Neurological Assessment and Monitoring Flashcards

The nurse is monitoring a patient's cerebral perfusion pressure (CPP). Which formula is used to calculate CPP?

Answer: CPP = MAP − ICP

Cerebral perfusion pressure is calculated as mean arterial pressure minus intracranial pressure (CPP = MAP − ICP).

Which reflex, when absent, suggests dysfunction at the level of the medulla?

Answer: Gag reflex

The gag reflex (CN IX and X) is mediated at the medulla; its absence indicates medullary dysfunction.

A positive Romberg test (patient sways when eyes are closed) indicates impairment in which system?

Answer: Proprioceptive or vestibular function

A positive Romberg test indicates impaired proprioception or vestibular function, as the patient cannot maintain balance without visual input.

When assessing for meningeal irritation, the nurse flexes the patient's hip and knee, then extends the knee. The patient reports pain and resists extension. This describes:

Answer: Kernig's sign

Kernig's sign is positive when the patient resists or experiences pain with knee extension after hip flexion, indicating meningeal irritation.

In continuous EEG monitoring, which finding requires the nurse to immediately notify the neurologist?

Answer: Nonconvulsive status epilepticus pattern

Nonconvulsive status epilepticus (NCSE) on continuous EEG is a medical emergency requiring immediate neurologist notification and treatment.

Which positioning intervention is standard for patients at risk for increased ICP?

Answer: Head of bed elevated 30 degrees with head midline

Elevating the head of bed to 30 degrees with the head in midline promotes cerebral venous drainage and reduces ICP.