - Eye opening to verbal command.

4 - Eyes open spontaneously.

Q: GCS verbal response grading

Answer:

Verbal response (5)

1 - No verbal response

2 - Incomprehensible sounds.

3 - Inappropriate words.

4 - Confused

5 - Orientated

Q: GCS motor response grading

Answer:

Motor Response (6)

1 - No motor response.

2 - Extension to pain.

3 - Flexion to pain.

4 - Withdrawal from pain.

5 - Localizing pain.

6 - Obeys Commands.

Q: diagnostic imaging for skull fx

Answer:

CT scan of the head.

Q: Normal ICP

Answer:

Normal adult intracranial pressure (ICP) is less than or equal to 15 millimeters mercury (mmHg)

Q: what does ICP above 15mmHg mean?

Answer:

are consistent with intracranial hy- pertension. Intracranial hypertension is a symptom of

underlying pathology which causes an imbalance between pressure and volume

Q: cerebral perfusion pressure (CPP)

Answer:

maintain cerebral perfusion pressure

(CPP), or the pressure needed to ensure blood flow to the brain

-A normal CPP is 60-100 mm Hg

Q: how to calculate CPP

Answer:

Remember this formula: CPP = MAP - ICP

Q: a CPP <50>

Answer:

ischemia and neuronal death.

Q: brain death

Answer:

Brain death is defined as the complete, irreversible cessation of all brain function as a result of

catastrophic damage to the brain and the absence of brain stem function.

Q: 3 cardinal findings of brain death

Answer:

1.coma/unresponsiveness,

2.absence of brainstem reflexes

3.apnea.

Q: The World Brain Death Project -clinical diagnostic criteria for brain deathAnswer:

-An established neurological diagnosis that is capable of causing the irreversible loss of brain

function must be present.

-All other conditions which can mimic brain death have been excluded (intoxication,

hypothermia, depressant drugs, shock, etc.).

-Both pupils must be fixed in a midsize or dilated position and not reactive to light.

-No evidence of arousal or awareness to maximal external stimulation (including noxious visual,

auditory, and tactile) exists.

-No evidence of corneal, oculocephalic, and oculovestibular reflexes.

-No evidence of facial movement to noxious stimulation.

-No evidence of the gag reflex to bilateral pharyngeal stimulation.

-No evidence of the cough reflex to deep tracheal suctioning.

-No evidence of brain-mediated motor responses in the limbs to noxious stimuli.

-No evidence of spontaneous respirations once one of the apnea test targets (pH <

7.30 or PaCO2 > 60 mm Hg) are achieved.

Q: Omar is a 28-year-old male who was involved in a motor vehicle crash (MVC). He

sustained significant intracranial hemorrhage and has been de- clared brain dead by the required

standards. His wife states that he is moving and has been squeezing her hand. What is the best

response to Omar's wife?

a. Unfortunately, your husband has died and will not come back to life.