Chapters 65-70: Neuro

A patient arrives to have an MRI done in the outpatient department. What information provided by the patient warrants further assessment to prevent complications related to the MRI?

"I am trying to quit smoking and have a patch on."

A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. What pin site assessments would the nurse report to the healthcare provider? Select all that apply.

A small amount of yellow drainage at the left pin insertion site A redness of the skin surrounding the insertion site Pain at the insertion site after administration of medication

The nurse is caring for a client who is being assessed for brain death. Which are cardinal signs of brain death? Select all that apply.

Absence of brainstem reflexes Apnea Coma

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

Absence of reflexes along with flaccid extremities

Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?

Apraxia Verbal apraxia refers to difficulty forming and organizing intelligible words although the musculature is intact

The nurse is aware that burr holes may be used in neurosurgical procedures. Which of the following is a reason why a neurosurgeon may choose to create a burr hole in a patient?

Aspiration of a brain abscess

If warfarin is contraindicated as a treatment for stroke, which medication is the best option?

Aspirin

Which drug should be available to counteract the effect of edrophonium chloride?

Atropine

The nurse teaches the client diagnosed with Huntington disease that it is transmitted as which type of genetic disorder?

Autosomal dominant

The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop?

Damage to the optic nerve

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?

Elevated 30 degrees

During assessment of cognitive impairment, post-stroke, the nurse documents that the patient was experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?

Frontal

Which cerebral lobes is the largest and controls abstract thought?

Frontal

A client with Guillain-Barre syndrome cannot swallow and has a paralytic ileus; the nurse is administering parenteral nutrition intraveneously. The nurse is careful to assess which of the following related to intake of nutrients?

Gag reflex and bowel sounds

While riding a bicycle in a race, a patient fell into a ditch and sustained a head injury. Another cyclist found the patient lying unconscious in the ditch and called 911. What type of concussion does the patient most likely have?

Grade 3 concussion

A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position?

Head of the bed elevated 45 degrees

The nurse is caring for a client with a traumatic brain injury and experiencing increased intracranial pressure. The nurse has administered mannitol, an osmotic diuretic, as ordered. This medication promotes the shift of fluid from the intracellular to the intravascular compartment. Therefore, it is necessary for the nurse to continually assess for which of the following?

Heart failure

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?

Heparin sodium Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke.

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is:

Hypertension

The nurse is assigned to care for clients with SCI on a rehabilitation unit. Which signs does the nurse recognize as clinical manifestations of autonomic dysreflexia? Select all that apply.

Hypertension Diaphoresis Nasal congestion

A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate?

Initiate seizure precautions.

The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question?

Insertion of a nasogastric (NG) tube

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?

Keeping the client in one position to decrease bleeding The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained.

A 53-year-old man presents to the emergency department with a chief complaint of inability to form words, and numbness and weakness of the right arm and leg. Where would you locate the site of injury?

Left frontoparietal region

A 53-year-old man presents to the emergency department with a chief complaint of inability to form words, and numbness and weakness of the right arm and leg. Where would you locate the site of injury?

Left frontoparietal region The patient is exhibiting signs of expressive aphasia with numbness/tingling and weakness of the right arm and leg. This indicates injury to the expressive speech center (Broca's area), which is located in the inferior portion of the frontal lobe.

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem?

Lioresal (Baclofen)

A new ancillary staff member is assisting the nurse with a client diagnosed with Parkinson's disease. The client needs assistance with eating but doesn't require thickened liquids to aid swallowing. Which instruction should the nurse give the ancillary staff member about eating assistance?

Make sure the client is sitting with the head of bed elevated to 90 degrees.

Pressure ulcers may begin within hours of an acute spinal cord injury (SCI) and may cause delay of rehabilitation, adding to the cost of hospitalization. The most effective approach is prevention. Which of the following nursing interventions will most protect the client against pressure ulcers?

Meticulous cleanliness

A patient is admitted to a specialty care unit with a diagnosis of an upper motor neuron lesion. The nurse assesses the patient and documents the presence of:

Muscle spasticity. An upper motor neuron lesion is associated with increased muscle tone, muscle spasticity, no muscle atrophy, and hyperactive and abnormal reflexes.

Which of the following drugs may be used after a seizure to maintain a seizure-free state?

Phenobarbital

Which of the following is standard test for early diagnosis of herpes simplex virus (HSV)-1 encephalitis?

Polymerase chain reaction (PCR)

A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture?

Position the client flat for at least 3 hours.

A nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely?

Positive Brudzinski's sign

Which of the following are clinical manifestations associated with increased intracranial pressure (ICP)? Select all that apply.

Seizures Nausea with or without vomiting Papilledema Headache

Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?

The client will remain free of injury if a seizure does occur

Which of the following diagnostic test may be performed to evaluate blood flow within intracranial blood vessels?

Transcranial Doppler Transcranial Doppler flow studies are used to study a tumor's blood flow within intracranial blood vessels

Which of the following teaching points is a priority in the management of symptoms for a client with Bell's palsy?

Use ophthalmic lubricant and protect the eye.

A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient?

Within 24 hours after exposure

A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with:

body temperature control.

A nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm?

cerebral angiography

A nurse is caring for client with late-stage Parkinson's disease. The client's plan of care includes a nursing diagnosis of "Potential for Injury." Which would not be included as a cause for this diagnosis?

choreiform movements

After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an:

evaluation of the corneal reflex response.

A client with fungal encephalitis receiving amphotericin B reports fever, chills, and body aches. The nurse knows that these symptoms

may be controlled by the administration of diphenhydramine and acetaminophen approximately 30 minutes before administration of the amphotericin.

A nurse is monitoring a client with Guillain-Barré syndrome. The nurse should assess the client for which responses? Select all that apply.

respiratory distress difficulty swallowing

Which diagnostic is most commonly used for spinal cord compression?

Magnetic resonance imaging (MRI)

The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?

Maintain cerebral perfusion pressure from 50 to 70 mm Hg

Which diagnostic procedure would the nurse anticipate first if the goal was to obtain a thin slice of a muscular body area?

computed tomography (CT) A computer tomography scan uses x-rays and computer analysis to produce three-dimensional views of the slices of the body. This is a good first test to obtain information.

The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain?

"I was brushing my teeth." Trigeminal neuralgia is a condition of the fifth cranial nerve that is characterized by paroxysms of sudden pain in the area innervated by any of the three branches of the nerve. Paroxysms can occur with any stimulation of the terminals of the affected nerve branches, such as washing the face, shaving, brushing the teeth, eating, and drinking.

The nurse is assessing the client's mental status . Which question will the nurse include in the assessment?

"Who is the president of the United States?"

The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for?

Burr holes

What part of the brain controls and coordinates muscle movement?

Cerebellum

Damage to the brain from traumatic injury can be divided into primary and secondary injuries. Which of the following is cause of a secondary injury associated with brain injury? Select all that apply.

Cerebral edema Ischemia Infection Seizures Hyperthermia

Which of the following is the earliest sign of increasing intracranial pressure (ICP)?

Change in level of consciousness (LOC)

When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?

Decerebrate

The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?

Diplopia and ptosis

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client?

Elevating the head of the bed to 30 degrees Because the client's gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the client's risk of aspiration.

A client with an incurable brain tumor is experiencing nausea and vomiting and has little interest in eating. His family states, "We don't know how to help him." Which of the following would be appropriate for the nurse to suggest to help improve the client's nutritional intake? Select all that apply.

Ensure that the client is free of pain for meals. Plan meals for times when the client is rested. Provide the client with foods that he likes.

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient?

High in protein and low in carbohydrate

Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?

Spasticity

Which condition occurs when blood collects between the dura mater and arachnoid membrane?

Subdural hematoma

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value?

The CPP is low. The normal CPP is 70 to 100 mm Hg. A CPP of 40 mm Hg is low.

A client who has a pituitary adenoma would report which symptoms related to the presence of this type of tumor? Select all that apply.

Morning headaches Chiasmal syndrome Polydipsia Anorexia

A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture?

Basilar

The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful?

Conception is not impaired; the birth process is determined with the physician.

The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began?

Drooping eyelids

Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply.

Eye opening Verbal response Motor response

The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy?

Increased ICP is 12 mm Hg.

A nurse assesses a patient who has been diagnosed with having a pituitary adenoma that is pressing on the third ventricle. The nurse looks for the associated sign/symptom. What is that sign/symptom?

Increased intracranial pressure

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

Lung auscultation and measurement of vital capacity and tidal volume

A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside?

Suction machine with catheters

The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client best indicates that the client is assuming independence?

The client grasps the affected arm at the wrist and raises it.

Which method is used to help reduce intracranial pressure?

Using a cervical collar

The critical care nurse is giving end-of-shift report on a client she is caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate?

Comatose

The nurse is discussing spinal cord injury (SCI) at a health fair at a local high school. The nurse relays that the most common cause of SCI is

Motor vehicle crashes

The nurse has been educating a client newly diagnosed with MS. Which statement by the client indicates an understanding of the education?

"I will stretch daily as directed by the physical therapist."

The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur?

Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.

At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply.

Bradycardia Hypertension Bradypnea

You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?

Autonomic dysreflexia

A 76-year-old male client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? Select all that apply.

Balloon angioplasty of the carotid artery followed by stent placement Carotid endarterectomy

At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply.

Bradycardia Bradypnea Hypertension

The nurse is caring for a client hospitalized after a motor vehicle accident. The client has a comorbidity of Parkinson's disease. Why should the nurse closely monitor the condition and the drug regimen of a client with Parkinson's disease?

Drugs administered may cause a wide variety of adverse effects.

A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease?

Edrophonium (Tensilon)

Which of the following tests confirms the diagnosis of myasthenia gravis (MG)?

Tensilon test Edrophonium chloride (Tensilon) is an acetylcholinesterase inhibitor that stops the breakdown of acetylcholine. The drug is used because it has a rapid onset of 30 seconds and a short duration of 5 minutes. Immediate improvement in muscle strength after administration of this agent represents a positive test and usually confirms the diagnosis.

Which are characteristics of autonomic dysreflexia?

severe hypertension, slow heart rate, pounding headache, sweating

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

use short, simple sentences Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension.