NUR 254 TEST 2
- Overall, as intracranial pressure increases LOC ?
Answer Decreases
- What assessment finding are specific to the diagnosis of Guillain-Barre Syndrome?
Answer Mediated by an immune respinse with acute lower extremity weakness with areflexia or diminished reflexes. An infection usually preceeds the development of GBS by about a month.Nerve damage results in numbness/tingling, muscle weakness, paralysis, pot, respiratory comp.
- Abnormal oculomotor eye movement where eyes follow head movement when the head is
turned side to side, producing a persistent forward gaze is know as what reflex?
Answer "Dolls eyes" decribes the test for the oculocephalic reflex. Assesses brainstem function in a comatose or severely lethargic patient. Normal=eyes move in the same direction the head is moved
Abnormal=eyes gaze/fixed without any eyemovement. cant do this with cervical spine injuries
- Abnormal posturing demonstrated with damage to the cerebrum and or midbrain. Legs are
rotated inward & upper extremities flexed?
Answer Decorticate (flexor) poaitioinign the body moves in towarn the core.
- How would the nurse "grade" muscle strength for a client who has full ROM against gravity,
but not full resistance?
Answer
- out of 5
Moderate weakness, full ROM against gravity, but not resistance 1 / 2
- A patient paralyzed from the neck down is said to have ?
Answer Quadraplegia or tetraplegia
- A patient with paralysis from the waist down would be documented as
?
Answer Paraplegic
- After performing iced calorics, what eye finding indicated brain death?
Answer No response/No nystagmus
- Abnormal posturing with damage to midbrain/brainstem where head is arched, legs and feed
are extended and arms extended?
Answer Decerebrate
when a pt has problems with their midbrain or pons, pts may display decerebrate (extension), where the arms are like E's and the legs and arms are extended
- A pt with spinal cord injury <8hrs ago, presents with hypotension, brady- cardia, and
absent reflexes and flaccid paralysis below the level of injury. What complication is this indicative of?
Answer Spinal shock
- How is cerebral perfusion pressure calculated? What is the normal value?-
Answer MAP - ICP = CPP
- / 2