ENA Neurological Emergencies 3.0

In which type of seizure may the patient experience the feeling of having been in an unfamiliar place before? A. Temporal lobe B. Absence C. Tonic-clonic D. Myoclonic

A A patient with a partial seizure originating in the temporal lobe is likely to experience an aura before the seizure. The aura, like the seizure, typically is sensory (causing the perception of smells, tastes, and sounds) and can include the feelings of dj vu (the feeling of having been in an unfamiliar place before), jamais vu (the feeling that a familiar place is unfamiliar), or both. These feelings do not occur with absence, tonic-clonic, or myoclonic seizures.

Which condition places a patient at risk for a stroke caused by an embolus? A. Brain tumor B. Arteriovenous malformation C. Bacterial endocarditis D. Aneurysm

C Risk factors for an embolic stroke include bacterial endocarditis; atrial fibrillation; recent surgery; recent long trips by car, air, or rail; recent long bone fracture; and artificial heart valves. Brain tumor, arteriovenous malformation, and aneurysm place a patient at risk for a hemorrhagic stroke.

Which factor is a relative contraindication for intravenous fibrinolytic therapy? A. History of a brain tumor B. Recent surgery C. International normalized ratio (INR) greater than 1.7 D. Blood glucose level less than 50 g/dL

D A blood glucose level below 50 g/dL or above 400 g/dL is a relative contraindication for intravenous fibrinolytic therapy. This therapy is contraindicated in patients who have a history of a brain tumor, have had recent surgery, or have an international normalized ratio (INR) greater than 1.7.

When caring for a patient with meningitis, you should perform which nursing intervention? A. Discuss stress management techniques. B. Initiate continuous positive airway pressure (CPAP) ventilation. C. Elevate the head of the bed to 30. D. Provide a quiet, darkened room.

D For a patient with meningitis, provide comfort measures such as minimizing noise, light, and other environmental stimuli. These stimuli can be extremely noxious because of meningeal inflammation and irritation from infected cerebrospinal fluid. The other interventions are not appropriate for a patient with meningitis. Use continuous positive airway pressure (CPAP) ventilation for a patient with Guillain-Barr syndrome. Elevate the head of the bed to 30 for a patient with a stroke or subarachnoid hemorrhage. Discuss stress management techniques for a patient with tension headaches.

Which disorder requires a biopsy for a definitive diagnosis? A. Myasthenia gravis B. Meningitis C. Guillain-Barr syndrome D. Temporal arteritis

D The definitive diagnosis of temporal arteritis requires a biopsy of the temporal artery. The diagnosis of myasthenia gravis is based on symptoms, antibody testing, electrophysiology testing, and the patient's response to the edrophonium (Tensilon). The diagnosis of meningitis is confirmed by a lumbar puncture and cerebrospinal fluid examination and culture and sensitivity testing. The diagnosis of Guillain-Barr&#-61;&#-87; syndrome is made through history, physical examination, and cerebrospinal fluid examination.

A patient presents with the sudden onset of left-sided weakness, right-sided facial droop, and garbled speech. For this patient, which intervention is your priority? A. Collect specimens for laboratory tests. B. Facilitate rapid computed tomography (CT) of the head. C. Obtain a 12-lead electrocardiogram tracing. D. Initiate intravenous access.

D This patient has signs and symptoms of an ischemic stroke. Although the patient needs all of these interventions, the priority is to maintain the airway, breathing, and circulation. Initiating intravenous access is the priority intervention because it helps maintain the patient's circulation.

Which action is a function of cranial nerve X (vagus nerve)? A. Equilibrium B. Jaw clench C. Facial movement D. Swallowing

D Cranial nerve X (vagus nerve) is responsible for swallowing, gag reflex, and involuntary visceral muscle control of heart and lungs. Cranial nerve VIII (acoustic nerve) is responsible for equilibrium. Cranial nerve V (trigeminal nerve) governs jaw clenching. Cranial nerve VII (facial nerve) controls facial movement.

Which condition poses the greatest risk for a stroke caused by a thrombus? A. Recent femur fracture B. Carotid stenosis C. Recent abdominal surgery D. Atrial fibrillation

B Carotid stenosis is a common cause of transient ischemic attacks and stroke due to thrombus. A patient with a recent fracture of a long bone (such as the femur) or surgery (such as abdominal surgery) is at risk for a stroke caused by an embolic occlusion. A patient with atrial fibrillation, which can cause clot formation in the left atrium, also is at risk for a stroke caused by an embolic occlusion.

Guillain-Barr syndrome causes the dysfunction in which cranial nerves? A. Cranial nerves II, III, and VI (optic, oculomotor, and abducens nerves) B. Cranial nerves III, VII, and IX (oculomotor, facial, and glossopharyngeal nerves) C. Cranial nerves V, VIII, and XII (trigeminal, acoustic, and hypoglossal nerves) D. Cranial nerves II, V, and VI (optic, trigeminal, and abducens nerves)

B Guillain-Barr syndrome causes the dysfunction of cranial nerves III through VII and IX through XII. The disorder does not usually affect cranial nerves II or VIII (optic and acoustic nerves).

Which finding is associated with a hemorrhagic stroke? A. Constricted pupils B. Rapid neurologic decline C. Tachypnea D. Decreasing pulse pressure

B A patient with a hemorrhagic stroke may experience a rapid neurologic decline, dilated pupil(s) due to pressure from the shifting brain tissue pressing on cranial nerve III (oculomotor nerve), a rapid decline in mental status and respiratory effort (bradypnea), and abrupt increases in intracranial pressure due to the blood volume pressing on the brain tissues (widened pulse pressure).

In which condition is placing the patient in droplet isolation a priority? A. Temporal arteritis B. Bacterial meningitis C. Febrile seizures D. Guillain-Barr syndrome

B Bacterial meningitis can be spread through airborne droplets or contact with oral secretions from infected individuals. Therefore, you should place all patients with suspected bacterial meningitis in droplet isolation for the first 24 hours of antibiotic therapy. Patients with temporal arteritis, febrile seizures, and Guillain-Barr syndrome require only standard precautions.

Which type of headache is caused by vascular dilation that puts pressure on the trigeminal nerve? A. Tension B. Cluster C. Migraine D. Temporal arteritis

B Cluster headaches may result from vascular dilation that puts pressure on the trigeminal nerve. Tension headaches are typically related to physical or emotional stress. Migraine headaches may be caused by cerebral vasodilation and inflammation. Temporal arteritis is an inflammation of the carotid arteries and its branches.

When caring for a patient who is actively having a seizure, which intervention is the priority? A. Insert an oropharyngeal airway. B. Provide supplemental oxygen. C. Administer benzodiazepines. D. Check the blood glucose level.

B For a patient who is actively having a seizure, the priority is maintenance of the airway, breathing, and circulation. The first priority is to help the patient maintain an open airway. However, do not insert an object into the mouth of an actively seizing patient. The use of a nasopharyngeal airway may be helpful. The next priority is to provide supplemental oxygen, followed by obtaining intravenous or intraosseous access (if seizure activity allows). Then you would administer benzodiazepines and check the patient's blood glucose level.

Which disorder is characterized by a defect in neuromuscular transmission? A. Guillain-Barr syndrome B. Myasthenia gravis C. Temporal arteritis D. Meningitis

B Myasthenia gravis is a chronic disease in which an autoimmune process damages the nicotinic acetylcholine receptor sites on the neurons. This damage results in muscle weakness because the receptor sites in the neuron cannot be activated. Guillain-Barr syndrome is an acute, progressive demyelinating disease. Its signs and symptoms stem from diminished myelin in the peripheral nerves and nerve roots. Temporal arteritis is an inflammation of the carotid arteries that leads to decreased blood flow and eventual vessel necrosis and death. Meningitis results from an inflammation of the arachnoid and pia mater, two of the three meningeal layers covering the brain and spinal cord.

A patient with a febrile seizure is most likely to belong to which age group? A. Ages 1 to 3 months B. Ages 1 to 3 years C. Ages 6 to 8 years D. Ages 12 to 14 years

B The American Academy of Pediatrics defines a febrile seizure as a seizure that occurs in a febrile pediatric patient between ages 6 to 60 months (or 1 to 3 years) in the absence of intracranial infection, metabolic derangements, or a history of afebrile seizures.

Which sign or symptom is characteristic in a patient with Guillain-Barr syndrome? A. Symmetric ascending paralysis B. Photophobia C. Asymmetric descending paralysis D. Neck weakness and inability to control head movements

A Guillain-Barr syndrome is characterized by symmetric ascending paralysis that starts in the lower extremities but not asymmetric descending paralysis. Meningitis commonly causes photophobia and decreased mental status. In myasthenia gravis, signs of impending respiratory failure include increasing weakness in the intercostal muscles and then the diaphragm, paradoxical respiratory movements, and neck weakness that leaves the patient unable to control head movements.

A patient presents with a high fever, stiff neck, petechial rash, and lethargy. Which medication should you expect to administer? A. Benzodiazepines B. Calcium channel blockers C. Vasopressors D. Fibrinolytics

C The patient has classic signs and symptoms of meningococcal meningitis, a particularly dangerous disease because death can occur within hours of symptom appearance. You should obtain vascular access appropriate for potential sepsis treatment, including fluid resuscitation and vasopressor administration. Benzodiazepines are used to control generalized seizures. Calcium channel blockers are administered to treat cluster headaches. Fibrinolytics are administered to manage ischemic stroke in qualified patients.

Which sign or symptom is the earliest indication that a patient with a stroke has increased intracranial pressure? A. Widening pulse pressure B. Sluggish right pupil C. Restlessness D. Extensor posturing

C A change in the level of consciousness, such as restlessness, is one of the earliest indicators of increasing intracranial pressure and neurologic decline. For preverbal patients, the emergency nurse should ask a parent or caregiver about the patient's typical level of responsiveness. Pupillary changes, pulse pressure changes, and abnormal motor posturing occur later.

In which phase of a generalized seizure does a patient report a headache, muscle pain, and extreme exhaustion? A. Tonic phase B. Clonic phase C. Postictal phase D. Prodromal phase

C During the postictal phase of a seizure, a patient may report a headache, muscle pain from the intense motor activity during the seizure, and extreme exhaustion. In the tonic and clonic phases of a seizure, the patient experiences a generalized seizure. The prodromal phase is the first stage of a migraine headache but not a phase of a generalized seizure.

Temporary, intermittent neurologic deficits commonly precede which disorder? A. Subarachnoid hemorrhage B. Hemorrhagic stroke C. Ischemic stroke D. Cerebellar hemorrhage

C Transient ischemic attacks (temporary interruptions of the cerebral blood supply that produce brief neurologic deficits) commonly precede an ischemic stroke. They are warning signs that cerebral blood flow is impaired and the risk of ischemic stroke is increasing. Hemorrhagic stroke, including a subarachnoid hemorrhage and cerebellar hemorrhage, is characterized by an abrupt onset and occurs without warning.

The nurse should triage which patient as emergent? A. A woman, age 28, with unilateral, pulsating head pain accompanied by photophobia and phonophobia who ran out of her regular headache medication B. A man, age 32, who complains of intense, one-sided pain in the temporal region that has persisted for the past 90 minutes C. A woman, age 45, who complains of a nonpulsating headache with a bilateral distribution that started after an intense argument with her daughter D. A woman, age 63, who presents to the emergency department with a new headache and photophobia

D For any patient over age 60 who presents with a new headache or visual changes, consider temporal arteritis. This emergent condition requires immediate intervention because it can result in vision loss or blindness. The other patients have presentations that do not require emergent attention. The woman, age 28, is in the second phase of a migraine headache. The man, age 32, is experiencing a cluster headache. The woman, age 45, is experiencing a tension headache.

Administration of succinylcholine (Anectine) to a patient with Guillain-Barr syndrome causes which adverse reaction? A. Paresthesia B. Prolonged skeletal relaxation C. Bradycardia D. Hyperkalemia

D Succinylcholine (Anectine) can rapidly increase serum potassium to a dangerous level in a patient with a neuromuscular disorder such as Guillain-Barr syndrome. In such a patient, succinylcholine should be used with extreme caution, if at all, because sudden hyperkalemia can trigger lethal dysrhythmias, such as ventricular tachycardia or ventricular fibrillation. Succinylcholine is used to produce skeletal relaxation in preparation for intubation. Guillain-Barr syndrome has no effect on its duration of action. Succinylcholine does not cause paresthesia or bradycardia in patients with Guillain-Barr syndrome.

Which intervention is appropriate for a patient with a cluster headache? A. Initiate bilevel positive airway pressure (BiPAP). B. Administer lorazepam (Ativan). C. Prepare for plasmapheresis. D. Administer high-flow oxygen.

D The treatment for a cluster headache in the emergency department includes inhalation of high-flow oxygen for 15 minutes. Oxygen typically is effective within 10 minutes if it is going to successfully relieve a cluster headache. Lorazepam (Ativan) is used to treat status epilepticus. Bilevel positive airway pressure and plasmapheresis are used to treat Guillain-Barr syndrome.