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SSM SCRN Review exam
Questions & Answers
Guaranteed Pass A+!!!
ALL BRAND NEW 2024
Stroke Risk Factors - Answer- Age Gender (men >women) Genetics Stroke Primary Prevention - Answer- Tobacco cessation Blood pressure reduction Stroke Secondary Prevention - Answer- Prevention of another stroke Targets treatment for change once disease is present i.e. Blood Pressure control, LDL control, recognition of S/S stroke Frontal Lobe Functions - Answer- LOC Regulates personality and affect Impulsivity and judgement Abstract thinking Conjugate eye movements Frontal Lobe Precentral Gyrus - Answer- AKA Motor Strip Parietal Lobe Functions - Answer- Sensory: Interpretation of: Pain, temperature, light touch, vibration, two-point discrimination, proprioception Temporal Lobe - Answer- Functions: Hearing, Memory, Learning Seizures Wernicke's area - Answer- located in Temporal lobe responsible for understanding spoken language Occiptal lobe - Answer- Functions: Vision The right half of the occiptal lobe interprets information received from the right half of both the right and left eyes (and vice versa) Cerebrum - Answer- Made up of Basial ganglia and Limbic system Basial ganglia - Answer- Coordinates movement Limbic system - Answer- Amygdala, Cingulate gyrus, Hippocampus Amygdala and Cingulate gyrus - Answer- Memory and emotion
Hippocampus - Answer- Memory and learning Diencephalong - Answer- Thalmus, Hypothalmus, Pituitary and pineal gland Thalamus - Answer- Receives input from cerebral cortex and acts as relay center Hypothalamus - Answer- Hunger Thirst Autonomic functions Endocrine functions Pituitary and pineal gland - Answer- Hormonal modulation Sleep-wake cycle Spinothalamic Tract - Answer- An ascending pathway of the spinal cord. It is responsible for the transmission of pain, temperature, and crude touch to the somatosensory region of the thalamus. Corticospinal tract - Answer- A descending tract of the spinal cord which contains bundles of axons which originate in the cerebral cortex and descend to synapse within the brainstem or spinal cord. The neurons are called "upper motor neurons". Cerebellum - Answer- Coordination of motor function: Rapid alternating movements Balance and Position sense Brain Stem - Answer- Medulla, Midbrain, Pons Medulla - Answer- Foramen magnum to the pons CN XII, IX, X, XI Corticospinal tracts- pyramids: decussate and cross midline Midbrain - Answer- Coordinates Eye Movement, some reflexes related to hearing and vision CN II, III, IV Pons - Answer- Between medulla and midbrain CN VI, VII, VIII, V message center between cerebellum and cerebrum Cranial Nerve I - Answer- Olfactory-smell Cranial Nerve II - Answer- Optic- transmits visual information, visual fields, deficit=hemianopsia Cranial Nerve III - Answer- Occularmotor- eyeballs look up
SAH: Aneurysms form at vessel junctions and turns Small vessel strokes - Answer- smaller branching vessels Ischemic stroke: occlusion occurs due to atherosclerosis or other pathology ICH: Hemorrhage occurs due to amloyid angiopathy, tumor or vascular malformation Symptoms from Carotid Artery Stroke - Answer- Aphasia if dominant side Contralateral neglect if non-dominat side motor and sensory loss face, are and leg on contralateral side visual field deficit contralateral to occluded carotid artery Anterior Circulation is made up of what arteries? - Answer- Anterior Cerebral Artery (ACA) Middle Cerebral Artery (MCA) Posterior Cerebral Artery (PCA) Anterior Cerebral Artery Supplies - Answer- 5 segments A1-A3 commonly discussed Supplies: Frontal lobe, olfactory cortex, corpus callosum, leg motor cortex Symptoms of Anterior Cerebral Artery (ACA) stroke? - Answer- Major symptoms: Apathy, abulia and disinhibition Conjugate eye deviation Contralateral motor/sensory loss leg>arm What is the Middle Cerebral Artery? - Answer- Major structures: with M1-M4 covers Large cerebral territory Effects: Speech and language Motor and sensory cortex Gaze Symptoms of MCA Stroke? - Answer- Major stroke symptoms: Aphasia (dominant hemisphere) Neglect (non-dominant hemisphere) Forced eye deviation/gaze preference Contralateral homonymous heminaopsia Contralateral motor/sensory loss face/arm>leg Posterior Cerebral Artery (PCA) - Answer- Major structures: Occiptial lobe Midbrain Thalamus Corpus Callosum Symptoms of PCA stroke? - Answer- Major stroke symptoms: contraleral loss of pain temp and senstation
visual field loss Horner's syndrome Weber's syndrome Perinaud's syndrome Horner's Syndrome - Answer- Ptosis (sluggish pupil), miosis (small pupil), dilation lag and anhidrosis (impaired flushing and sweating) Weber's syndrome - Answer- Midbrain stroke from PCA or BA infarct Contralateral weakness of upper and lower extremities (corticospinal tract) Ipsilateral gaze weakness (cranial nerve 3) Also known as Lateral medullary syndrome Perinaud's Syndrome - Answer- Also know as dorsal midbrain syndrome Vertical gaze palsy- sun setting sign Pupils mid-dilated, light dissociation Convergence-retraction nystagmus Wallenberg Syndrome - Answer- Verterbral or PICA stroke Ipsilateral CN V involvement (sensory, pain, temp loss on ipsilateral face) Ipsilateral ataxia (cerbellum) Nystagmus, N/V, vertigo Posterior Circulation is made up of what arteries? - Answer- Verterbral arteries Basilar artery Anterior Inferior Cerbellar Artery (AICA) Posterior Inferior Cerbellar Artery (PICA) Posterior inferior Cerbellar artery stroke symptoms? - Answer- Major structure=major symptoms Horner syndrome Wallenberg syndrome Ipislateral limb ataxia Decrease pain and temperature sensation contralateral body Anterior Inferior Cerbellar Artery - Answer- Major structure=major symptoms Ipsilateral deafness Ipsilateral facial motor/sensory loss Ipsilateral limb ataxia Decreased pain and temperature senstation contralateral body Basilar Artery Stroke Symptoms - Answer- Decreased LOC Facial paresis Occulomotor difficulties
How soon after a stroke does neuroplasticity begin? - Answer- 1 - 3 days but takes months to years What is the success of neuroplasticity and recovery post stroke depend upon? - Answer- 1. Repetition
- Robotic therapy
- Desire What is a carotid-cavernous fistula? - Answer- An AV fistula where high pressure arterial blood enters the low pressure venous cavernous sinus What is a Type A Carotid Cavernous Fistula? - Answer- Direct connection b/t intracavernous branches of the internal carotid artery and the cavernous sinus Caused by high flow and pressure patients present with hearing swishing noise unilateral bulging eye What kind of flow is associated with Type B, C and D Carotid Cavernous Fistulas? - Answer- Low Flow and Low Pressure A cavernous angioma is associated with what kind of lesion? - Answer- Purple low flow/low pressure vascular lesion Where are the majority of Dural Arteriovenous Fistulas located? - Answer- Posterior Fossa How much does CSF does the body produce an hour? - Answer- Approximately 20ml/hr Where is CSF produced? - Answer- Chorid plexus in the lateral, third and fourth ventricles What are some stroke mimics? - Answer- Hypoglycemia Seizure and Todd's paralysis Migraines with aura Degenerative Neurological Disorders (MS) Indigestions (tylenol, opioid, lithium) EMS Management of Stroke - Answer- Maintain 02sat >94% Administer NS HOB flat if hypotensive Glucose check IV access Treat SBP> NPO Cincinnati pre-hosptial stroke scale includes? - Answer- Facial Droop
Arm Weakness Speech Los-Angeles pre-hospital stroke scale includes? - Answer- Facial weakness Arm strength Grip Blood Glucose Phase 1 of Stroke Care? - Answer- Emergency/Hyperacute First 3-24 hours Phase 2 of Stroke Care? - Answer- Acute Care 24 - 72 hours How many hours of therapy does a patient get in acute rehab? - Answer- At least 3 hours of therapy per day Therapy is provided 5 - 7 days per week How many hours of therapy does a patient get in sub cute rehab? - Answer- less than 3 hours per day 3 - 5 days per week What are the 7 D's of stroke care? - Answer- Detection Dispatch Delivery Door Data Decision Drug How long does an ED doc have to see a stroke patient? - Answer- Less than 10 min How soon does a CT need to be done for a stroke patient upon arrival to the hospital? - Answer- Less than 25 min How long does the stroke team have to get the CT read for a stroke patient? - Answer- Less than 45 min How long does the ED have to administer tPA for a stroke patient? - Answer- Less than 60 min How fast does the stroke patient need to be admitted to a stroke unit from the ED? - Answer- Less than 3 hours What are the 3 most important Pneumba saving interventions? - Answer- Maintain oxygen greater than 94%
What does the Functional Independence Score Measure (FIM)? - Answer- Physical and cognitive disability Higher the score the better What does a Hunt and Hess score evaluate? - Answer- Measures deficit of SAH and predicts outcome The higher the number the worse my patient is Grading scale 1- 5 1: Asymptomatic or mild HA 5: Coma, extensor posturing What does an ICH score predict? - Answer- Mortality- higher the score the worse the outcome What are the components of an ICH score? - Answer- GCS ICH volume IVH Location Age An ICH score of 0 gives the patient what mortality risk? - Answer- No mortality An ICH score of 5 or 6 gives the patient what mortality risk? - Answer- 100% mortality Fisher- Miller grading score tells us what? - Answer- Amount of blood in Subarchonid space. The higher the number =more blood A Fischer Score of 1 means what? - Answer- No subarachnoid blood on CT A Fischer Score of 4 means what? - Answer- Thick SAH with IVH in both lateral ventricles What is an ABCD2 score? - Answer- Risk assessment tool which predicts short-term stroke risk after a TIA. What are the components of an ABCD2 score? - Answer- A: Age > B: Blood Pressure SBP > 140 OR DBP > 90 C: Clinical Features of TIA : Unilateral weakness OR Speech impairment D: Duration of TIA D: Diabetes What does an ABCD2 score of 0 - 3 mean? - Answer- 2 day risk of stroke: 1% May not require hospitalization unless another indication (such as A-fib) Have pt follow up as outpatient
What does an ABCD2 score of 4 - 5 mean? - Answer- 2 day stroke risk of 4% Hospital observation justified What does an ABCD2 score of 6 - 7 mean? - Answer- 2 day stroke risk of 8% Hospital observation worthwhile What is the standard tPA dose? - Answer- 0.9mg/kg, max dose of 90mg 10% of total dose administered in IV bolus over 1-2 minutes Remaining 90% of dose administered over 1 hour What do you follow the tPA dose immediately with? - Answer- 50 - 100 ml of NS at the same rate What is the tPA treatment window time period? - Answer- 4.5 hours in most patients What are the relative contraindications for administration of tPA? - Answer- Age> Severe stroke measured by NIHSS> Oral antigoagulant use regardless of INR History of diabetes History of ischemic stroke Goal time frame to administer tPA? - Answer- Less than 60 min Possilbe side effects of tPA? - Answer- ICH - stat head CT if change in LOC Orolingual angioedema How do you treat angioedema related to post-tpa administration? - Answer- Histamine antagonist (benadryl) and corticoseterioids Blood pressure parameters for initiation of tPA? - Answer- BP less than 180/ 105 Treat if BP greater than 185/ What are the BP parameters for 24 hours after tPA administration? - Answer- Less than 180/ What is a potential complication of elevated BP after tPA? - Answer- Spontaneous ICH What drugs are used to treat BP prior to administration of tPA? - Answer- Labetalol 10mg IVP x Then Nicardipine drip at 2.5mg/hr- titrate by 2.5mg/hr every 5 - 15 min What is the time frame for VS and neuro checks post tPA? - Answer- every 15 min x 2 hours every 30 min x 6 hours every 1 hour x 16 hours
pulls fluid from the cerebrum into vascular compartment Monitor: Sodium, Bun, Cr, serum osmolality How does hypertonic saline (3%) work to decrease ICP? - Answer- Pulls fluid into vascular space Monitor: chemistries every 4 - 6 hours What is the normal osmolarity range? - Answer- 282 - 295mOsm/L How does CO2 regulation decrease ICP? - Answer- Decrease CO2= cerebral vasoconstriction Associated with hypo-perfusion Used as very short term rescue therapy Benefits of Barbiturate coma therapy? - Answer- Decreased cerebral metabolic rate and oxygen consumption decrease cerebral blood volume decrease excitation neurotransmitter release When is it appropriate to use Barbiturate coma to decrease ICP? - Answer- Used when patient has been non responsive to other ICP treatment modalities What are the risks associated with Barbiturates? - Answer- Direct myocardial depressant Hypotension via venous dilation and pooling What are the benifits of a craniectomy? - Answer- Removal of bone flap allow for swelling effective at reducing ICP Questionable impact on long term outcome What organ metabolizes most contrast mediums? - Answer- Liver What is the most important intervention to protect the kidneys after contrast administration? - Answer- Hydration (specifically pre-procedural) What are the benefits of a CT Angiogram? - Answer- Quick vessel imaging Detection of thrombus or vascular abnormality Vasospasm monitoring in SAH 3D reconstruction of vessel anatomy What are the benefits of CT Perfusion? - Answer- Cerebral blood volume Reflects time and speed of blood flow to brain tissue Non-invasive Differentiates between no flow and low flow states
What is a "spot sign" on a CTA? - Answer- Contrast extravasation- artery at leaking At higher risk of hematoma expansion What is the number 1 nursing intervention after identification of a "spot sign" on a CTA?
- Answer- Blood Pressure Management Why and when should an MRI be done in strokes? - Answer- More sensitive for ischemia from time of onset Better detection of ischemia Preferred test for brainstem or cerebellum stroke Obtain 24 hours after initial stroke Types of imagining associated with MRI? - Answer- Diffusion and Perfusion If Perfusion>Diffusion patient will not do well Pretest care for MRI? - Answer- Safety evaluation: Presence of metal Anxiety and agitation Ability to undergo 1 - 2 hour test with minimal supervision Indication for MR Angiogram? - Answer- Detect high grade atherscolerotic lesions of brain vessels Detect arterial dissection (Carotid and Vertebral) What is the indication for Diagnostic Cerebral Angiogram? - Answer- Gold standard for cerebral vascular: Aneurysm AVM Fistula Large Vessel occlusion Risks associated with Diagnostic Cerebral Angiogram? - Answer- Clot formation Vessel perforation Insertion site hematoma Post Cerebral Angiogram Care - Answer- Lay flat and extremity extended x 6 hours Assessment of catheter site and pulses on extremity When is an EEG indicated? - Answer- Gold standard for seizures Generally more adjunctive aid rather than diagnostic What kind of patients should you ask for a Carotid Duplex? - Answer- Used in screening of high risk patients. When detected, confirmatory tests with better sensitivity and specificity may be ordered: CTA of neck, MRA of neck, catheter angiography
Warfarin Dabigatran (Pradaxa) Riveroxaban (Xarleto) Apixaban (Elquis) How do thiazide diuretics lower the blood pressure? - Answer- Inhibit reabsorption of Na and CL ions in distal tubules in the kidney How do ACE inhibitors lower the blood pressure? - Answer- Blocks the conversion of anigiotension I to II thereby lowering arteriolar resistance and increasing venous capacity, decreasing cardiac output, index and volume How do Calcium Channel Blockers lower the blood pressure? - Answer- Prevents calcium from crossing into cells thereby causing arterial vasodilation and smooth muscle relaxation How do beta blockers lower the blood pressure? - Answer- Slows HR and decreases Cardiac output by blocking B1 receptors in the heart How do ARB's lower the blood pressure? - Answer- Vasodilates (due to blocking of angiotension II) What is the mechanism of action of Dobutamine? - Answer- Increases contractility and cardiac output **Monitor HR as may cause tachyarrythmias How does Epi gtt raise the BP? - Answer- Vasoconstriction (will also increase HR) How does Levophed work? - Answer- Raises the blood pressure by vasoconstriction What is the mechanism of action of Neosynephrine? - Answer- Alpha 1 agonist results in blood pressure increase without significant heart rate effect How do statins lower cholesterol? - Answer- Inhibits cholesterol synthesis in the liver Increases LDL uptake Therefore, less circulating cholesterol for atherosclerosis plague production What effect to statins have, other than lowering cholesterol? - Answer- Exerts anti- inflammatory properties by improving endothelial function What class of drug is Nimodipine? - Answer- Calcium channel blocker How does Nimodipine improve outcomes in SAH patients? - Answer- Prevention of vasospams What is the dose of Nimodipine? - Answer- 60mg every 4 hours for 21 days
Can be decreased if BP drops to 30 mg every 2 - 4 hours How does manitol work to lower ICP? - Answer- Osmotic diuretic- draws fluid into the vascular space for excretion by the kidneys Why do we give hypertonic saline? - Answer- Decrease cerebral edema Decreases elevated ICP How does hypertonic saline work? - Answer- increases serum sodium creating osmotic pull to bring fluid into the vessels What type of drug is Dilantin and how does it work? - Answer- Anticonvulsant Works by blocking high frequency firing of action potentials (blocks NA) What kind of drug is Keppra and what is used to treat? - Answer- Anticonvulsant- used to treat seizures by inhibiting Ca movement What kind of drug is Dantrolene? - Answer- Muscle relaxant used to treat malignant hyperthermia What kind of drug is Baclofen? - Answer- GABA agonist used to treat spasticity What is Gabapentin used to treat? - Answer- Neuropathic pain or seizures Broca's area - Answer- Motor speech area located in left parietal lobe When is the rehab discussion started for a stroke patient? - Answer- Upon admission What are the quality stroke metrics? - Answer- Participation in quality improvment projects: Plan (who, what, where and when) Do (carry out idea) Study (analyze data, summarize what was learned) Act (make changes) What does patient stroke education need to include? - Answer- 1. Warning S/S of stroke
- Risk Factors
- Medications
- Follow up with MD
- Call 911 for stroke S/S What are some S/S of re-perfusion syndrome? - Answer- Ispsilateral HA Contralateral Neuro deficits Seizures
