Nursing Science

Question 1

GCS consists of

Answer 1

Eye opening response

Verbal response

Motor response

Question 2

Eye opening response

4

Answer 2

Eyes open spontaneously

Question 3

Eye opening response

2

Answer 3

Eyes open to pain (not applied to face)

Question 3

Eye opening response

3

Answer 3

Eyes open to verbal command, speech, or shout

Question 3

Verbal response

5

Answer 3

Orientated

Question 3

Eye opening response

1

Answer 3

No eye opening

Question 4

Verbal response

4

Answer 4

Confused conversation but able to answer to the questions

Question 5

Verbal response

3

Answer 5

Inappropriate responses, word discernible

Question 6

Verbal response

2

Answer 6

Incomprehensible sounds or speech

Question 7

Verbal response

1

Answer 7

No verbal response

Question 8

Motor response

6

Answer 8

Obeys command for movements

Question 9

Motor response

5

Answer 9

Purposeful movement to painful stimulus

Question 10

Motor response

4

Answer 10

Withdraws from pain

Question 11

Motor response

3

Answer 11

Abnormal (spastic) flexion, decorticate position

flexes elbow and wrist while
extending lower legs to pain

Question 12

Motor response

2

Answer 12

Extensor (rigid) response, decerebrate posture

extend upper and lower
extremities to pain

Question 13

Motor response

1

Answer 13

no motor response

Question 14

Minor brain injury points

Answer 14

13-15 points

Question 15

Moderate brain injury points

Answer 15

9-12 points

Question 16

Severe brain injury points

Answer 16

3-8 points

Question 17

Signs & Symptoms of Increased in ICP (6)

Answer 17

Headache

Nausea/Vomiting

Altered level of consciousness

Papilloedema

Dilated pupils

Cushing reflex (late signs)
– Bradycardia
– Widening of pulse pressure
– Altered breathing pattern

Question 18

Goals for ischemic stroke

Answer 18

Achieve timely recanalization of the
occluded artery and reperfusion of the ischemic tissue

Optimise collateral flow

Avoid secondary brain injury

Question 19

Goals for Haemorrhagic Stroke

Answer 19

MAP – ICP = CPP(>60 mmHg)
CPP: CEREBRAL PERFUSION PRESSURE

MAP
* Normovolemia
* Maintain BP

ICP
* CSF Drainage
* Osmotic Therapy
* Venous Drainage

CPP
* Ventilation &
Oxygenation
* Control cerebral
metabolism

Question 20

Indication for CLC (7)

Answer 20

Indications for CLC:

 Hypoxia

 Metabolic imbalance such as hypoglycaemia

 Falls or trauma to the head

 Unresponsiveness

 Neurological disease process e.g. stroke, brain tumours,

 Epilepsy

 New admission to form a baseline assessment

Question 21

Medical conditions that may affect conscious level assessment (8)

Answer 21

• periorbital swelling/maxillofacial injuries
• glaucoma/ cataract/ eye disorders
• difficulty in hearing
• sedation and/or analgesia prescribed (if any)
• alcohol intoxication
• dysphasia/aphasia
• tracheostomy/ intubated
• high spinal injuries/ paralysis

Question 22

Pain stimulus

Answer 22

i) pressure on lateral inner aspect of third or fourth finger as shown or nailbed if eyes remain close OR ii) trapezius squeeze if eyes remain close OR iii) pressure over the supra-orbital notch/ridge using the thumb if eyes still remain close

Question 23

Document ‘T’ if patient has

Answer 23

tracheostomy or ETT;

Question 24

Document ‘D’ if patient has

Answer 24

dysphasia.

Question 25

Motor strength 5

Answer 25

able to overcome gravity and maximum resistance

Question 26

Motor strength 4

Answer 26

able to overcome mild to moderate resistance

Question 27

Motor strength 3

Answer 27

able to lift up the arm but unable to overcome the resistance (>anti- gravity strength)

Question 28

Motor strength 2

Answer 28

able to moves along the non-gravity surface but unable to lift up (

Question 29

Motor strength 1

Answer 29

visible muscle movement/muscle contraction

Question 30

Any decrease of GCS score ≥_____ suggests possible underlying neurological deterioration and must be reported to the doctor in charge. Thus, it is always important to refer to the GCS baseline of patient.

Answer 30

2

Question 31

Care of patient with EVD

Answer 31

* Ensure HOB 30degress unless contraindicated * Maintain patient’s head and neck in neutral position. * Monitoring of patient as ordered (e.g. Hourly, 4-hourly or 8-hourly)

Question 32

Levelling of EVD System

Answer 32

Position the patient with HOB 30degrees or as ordered by doctor. Adjusts the height of the EVD such that its zero mark on the EVD scale level with the #tragus of ear using the carpenter’s spirit level. (#When the patient is lying on one side, this anatomical reference point becomes at the midsagittal line (between the eyebrows). Adjust the collection drip chamber aligned to the desired height as ordered (e.g. 10cm above tragus of ear). *Always level transducer and drainage chamber - at beginning of shift and - if change in position of bed. (*applicable in ICU setting) Ensure the correct height setting of EVD system to prevent over drainage or under drainage of CSF

Question 33

Characteristics of normal CSF

Answer 33

Clear & colourless

Question 34

Characteristics of abnormal CSF (Xanthochromia discoloured)

Answer 34

usually pale yellow, due to breakdown of RBC from previous bleeding

Question 35

Characteristics of abnormal CSF (Turbid, Cloudy)

Answer 35

Occurs due to presence of CNS infection e.g.meningitis.

Question 36

Characteristics of abnormal CSF (Bright red)

Answer 36

indication of an acute hemorrhage

Question 37

RAPIDS TOOL Airway (5)

Answer 37

Assess for the signs of airway obstruction (look/listen/feel) Perform head tilt chin lift or jaw thrust Place patient on the side Insert artificial airway (e.g. oropharygneal / nasopharyngeal airway) Perform suctioning

Question 38

RAPIDS TOOL Breathing (9)

Answer 38

Count respiratory rate Assess breathing pattern (e.g. regularity/depth) Assess chest movement Check for cyanosis Measure oxygen saturation level Auscultate chest for breath sound Place patient in head-up position Initiate oxygen Titrate oxygen (keep SpO2 > 94%; For COPD, keep SpO2 90-92% or at baseline)

Question 39

RAPIDS TOOL Circulation (12)

Answer 39

Count pulse rates Palpate pulses (e.g. regularity / strength) Measure blood pressure Check for peripheral skin (e.g. colour/temperature/moisture) Measure capillary refill time (normal < 2 seconds) Measure body temperature Check urine output (oliguria < 0.5ml/kg/hr) Lower patient head of bed position Establish intravenous (IV) access Prepare or administer IV Normal Saline 0.9% Attach cardiac monitor Perform 12 lead electrocardiogram (ECG)

Question 40

RAPIDS TOOL Disability (3)

Answer 40

Assess level of consciousness using AVPU or GCS Examine pupils (size/equality/reaction) Monitor blood glucose level

Question 41

RAPIDS TOOL Expose/Examine (6)

Answer 41

Expose body for physical examination (e.g. inspection/ palpation/percussion/ auscultation ) Examine invasive catheter/ tube/ lines/ drainage Examine pain (e.g. PQRST) Examine patient’s recorded chart or notes (e.g. history, baseline, trend) Examine prescribed medicine Examine investigations result (e.g. laboratory/diagnostic)