chapter 61 vidlec part 1

Question 1

is the most important indicator of the patient’s condition with altered LOC

Answer 1

level of responsiveness and consciousness

Question 2

continuum from normal alertness and full cognition (consciousness) to coma

Answer 2

level of consciousness

Question 3

is altered LOC a a disorder or not?

Answer 3

NO; result of pathophysiology

Question 4

unconsciousness, unarousable unresponsiveness

Answer 4

coma

Question 5

this score indicates coma

Answer 5

8 and below

Question 6

this score indicates deep coma

Answer 6

3 below

Question 7

unresponsiveness to the environment, makes no movement or sound but sometimes opens eyes

Answer 7

akinetic mutism

Question 8

devoid of cognitive function but has sleep-wake cycles

Answer 8

persistent vegetative state

Question 9

inability to move or respond EXCEPT FOR EYE movements due to a lesion affecting the pons

Answer 9

locked in syndrome

Question 10

easiest way to check LOC?

Answer 10

orientation

Question 11

what question to ask in orientation?

Answer 11

time
place
person

Question 12

what is assessed in LOC?

Answer 12

eye signs
verbal response
motor response
alertness
reflexes

Question 13

moves one’s body

Answer 13

decorticate

Question 14

the worst between the two, the body extends

Answer 14

decrebrate

Question 15

decerebrate produces severe damages to what part of the brain?

Answer 15

midbrain
pons

Question 16

the body temperature of an unconscious patient is NEVER taken by which route:

Answer 16

mouth

Question 17

what nursing intervention should you do to px with pneumonia?

Answer 17

turn px every 2 hrs
chest physiotherapy

Question 18

what position is recommended for aspiration with altered LOC?

Answer 18

fowler ; 90 degrees

Question 19

what nursing intervention should you do to px with Deep Vein Thrombosis (DVT)

Answer 19

use anti-embolic stockings
elevate legs

Question 20

because of limited space in the skull, an increase in any one of components of the skull (brain tissue, blood, CSF) will cause a change in the volume of the others

Answer 20

monroe kellie hypothesis

Question 21

what is normal ICP

Answer 21

10-20 mmhg

Question 22

increased ICP ______ cerebral perfusion and causes ischemia, cell death, and (further) edema

Answer 22

decreased cerebral perfusion

Question 23

brain tissues may shift through the dura and result in

Answer 23

herniation

Question 24

refers to the brain’s ability to change the diameter of blood vessels to maintain cerebral blood flow

Answer 24

autoregulation

Question 25

decreased CO2, __________

Answer 25

vasoconstriction

Question 26

increased CO2, __________

Answer 26

vasodilatation

Question 27

it INCREASE the difference between the diastolic and systolic bp

Answer 27

widened BP

Question 28

what is the earliest sign of increasing ICP ?

Answer 28

change in LOC

Question 29

CPP means

Answer 29

cerebral perfusion pressure

Question 30

formula for CPP

Answer 30

MAP - ICP

Question 31

normal CPP is _____

Answer 31

70 to 100

Question 32

cushing's triad consists of:

Answer 32

decreased heart rate irregular respiration widened pulse pressure or bradycardia bradypnea HPN

Question 33

a CPP of less than ___ results in permanent damage

Answer 33

50

Question 34

in a state of depressed cerebral functioning with UNRESPONSIVENESS TO SENSORY AND MOTOR FUNCTION

Answer 34

altered LOC