Neuro

A nurse is taking care of four clients. Which client should the nurse see first? •17-year-old client 24 hours postappendectomy •A 33-year-old client with a recent diagnosis of Guillain-Barré syndrome •50-year-old client 3 days post-myocardial infarction (MI) •50-year-old client with diverticulitis

G-Barré syndrome is characterized by ascending paralysis and potential respiratory failure. The order of client assessment should follow client priorities, with disorders of airway, breathing, and then circulation.

Quadriplegic pt in spinal shock. What do u expect?

Absence of reflex along with flaccid extremities

Right stroke pt has left sided flaccidity. What nursing intervention best prevents shoulder subluxation?

Bc of weight of the flaccid extremity, the shoulder may disarticulate.

Cranial nerve V

Chewing

client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. In this syndrome, polyneuritis leads to progressive motor, sensory, and cranial nerve dysfunction. On admission, which assessment is most important for this client?

Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis

Papilliedema

ICP in or around the brain causes part of the optic nerve inside the eye to swell S/S H/A, VOMITING HEADACHE, fleeting disturbances in vision

Pt with Amyotrophic lateral sclerosis & resp distress. What sign does nurse observe for as 1st sign of low O2?

Restlessness

Bradykanesia

Slow movement

Chewing is a function of cranial nerve

V.

Cranial nerve II doesn't have

a motor function

Swallowing

function of cranial nerves IX and X.