PCCN Neurological

A patient with an epidural hematoma present with a classic history of a. A brief period of unconsciousness followed by a full recovery and then an abrupt decline in mental status b. Fainting associated with head trauma, a complete loss of consciousness and seizure activity c. Head trauma with no loss of consciousness, symmetrical extremity movement and normal pupils d. Head trauma with bilateral pupils dilation, decorticate posturing and decrease blood pressure

a. A brief period of unconsciousness followed by a full recovery and then an abrupt decline in mental status A brief period of unconsciousness followed by a full recovery and then an abrupt decline in mental status is the classic presentation of an epidural hematoma. This is an arterial bleed above the level of the Dura that presents in this classic fashion. The patient should have an immediate computerized tomography (CT) scan and possible operative procedure to decompress the hematoma and skull fracture

The most sensitive indicator of changes in intracranial pressure in the unresponsive patient is: a. A change in pulse pressure b. A change in pupillary response c. Blood glucose levels d. Response of the cranial nerves

a. A change in pulse pressure In patient who are unresponsive, the second physical assessment sign to change is the pulse pressure: the systolic pressure raises, the diastolic drops and the patient's heart rate slows. The triad of changes associated with increasing intracranial pressure occurs in this order: Change in mental status, widening of pulse pressure and slowing of the heart rate, followed by pupillary changes.

The nurse anticipates that a patient with an uncomplicated acute spinal cord injury at C7 to C8 will be able to a. Breathe unassisted b. Sit up unsupported c. Maintain voluntary bowel function d. Coordinate fine hand movement

a. Breathe unassisted A cord injury at level C7-C8 would allow full movement of the diaphragm and intercostal muscles, so breathing and coughing will be normal. At that level, however, the muscles associated with sitting in the up right position, bowel function and fine hand motor movement would be impaired.

If hyperventilation is used to control increased intracranial pressure, it should be directed at achieving which of the following goals? a. CO2 between 32 mmHg and 35 mmHg b. Increasing the PO2 to 200 mmHg c. Maintaining a respiratory rate of 30 breaths per minute d. Lowering the serum pH

a. CO2 between 32 mmHg and 35 mmHg Decreasing the CO2 to just below normal will cause the arterial blood vessels to remain normal. High CO2 dilates the vessels and a severe drop in CO2 can cause vasospasm with lowered blood flow.

The ICU CAM scale is useful in assess which ICU disorder a. Delirium b. Post traumatic stress disorder (PTSD) c. Dementia d. Locked in syndrome

a. Delirium A useful tool in identify delirium syndrome in the ICU, not a scale used for PTSD or dementia or the neurologic syndrome of Locked In state. There are 9 items in the scale to be assessed frequently in the ICU setting. The CAM score is a validated and commonly used score to help monitor neurologic state and identify the presence or absence of delirium.

What is triple H therapy for the patient with cerebral aneurysm rupture? a. Hypertension, hypervolemia, hemodilution b. Hypertension, hypovolemia, hemodilution c. Hypotension, hypovolemia, hemoconcentration d. Hypotension, hypervolemia, hemoconcentration

a. Hypertension, hypervolemia, hemodilution A complication of a cerebral aneurysm rupture is a cerebral vasospasm comprising the circulation to an area of the brain already at risk for hypo perfusion. The treatment to try to prevent vasospasm is known as "triple H Therapy" and includes allowing the patient to become hypertensive, hypervolemic (fluids are given) and hemodiluted (secondary to fluid administration). This will cause a vascular fluid "stent" to prevent the spasm.

Which of the following are measured that would improve the cerebral perfusion pressure? a. Increase the mean arterial pressure (MAP) b. Decrease the pulse pressure c. Decrease the heart rate d. All of the above

a. Increase the mean arterial pressure (MAP) Cerebral perfusion pressure (CPP) is determined by subtracting age intracranial pressure from the mean arterial pressure (MAP). By improving MAP, the CPP will increase. Lowering the ICP would also increase CPP. Heart rate does not affect CPP. A narrowing pulse pressure would lower the MAP and have a negative effect on intracranial pressure.

The single most important index of neurological function is a. Level of consciousness b. Pupillary reaction c. Extremity movement and strength d. Vital signs

a. Level of consciousness The first aspect of neurological demise is a change in level of consciousness. As intracranial pressure increases, there is disruption of the cerebral cortex and the reticular activating system, which causes a change in level of consciousness or a change in behavior.

When a patient has a stroke while in the hospital, the same protocol for care is deployed. The patient should be assessed by the stroke team and sent for a computerized tomography (CT) scan as soon as possible. Before sending the patient to CT, the nurse should notify the stroke team, then: a. Place the patient in head elevated position, measure vital signs, providing a safe airway with oxygen, monitor the 12 lead ECG, initiate intravenous access, glucose and electrolyte monitoring, obtain a type and cross match b. Await arrival of the stroke team before initiating any interventions c. Call the physician for further direction d. Initiate basic cardiac life support while awaiting arrival of the strike team

a. Place the patient in head elevated position, measure vital signs, providing a safe airway with oxygen, monitor the 12 lead ECG, initiate intravenous access, glucose and electrolyte monitoring, obtain a type and cross match This approach has the patient read for the stroke team. According to ACLS and the American Heart Association, the stroke patient should receive appropriate assessment and movement to the CT scan as soon as possible. The goal for the emergency department is a CT scan completed and read by a radiologist within 45 minutes. This is the same goal for the hospitalized patients. Performing the above assessment enables the stroke team to move the patient through the protocol quickly and without delay.

A patient with a diffuse axonal injury has suffered from a severe head injury that includes: a. Shearing injury of the brain tissue b. Edema of brain tissue only c. Laceration of a small blood vessel under the Dura d. Laceration of an artery above the Dura

a. Shearing injury of the brain tissue A diffuse axonal injury is a high velocity injury that shears the brain tissues and blood vessels. This injury may include both hemispheres, diencephalon, and brain stem. The injury is severe and is not reversible.

A 45 year old male is admitted to your unit with a diagnosis of intracranial hypertension due to a severe traumatic brain injury. The current vital signs include a blood pressure of 110/70 mmHg, an intracranial pressure (ICP) of 30 mmHg, a pulse rate of 140 breaths per minute. Based on the preceding information, what is the cerebral perfusion pressure (CPP)? a. 84 mmHg b. 53 mmHg c. 120 mmHg d. Not calculable

b. 53 mmHg To determine CPP, MAP must be calculated: MAP = [(2 x diastolic pressure) + systolic pressure]/3 MAP = [ (2 x 70) + 110]/3 MAP = (140 + 110)/3 = 250/3 = 83 mmHg CPP = MAP - ICP CPP = 83 - 30 = 53 mmHg

What is myasthenia gravis? a. A neuromuscular disorder in which the myelin sheath is destroyed at varying levels. b. A neuromuscular, autoimmune disorder that affects the neuromuscular junction c. A neuromuscular disorder seen after viral infections d. A fatal neuromuscular disorder of the upper and lower motor neurons that cause muscle weakness

b. A neuromuscular, autoimmune disorder that affects the neuromuscular junction Myasthenia gravis is a neuromuscular disorder that occurs when an autoimmune response at the neuromuscular junction destroying acetylcholine receptors. This causes weakness in swallowing and respiratory muscle. A neuromuscular disorder that causes myeline sheath destruction = multiple sclerosis A neurological disorders caused by viral infections are associated with Guillain-Barre Syndrome A fatal neuromuscular disorder that causes upper and lower motor neuron weakness = amyotrophic lateral sclerosis (ALS).

A patient with diffuse axonal injury is admitted to the ICU. The patient is extremely labile. The family is asking about organ donation and determination of brain death. What are the criteria for brain death? a. No spontaneous movement, equal pupils and normal respirations b. Absence of brain stem reflexes and continued apnea after withdrawal from the ventilator for ten minutes c. Normal temperature, normal blood pressure and normal PaO2 d. Absence of brain stem reflexes with normal respirations.

b. Absence of brain stem reflexes and continued apnea after withdrawal from the ventilator for ten minutes Brain death has a definition that includes: complete absence of brain stem reflexes, a complete comatose patient that has no response to painful stimuli, absence of reflexes, continued apnea after withdrawal from the ventilator for ten minutes and no flow to the cerebral cortex as evidenced by perfusion studies, EEG, flow doppler or angiography.

The drug of choice to manage status epileptics is: a. Phenobarbital (Luminal) b. Ativan (Lorazepam) c. Dilantin (Phenytoin) d. Tegretol ( Carbamazepine)

b. Ativan (Lorazepam) The first line drug for the treatment of status epileptics and a first time seizure is the benzodiazepine (Ativan). This drug is fast acting and affects the neurotransmitter gamma-aminobutyric acid (GABA) which results in a sedative, hypnotic, anticonvulsant and muscle relaxant effect.

What is the formula for calculating cerebral perfusion pressure (CPP)? ( SBP = systolic blood pressure, MAP = mean arterial pressure, ICP = intracranial pressure, CVP = central venous pressure)? a. CPP = SBP - MAP - ICP b. CPP = MAP - ICP c. CPP = ICP - MAP d. CPP = MAP - CVP - ICP

b. CPP = MAP - ICP The Calculation is cerebral pressure equals mean arterial pressure (the driving pressure to fill the cerebral circulation) minus the intracranial pressure. The two determinants of perfusion to the brain are MAP & ICP

After a patient with myasthenia gravis has had a thymectomy, what electrolyte is commonly followed? a. Potassium b. Calcium c. Sodium d. Phosphorus

b. Calcium After the thymectomy, calcium levels may drop causing worsening muscle weakness in this patient The physician will discuss a protocol for calcium replacement with tight control.

Treatment for diabetes insipidus (DI) may include which of the following a. Fluid restriction b. Fluid resuscitation c. Potassium replacement d. Diuretic therapy

b. Fluid resuscitation Since the patient with Di is dehydrated, fluid resuscitation is required. When fluids are replaced sodium levels return to normal. Careful administration of fluid is recommended secondary to the patient with increased intracranial pressure.

Nursing care of the patient with cerebral aneurysm includes a. Ambulation and monitoring of vital and neurological signs b. Glasgow coma scale assessments and monitoring for cerebral vascular spasm c. Maintaining normal intracranial pressure d. Maintaining systolic blood pressure less than 120 mmHg

b. Glasgow coma scale assessments and monitoring for cerebral vascular spasm After cerebral aneurysm rapture or repair, the patient must be monitored for complications. The most common of which is cerebral vascular spasm. This is caused by meningeal irritation caused by the presence of blind in the subarachnoid space. The earliest sign of vasospasm is a change in level of consciousness (LOC). This change in LOC may be detected early using a neurological mental status scale such as the Glasgow comas score. Ambulation and monitoring of vital signs is also correct but the best answer includes mental status changes. Systolic blood pressure may need to be elevated in the stroke patient; with systolic blood pressure as high as 180 mmHg.

An 87 year old patient is admitted with a diagnosis of a hemorrhagic stroke. He has developed communicating hydrocephalus. This is caused by what mechanism? a. Closed head injury b. Subarachnoid hemorrhage c. Epidural bleed d. Any cerebrovascular accident

b. Subarachnoid hemorrhage Bleeding from the subarachnoid hemorrhage causes a blockage in the arachnoid villii. This disrupts the absorption of cerebrospinal fluid (CSF) thereby, causing a communicating hydrocephalus.

A patient with closed head injury has developed a fever of 40 degrees C. The critical care nurse understands that increasing temperature a. May reduce intracranial pressure (ICP) b. Will increase oxygen requirements of the brain tissue c. Has no effect on neurologic functioning d. Is easily lowered with Acetaminophen (Tylenol)

b. Will increase oxygen requirements of the brain tissue Elevated systemic and brain temperature will increase the oxygen requirements of the brain tissue, at a time when oxygen delivery may be in jeopardy. Increased temperature may actually increase ICP. If the temperature is secondary to the brain injury, Acetaminophen (Tylenol) will not decrease the hypothalamic mediated increased temperature.

The actual definition of post traumatic stress disorder includes: a. A typical disorder that accompanies all critical illnesses b. A mental health condition with symptoms similar to hyperactivity c. A mental health condition that is triggered by a terrifying event d. A disorder that does not respond to psychotherapy

c. A mental health condition that is triggered by a terrifying event The definition of PTSD is a mental health condition that is triggered by a terrifying event, either experiencing it for witnessing the event. Post traumatic stress disorder (PTSD) may occur following critical life threatening illness but does not always occur. The symptoms of PTSD include flashbacks, nightmares, and severe anxiety, which may mimic hyperactivity such as tactic cardia, restlessness and hyperventilation but is not the actual definition, only suggests symptomatology. PTSD does not respond to psychotherapy and may require the use of medications with therapy.

While assessing the laboratory data of a patient with head trauma, which findings necessitates notification of the physician? a. A serum osmolarity of 275 mOsm b. A serum sodium level of 138 mEq/L c. A urine specific gravity of 1.005 d. A urine osmolarity of 650 mOsm

c. A urine specific gravity of 1.005 Normal urine specific gravity is 1.010 to 1.030. Because this value is low, there is indication that the urine is very dilute, a finding that points to possible Diabetes Insipidus (DI). A common complication of head injury is DI (a deficiency of ADH- causing excessive urinary out put with a resultant hypernatremia and intravascular dehydration)

A patient who has a spinal cord injury that results in ipsilateral motor loss and contralateral loss of pain and temperature is said to have a. A total spinal cord transaction b. Anterior cord syndrome c. Brown-Sequard Syndrome d. Central cord syndrome

c. Brown-Sequard Syndrome This type of cord injury is from a hemisection lesion that results in a specific type of physical finding. The ipsilateral leg has a motor loss secondary to the motor neurons entering the cord traveling up to the brain stem and crossing over (this results in loss of motor function of the same side). The contralateral leg has a sensory loss (loss of pain and temperature), since these sensory neurons travel to the cord to the brain. Both the sensory and the motor neurons are affected but on opposite sides of the body.

High risk behavior such as intravenous drug abuse may include septicembolization and endocarditis with severe heart failure. Which of the following should the nurse immediately report? a. Fever of 38 degrees b. Respiratory rate of 18 c. Complete heart block d. Increasing need for narcotics

c. Complete heart block The development of complete heart block in the presence of endocarditis is an urgent complications and should be reported immediately. The abscess from the endocarditis (infection around the valve) may have eroded into the conduction system of the heart causing complete here block. This may require urgent pacing and possible urgent surgery. In this patient with high risk behavior and drug abuse, it is uncommon for the patient to experience increased need for narcotics. Cross tolerance to many narcotics may occur. Fever of 38 degrees is not typically high enough to require a notification to the physician (usually a fever of higher than 38.5 is reportable). A respiratory rate of 18 is normal, unless the patient has changed in respiratory pattern.

Why is it important to stop seizure activity in status epilepticus? a. Oxygen deprivation can occur due to impeded airway b. There is risk of cerebrovascular accident c. Continued seizure activity causes lactic acidosis and cerebral edema d. The risk of bodily injury increase with continued seizure.

c. Continued seizure activity causes lactic acidosis and cerebral edema With continued seizure activity, the brain becomes hyper metabolic utilizing large amounts of oxygen and creating lactic acid as a consequence of oxygen debt. Lactic acid increases brain injury and edema.

A patient with closed head injury has a sudden increase in urine output. In one hour, it has got from 65 mL/hour to 980 mL/hour. The urine changes from the traditional yellow color to a clear water like color. What can cause this sudden in crease in pale urine? a. A volume shift from third spacing b. Syndrome of Inappropriate Antidiuretic Hormone (SIADH) c. Diabetes Insipidus d. Diuresis from steroids.

c. Diabetes Insipidus After a closed head injury, a common complication is pressure on the anterior pituitary causing diabetes insipidus. This causes a large urine output of free water. Specific gravity of the urine is close to water. The patient becomes dehydrated with an an increased serum sodium.

Cushing's Triad indicates increasing intracranial pressure (ICP). What are the signs of Cushing's triad? a. Lowered systolic pressure, decreased heart rate, narrowed pulse pressure b. Lowered systolic pressure, increased heart rate, narrowed pulse pressure c. Elevated systolic pressure, decreased heart rate , widened pulse pressure. d. Elevated systolic pressure, increased heart rate, widened pulse pressure.

c. Elevated systolic pressure, decreased heart rate, widened pulse pressure. As the ICP increases, a variety of changes in the vital signs occur. These changes are know as Cushing's triad. Cushing triad includes an elevated systolic pressure, a decreased heart rate and a decreased diastolic pressure resulting in a widening pulse pressure.

What are the common symptoms of myasthenia gravis? a. Ptosis, proximal muscle weakness and spasticity b. Dysphonia, sialorrhea and atrophy c. Fatigue, proximal muscle weakness and respiratory weakness d. Generalized weakness, hyperreflexia and dyspnea

c. Fatigue, proximal muscle weakness and respiratory weakness The most common symptoms with myasthenia gravis are difficulties with swallowing and respiratory compromise. This is due to the proximal muscle weakness secondary to the lack of acetylcholine receptors at the neuromuscular junction. Generalized weakness can also occur causing fatigue.

The most common type of stroke is: a. Hemorrhagic b. Aneurysmal c. Ischemic d. Traumatic

c. Ischemic In the US, 85% of strokes are ischemic in nature, Ischemic stroke may be embolic or thrombotic in nature.

When managing a patient with increased intracranial pressure (ICP), the nurse should maintain: a. Normal CO2 levels b. Increased CO2 levels c. Moderately restricted CO2 levels d. CO2 levels do not affect intracranial pressure

c. Moderately restricted CO2 levels Maintaining CO2 levels at approximately 32-35 Torr will maintain normal cerebral blood flow. Allowing the CO2 levels to increase causes arterial dilation and increase blood flow to the brain. This will also increase ICP. Maintaining moderately low CO2 levels at 32-35 Torr, the blood flow is maintained at normal range with no increase to ICP.

Hypothermia following spinal cord injury is usually attributable to a. Hypothalamic dysfunction b. Brain stem involvement c. Peripheral vasodilation d. Lack of muscular movement

c. Peripheral vasodilation After spinal cord injury, the area below the level of the injury losses sympathetic nervous stimulation so the arterial system vasodilator. With this massive vasodilation, the patient loses heat control and temperature drops. Hypothalamic dysfunction does not occur since there is not a head injury, only spinal cord involvement. The brainstem is also not involved with this injury. Although muscular movement may produce some heat, the loss of heat production associated with muscular movement is not enough to cause hypothermia.

How does a patient's blood pressure (BP) change as intracranial pressure (ICP) climbs? a. Both the systolic and diastolic pressure increase b. Both the systolic and diastolic pressure decrease c. The systolic pressure increase while the diastolic pressure decreases d. The systolic pressure decreases while the diastolic pressure increases

c. The systolic pressure increase while the diastolic pressure decreases With increasing ICP and the brain stem edema, the systolic pressure elevates with a decrease in diastolic pressure, thereby, widening the pulse pressure. This is a significant change that accompanies increasing ICP. There will be also a decreased heart rate.

Which of the following corresponds most closely to the range of minimum cerebral perfusion pressure (CPP)? a. 30 to 40 mmHg b. 40 to 50 mmHg c. 50 to 60 mmHg d. 60 to 70 mmHg

d. 60 to 70 mmHg The normal CPP is between 60 to 100 mmHg. Although most neurosurgeons and neurologists believe the lowest CPP should be ta 70 mmHg, the most common acceptable CPP is 60to 70 mmHg.

What is the normal goal for cerebral perfusion pressure CPP? a. 50-80 mmHg b. 20-40 mmHg c. 10-20 mmHg d. 70-90 mmHg

d. 70-90 mmHg The actual CPP range is 60-100 mmHg; however, most neurosurgeons prefer the CPP to be at least 70 in the head injured patient. Make sure you are aware of the physician's preference where you are working.

A basal skull fracture may cause which of the following? a. Cranial nerve injuries b. Battle's sign c. Cerebralspibnal fluid from the nose or ears (Otorrhea or rhinorrhea d. All of the above

d. All of the above Basal skull fracture may have multiple effects Injuries to the cranial nerves of the face such as; palsy, oculomotor nerve damage which can reduce movement of the eyes, hearing abnormalities Raccoon's eyes (Ecchymosis around both eyes) Battle's sign (bluish discoloration behind one or both ears) CSG leakage from either the nose or the ears.

Which statement is accurate regarding the differentiation of cerebrospinal fluid (CSF) in bacterial and viral meningitis? a. Higher level of protein in bacterial versus viral meningitis b. Lower sugar content seen in bacterial versus viral meningitis c. CSF is purulent and turbid in bacterial meningitis but may be clear in viral meningitis d. All of the above

d. All of the above With bacterial meningitis, the CSF is cloudy or turbid secondary to increased WBC and the increase in protein content. The sugar in the CSF is lower than serum glucose since bacteria ingest the sugar as a substrate for energy-Viral organisms do not use sugar as an energy substrate.

How much reserve oxygen exists in the brain? a. 100 mL b. 225 mL c. 450 mL d. None

d. None Although fat, muscle and certain body tissues can sequester oxygen for later use; these tissues are not found in the brain. Brain tissue does not reserve oxygen