Page 2012 - Saunders Comprehensive Review For NCLEX-RN

2. Hemorrhage
3. Tumors
4. Infection
5. Toxicity
6. Metabolic disorders
7. Hypoxic conditions
8. Hypertension
9. Cigarette smoking
10. Stress
11. Aging process
12. Chemicals, either ingestion or environmental exposure
B. Assessment of cranial nerves (see Chapter 12)
C. Assessment of level of consciousness (LOC) (see Chapter 12)

Level of consciousness is the most sensitive indicator of neurological status.

D. Assessment of vital signs: Monitor for blood pressure or pulse
changes, which may indicate increased ICP.

E. Assessment of respirations (Box 58-2)

F. Assessment of temperature

1. An elevated temperature increases the metabolic rate
of the brain.
2. An elevation in temperature may indicate a
dysfunction of the hypothalamus or brainstem.
3. A slow rise in temperature may indicate infection.

G. Assessment of pupils (Fig. 58-1)

1. Unilateral pupil dilation indicates compression of
cranial nerve III.
2. Midposition fixed pupils indicate midbrain injury.
3. Pinpoint fixed pupils indicate pontine damage.

H. Assessment for posturing (see Chapter 38, Fig. 38-3)

1. Posturing indicates a deterioration of the condition.
2. Flexor (decorticate posturing)
a. Client flexes 1 or both arms on the chest
and may extend the legs stiffly.
b. Flexor posturing indicates a
nonfunctioning cortex.
3. Extensor (decerebrate posturing)
a. Client stiffly extends 1 or both arms and
possibly the legs.
b. Extensor posturing indicates a
brainstem lesion.

2012