Neurological Saunders

The purpose of tens that needs further teaching

"Hospitalization is required because the unit is not portable.", The TENS unit is portable and the client controls the system for relieving pain and reducing the need for analgesics. It is attached to the skin of the body by electrodes. Hospitalization is not required.

Client is unconscious with a frontal head injury, diagnosed with a epidural hematoma is suspected. Which is the highest priority for the E R nurse to tell the transferring nurse

"Was the client awake and talking right after the injury?"Epidural hematomas frequently are characterized by a "lucid interval" that lasts for minutes to hours, during which the client is awake and talking. After this lucid interval, signs and symptoms progress rapidly, with potentially catastrophic intracranial pressure increase. Epidural hematomas are medical emergencies.

instructed the family of a client with a stroke (brain attack) who hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands

"We need to encourage head turning to scan the lost visual field."Homonymous hemianopsia is loss of half of the visual field.

Ptosis

(drooping) of the eyelid is caused by pressure on and dysfunction of cranial nerve III. Once ptosis occurs, it is ongoing; it does not relate to LOC.

Decerebrate

(extension) posturing is characterized by the rigid extension and pronation of the arms and legs. Option 1 is incorrect. Options 2 and 4 describe decorticate (flexion) posturing.

Cranial Nerve III: Oculomotor

Accommodation reflex is associated with this nerve and is part of the ocular motor system

Spinal cord injury at C5 weakened respiratory effort and ineffective cough and using accessory muscles in breathing, the nurse suspects presence of which problem

Altered breathing pattern rate depth rhythm timing and chest wall movements

A older client is is in acute state of disorientation, family state client was clear thinking this morning. Nurse determine which is least likely for this situation

Alzheimer's disease because it is a chronic disease

Monitoring a client with a head injury for signs an symptoms of I C P. The nurses notices presence of Cushing reflex, how do you assess this

Blood pressure which is a late sign of increased I C P which is wide pulse pressure bradycardia

Client had a stroke and is experiencing a neurological deficit involving the hippocampus, what signs an symptoms most likely noted

Cannot recall what was eaten for breakfast today

Autonomic Dysreflexia

Complication of spinal cord injury, elevated the head of the bed an examine for noxious stimuli, also the blood pressure but that is not the initial action

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully?

Consistently uses adaptive equipment in dressing self

temporal lobe damage

Difficulty understanding language

Ataxia

Disturbance in gait

Nurse is teaching about safety precautions, what would indicate the need for further teaching

Drink alcohol in small amounts only on the weekend, these clients need to avoid alcohol they can interact with the medication or precipitate a seizure

Which assessment finding would. Nurse expect to find with the client hospitalized with diagnosis of brain attack stroke who has difficulty chewing

Dysfunction of cranial never 5

The client is. Newly diagnosed with hemiplegia, what part of there medical history would be concerning

Emphysema respiratory is a priority in the acute phase of a stroke. Clients is vulnerable for atelectasis and pneumonia.

Aneurysm precaution avoid taking which action when giving respiratory care to this client?

Encouraging hourly coughing, could increase I C P no straining, blowing nose, sneezing

The nurse is assessing the function of cranial nerve XII in a client who sustained a brain attack (stroke). To assess function of this nerve, which action would the nurse ask the client to perform?

Extend the tongue hypoglossal

Client is experiencing hyperthermia. What would be appropriate in lowering clients body temperature

Give tepid bath, apply hypothermia blanket, administering acetaminophen

Performing assessment with thrombotic stroke, which assessment questions specific to this type of stroke

Have you had any mumbles or tingling or paralysis in any of your extremities. This type of stroke does not occur suddenly, person may experience loss of speech, hemiparesis, parenthesis on one side of the body. Dizziness cognitive changes an seizure

Admitting a client with a basal skull fracture who is at risk for increased I C P place client in which position

Head midline, neck in a neutral position, head of bed elevated 30 - 45

The nurse is at risk for increased I C P after stroke. Which activities performed by the nurse will assist with preventing increased I C P

Hyper oxygenation before suctioning, maintaining the head and neck in midline position, maintaining the head of the bed at 30 degrees elevation

Caring for an unconscious client who is experiencing persistent hyperthermia with no signs of infection. On the basis of these findings the nurse suspects dysfunction in which area of the brain?

Hypothalamus damage can cause persistent hyperthermia central fever can have absence of sweeting

What are some manifestations of secondary brain injury

Hypoxia, ischemia, hypotension, increased I C P secondary brain injury can happen several hours to days after initial brain injury

Giving a client with Bell's palsy instructions on preserving muscle tone in the face and preventing degeneration. The client needs further teaching

I will expose my face to colds to decrease the pain, this can cause discomfort, to prevent atrophy perform facial massages, and electrical nerve stimulation local heat may improve blood flow

Strategies with myasthenia gravis at home, what indicated the need for further teaching

Im going to the beach to relax, patient should avoid stress, infection, heat, surgery and alcohol. Wear a medical alert bracelet, take medication one hour before they eat, also obtain portable suction machine an resuscitation bag

Caring for a client with diagnosis of right hemispheric stroke. The client is alert an oriented to time place. What would your interpretation

Is likely to have perceptual an spatial disabilities

Visiting a patient with trigeminal neuralgia, on assessment you would ask the client which question to elicit the most specific information regarding this disorder

Is the pain your experiencing a stabbing like pain that is sudden an last for seconds or minutes, similar to a electric shock spasms twitching closure of eyes

Spinal cord injuries are at risk for developing autonomic dysreflexia, interventions

Keep lines wrinkle free, prevent pressure on lower limbs, turn an reposition every 2 hours Most common cause is a distended bladder, straight cath every 4 to 6 hours, check catch for kinks, constipation an fecal impaction can cause it, tactile, thermal or painful stimuli as well

The nurse is performing an assessment on a client with Guillain-Barré syndrome. The nurse determines that which finding would be of most concern?

Lung vital capacity of 10 mL/kg , respiratory is a major concern. Clients often are intubated and mechanically ventilated when the vital capacity is less then 15

planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention would be included in the plan of care?

Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

Patient with spinal cord injury expresses little interest in food and particular about choices of meals that are actually eaten, how would you interest this information

Meals represent an area that client can control and need to be encouraged, as long as its nutritionally reasonable. Depression is common an control over food may be all they have left

Carrying for a client with intracranial aneurysm who has been alert. Which sign and symptom are an early indication that the level of consciousness is deteriorating

Mild drowsiness, slight slurred speech, less frequent spontaneous. Early changes in L O C relate to orientation, alertnessand verbal responsiveness. Mild drowsiness, slight slurring of speech, and less frequent spontaneous speech are early signs of decreasing LOC.

Caring for a client with Alzheimer's disease, the client has changes in which component of the nervous system

Neuronal dendrites

A client with multiple sclerosis tells home health care nurse about having increasing difficulty in transferring from the bed to a chair, what is the initial nursing action

Observe the client demonstrating the transfer technique. A restorative program is started after, assessment needs to be completed first

A client with a history of myasthenia gravis presents at a clinic with bilateral ptosis and is drooling, and myasthenic crisis is suspected. The nurse assesses the client for which precipitating factor?

Omitting doses of medication crisis is caused by under medication and responds to cholinergic crisis

Autonomic Dysreflexia

Overreaction of the involuntary nervous system

A client with a traumatic brain injury is on mechanical ventilation. The nurse promotes normal intracranial pressure (ICP) by ensuring that the client's arterial blood gas (ABG) results are within which ranges?

Pao2 80 to 100 mm Hg, Paco2 35 to 38 mm Hg

Client is experiencing seizure activity, what information needs to be determined

Post etical status, duration of seizure, changes in pupil sizes or eye deviation, seizure progression an type of movement

Client has damage to Wernickes area form a stroke, which signs an symptoms would be noted

Problems understanding language

The client has impairment of cranial nerve II. Specific to this impairment, what would the nurse plan to do to ensure client safety

Provide a clear path for ambulation without obstacles

Client with Gillian barre syndrome has ascending paralysis is intubated and receiving mechanical ventilation. What coping strategies would you provide

Provide information, give positive feed back and encourage relaxation, patient are very fearful with ascending paralysis

Patient who has had a stroke has partial hemiplegia of the left leg, this patient can be provided with support an stability by using

Quad Cane which provides greater support an stability

Assessing the status of a client wearing a halo device, what finding requires intervention

Red skin under the jacket its to tight

Admitting an client with Gillian Barr syndrome, client has ascending paralysis to the level of the waist, known the complication of this disorder, what's the most essential i team you would bring.

Risk for respiratory failure, an cardiac dysrhythmias. You need a ECG monitor.

Caring for patient with Parkinson's which finding about gait do you expect

Shuffling, short accelerating steps. The client leans forward with the head, hips, and knees flexed and has difficulty starting and stopping.

The nurse is trying to communicate with a patient who has aphasia, what is most helpful to the client

Speaking to the client at a slower rate, allowing time for a patient to respond, looking directly at the client during in attempts to communicate

Stroke right sided hemianopsia, how would you help the client adapt to this problem

Teach the client to scan the environment so they can take in the entire visual field

Recent Bell's palsy, upset about the changes in facial appearance, which statement provides emotional support

This is not a stroke an most recover in 3 to 5 weeks

oculocephalic response dolls eyes, on an unconscious client with an head injury, the nurse turns the clients head an notices the movement in the same direction

This would be abnormal

The client with spinal nerve injury has cervical tongs applied in the emergency department. What would the nurse include when planning care for this client

Using rotorest bed, ensure weighs hang freely, assess skin integrity of the weights and pulleys, comparing the amount of prescribed traction with the amount in use

Which cranial nerves control taste, anterior two thirds and posterior third of the tongue

VII (facial) and IX (glossopharyngeal)

Speaking loudly may help overcome a deficit to cranial nerve

VIII Vestibulocochlear

Client is brought to the hospital by a neighbor who heard the client taking and wondering at 3am the nurse would first determine what about the client

Whether this is a change in usual level of orientation

Early signs of increased I C P

early signs include a slight change in level of consciousness, headache, nausea, vomiting, visual disturbances (diplopia), and seizures.

Cranial surgery 5 days ago does not seem to progressing as fast as his family would have hoped, nurse implement which approach to the family at this time

emphasize approach in a realistic manner

Nystagmus

involuntary eye movements.

CN XI

is responsible for neck and shoulder movement.

CN XII

is responsible for tongue movement.

Respiratory outcome for a client with Gillian barre, what are acceptable outcomes

outcomes include clear breath sounds on auscultation, spontaneous breathing, normal vital capacity, normal arterial blood gas levels, and normal pulse oximetry.

Evaluating respiratory status with client with a stroke, airway patent if which is identified

18 breathes per minute saturation 98%

Caring for patient with neurogenic bladder caused by multiple sclerosis, planing on administering 200 ml H20 a day which pan is most helpful to the client

400 - 500 ml with each meal and 200 to 250 ml mid morning, mid afternoon, and late afternoon to minimize urinating at night

Assesses a client with a head injury, the neurologist would avoid the oculocephalic response

A cervical spinal cord injury, eye movement in an unconscious person is tested by ocuulocephalic response.

discharged after moderately severe head injury. Family states client is behaving differently than before accident. Client is more fatigued, irritable and has memory problems. Previously very even-tempered, is now prone to outbursts an has a temper now. Nurse determines behaviors are

A long-term sequela of the injury. Head injuries usually have residual physical and cognitive disabilities, personality changes, increased fatigue, irritability, mood alterations, and memory changes. May require frequent to constant supervision. Assesses the family's ability to cope, makes appropriate referralssupport groups,

home visit with a client with residual cognitive deficit, client had memory problem, short attention span, is easily distracted, and processes information slow, which referral does this client need

A neuropsychologist

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which finding would indicate client is developing meningitis as a complication of surgery?

A positive Brudzinski's sign. Signs of meningeal irritation nuchal rigidity, a positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is a stiff neck and soreness, especially noticeable when neck is flexed. Kernig's sign is positive when client feels pain and spasm of hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski's sign is positive when client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest.

The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation?

A significant sway when the client stands erect with feet together, arms at the sides, and the eyes closed

client with myasthenia gravis has become increasingly weaker. provider prepares to identify whether client is reacting to an overdose of medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis?

A temporary worsening of the condition. An edrophonium injection makes the client in cholinergic crisis temporarily worse. An improvement in the weakness indicates myasthenia crisis.

Client with spinal cord injury becomes angry an belligerent when the nurse tries to administer care, the nurse performs which action

Acknowledge anger and continue care

A client has a neuro deficit involving the limbic system, what would you define on assessment

Affect is flat with periods of emotional liability this system is responsible for feelings an emotion

Evaluating the function of the limbic system as part of the neurological c status of a client, what would the nurse assess

Affect or emotions

Client with myasthenia gravis is having difficulty with airway clearance an maintaining an effective breathing pattern, what's most important to have available

Ambu bag an suction equipment

Nurse testing of the oculovestibular reflex in an unconscious client who has a head injury. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left, followed by eye movement back to midline. The nurse understands that this finding indicates which situation?

An intact brainstem

Caring for a client with complete right sided hemispheres from a stroke. What characteristics are associated with this condition

Aphasia language disorder effecting communication, right sided weakness, weakness on the right side of face an tongue,

Visiting a client with Multiply sclerosis taking oxybutynin, nurse evaluates the effectiveness of the medication by asking the client which assessment question?

Are you getting up at night to urinate, expected effects would be to decrease urine

Assessing Bell's palsy. Which question would elicit information regarding this clients disorder

Are you having any trouble chewing food, manifestation include facial droop, increased lacrimation, painful sensation in the eye, face, or behind the ear, and speech and chewing difficulties

client who had a stroke with global aphasia, nurse would incorporate communication strategies into plan of care because of which characteristics of clients speech.

Associated with poor comprehension Global aphasia is a condition in which the affected person has few language skills as a result of extensive damage to the left hemisphere. The speech is nonfluent and is associated with poor comprehension and limited ability to name objects or repeat words

Assessing a clients gait, notes that it is unsteady and staggering.

Ataxic

client with myasthenia gravis arrives at the hospital emergency department in suspected crisis. The nurse ensures that which medication is available in the event that the client is in cholinergic crisis?

Atropine sulfate

Spinal cord injury that results in paraplegia sudden onset of severe nausea an headache, sweeting with flushing skin, systolic is 210 what should you immediately suspect

Autonomic dyslexia

client with trigeminal neuralgia measure to prevent episodes of pain, what would you instruct

Avoid activities that may cause pressure near the face

client with a suspected diagnosis of Huntington's disease. The nurse would expect to note documentation of which early symptom of this disease?

Balance and coordination problems, Early symptoms of Huntington's disease include restlessness, forgetfulness, clumsiness, falls, balance and coordination problems, altered speech, and altered handwriting.

Lower back pain that radiates down left posterior thigh. Ask if it's worsened or aggravated by which

Bending or lifting this would be contraindicated with a herniated lumbar disk. Also lifting sneezing an coughing

Visiting a client with myasthenia gravis, what are methods to minimize risk for aspiration

Chew food thoroughly, cut into small pieces, sit straight up in a chair while eating, swallow while chin is tipped slightly downward to the chest

Prescription to administer a medication to a client who is experiencing shivering as a result of hyperthermia. Which medication would the nurse anticipate to be prescribed?

Chlorpromazine

The nurse reviews the primary health care provider's (PHCP's) prescriptions for a client with Guillain-Barré syndrome. Which prescription written by the PHCP would the nurse question?

Clear liquid diet clients with dysphagia are more likely to aspirate clear liquids than thick or semisolid foods

Reviewing records for a client with a thrombotic brain attack stroke, what would you expect to note in the assessment section

Client complains of sever headache, which was followed by sudden onset of paralysis

The nurse is assessing a client's muscle strength and notes that when asked, the client cannot maintain the hands in a supinated position with the arms extended and eyes closed. How would the nurse correctly document this finding on the medical record?

Client is exhibiting pronator drift.

A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis?

Cloudy or turbid CSF, elevated protein, and decreased glucose levels, elevated blood pressure. Should be clear

A client who suffering a brain attack stroke is prepared for discharge. The provider has prescribed ROM exercises for clients right side. What action would you include in the pan of care

Consider the use of active, passive, or active-assisted exercises in the home. Nurse must consider small forms of ROM goal is to to assume as much self care as possible

Assessing a stroke, brain attack, on assessment the nurse is unable to understand the nurses commands, which condition would the nurse document

Damage to auditory association areas located in the temporal lobe and related to understanding spoken language

Performing an assessment on a client with a brain injury, assuming a posture with extremities inward

Decorticate rigidity

hyperthermia, assessment findings

Decreased heart rate, blood pressure, and metabolic needs

A client is diagnosed with Bell's palsy. The nurse assessing the client expecting to note which symptoms

Difficulty closing the eyelid on the affected side, face drooping, a asymmetrical smile, a widening or palpebral fissure which is the opening between the eyelids

Assessing a client with a brain stem injury. In addition to obtain the clients vital signs and determining the Glasgow scale score, what priority intervention would nurse implement

Draw blood for arterial blood gas analysis. Specific to the area of the brain involved

admitting a client with Guillain-Barré syndrome to unit. The client complains of inability to move both legs and reports tingling sensation above the waistline. Knowing the complications of the disorder, the nurse would bring which most essential items into the client's room?

Electrocardiographic monitoring electrodes and intubation tray. The client is at risk for respiratory failure because of ascending paralysis. intubation tray needs to be available. Another complication is cardiac dysrhythmias, which necessitates electrocardiographic monitoring. client is immobilized, the nurse needs to assess for deep vein thrombosis and pulmonary embolism routinely.

A client with neurological impairment experiences urinary incontinence. What would help the client adapt to the situation

Establishing a toileting schedule

Client nervous about M R I , what statement would be most reassuring

Even though you are alone, there will be a voice communication during the procedure

A client recovering from a head injury is participating in care. client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?

Exhaling during repositioning decreases, activities that increase. intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis

Patient recovering in from a head injury participating in care. Nurse determines that client understands measures to prevent elevation in ICP if the nurse observes the client doing which activity

Exhaling during reposting

planning to perform an assessment of the client's level of consciousness following a head injury using the Glasgow Coma Scale. Which assessments would the nurse include in order to calculate the score

Eye opening, Best verbal response, Best motor response

Assessment of a client with Bell's palsy, what would you expect to find

Facial dropping, pressure on cranial nerve VII. You would also see paralysis of facial muscle, increased lacrimation, painful sensation in the eye, face, or behind the ear, speech or chewing difficulty,

Craniotomy patient having a issue with body image, nurse developed goals client has not meet the goals. Client has meet outcome if they state

Facial puffiness will be a permanent problem

Evaluating neurological signs of a client in spinal shock following spinal cord injury, which would indicated that spinal shock is persistent

Flaccid paralysis

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present?

Fluid separates into concentric rings and tests positive for glucose. Halo show an fluid test positive for glucose

The client with a head injury opens eyes to sound, has no verbal response, and localizes to painful stimuli when applied to each extremity. How would the nurse document the Glasgow Coma Scale (GCS) score?

GCS 9 the highest possible score is a 15, under 8 indicates a comma is present

trigeminal neuralgia medication

Gabapentin

Teaching a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care, which indicates further teaching is needed

Getting out of bed, sitting straight up and swinging the legs over the side of the bed. Patient are actually taught to get out of bed by sliding to the edge of the mattress, rolls on there side then pushes up from the bed

Client admitted with a basal skull fracture, who at risk for increased I C P. Client would put the client in which position

Head midline, neck in neutral position, head of bed 30 - 45 degrees

client who has had a craniotomy an has supratentorial incisions. Which position will the client be placed in

Head of the bed 30 - 45 degree, head midline which will prevent rise in I C P an promote venous return

The nurse is caring for a client who has just been admitted to the hospital with a diagnosis of a hemorrhagic stroke. The nurse would place the client in which position?

Head of the bed elevated 30 degrees with the head in midline position, to reduce increase I C P head needs to be in a midline, neutral position to facilitate venous drainage from the brain.

Caring for a client with a spinal injury 48 hours ago what would nurse assess for when monitoring for gastrointestinal complications

Hematest-positive nasogastric tube drainage for development of stress ulcer can occur and can be detected by hematest positive nasogastric tube aspiration or stool, also at risk for paralytic lieu's absent bowel sounds and abdominal distinction

Brought to the emergency room with a seizure 1 hour ago. Family reported that the clients jaw was moving as though grinding food. In helping determine origin what would the nurse include in the clients assessment

History of prior trauma

Caring for a client at risk for increased intracranial pressure, what will nurse perform to prevent risk increased I C P

Hyper oxygenate, maintain the head midline, maintain the head of the at a 30 degree angle

Instructing a client with Parkinson's disease about preventing falls, what statement would require further teaching

I dont need my walker when walking, client with Parkinson's is instructed regarding safety,

client diagnosed with Parkinson's disease. taking benztropine orally daily, tell the spouse to report which side effect if it occurs?

Inability to urinate, this med causes urinary retention

creating a plan of care for a client with a diagnosis of stroke (brain attack) with anosognosia. To meet the needs of the client with this deficit, the nurse would include activities that will achieve which outcome

Increase the client's awareness of the affected side. activities that remind the client to perform actions that require looking at the affected arm or leg, as well as activities that will increase the client's awareness of the affected side

Assigned to an unconscious client, client is lying supine in the bed, head of the bed is elevated 5 degrees. NG tube is running 70ml/hr. The nurse auscultates adventitious breath sounds. What's your judgment

Increased risk for aspiration,

admitted with exacerbation of multiple sclerosis, assessing for possible precipitating risk factors, what would be unrelated

Ingestion of fruits an vegetables, onset can include physical stress (e.g., vaccination, excessive exercise), emotional stress, fatigue, infection, physical injury, pregnancy, extremes in environmental temperature, and high humidity

Creating a plan of care for a client with a stoke, who has right homonymous hemianopsia. plan of care

Instruct client to turn head to inspect the right visual field, this is loss of the visual field

planning discharge teaching for a client started on acetazolamide for a supratentorial lesion from a head injury. Which information about action of the medication would be included

It decreases cerebrospinal fluid production.

family with client with increased I C P from head injury are talking at the patients bedside, they are discussing condition, the nurse intervene based on

It is possible that the client can hear the family

Client with neurological disorder also has trouble breathing, which activity would be appropriate

Keep suction at bedside, elevate head of bed to 30 degrees, keep head an neck in alignment, administer respiratory treatments

A postoperative craniotomy client who sustained a severe head injury is admitted to the neurological unit. What nursing intervention is necessary for this client?

Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head. Which enhances venous return and decrease chances of increased I C P

A spinal fusion after a herniated lumbar disk. Intervention for maintenance an safety

Keep the head of the bed flat, place pillows under the length of legs, use log rolling for repositioning, assist with eating

The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP?

Late signs of increased ICP include a significant decrease in level of consciousness, bradycardia, decreased motor and sensory responses, alterations in pupil size and reactivity, posturing, Cheyne-Stokes respirations, and coma.

Client in a wheel chair after spinal cord accident 4 months ago. To prevent autonomic dysreflexia

Leaving the client in an unchilled area of the room

Caring for a client with a supratentorial lesion from a brain injury. The nurse assesses which measurement as the most critical index of central nervous system (CNS) dysfunction?

Level of consciousness

A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action?

Listen to breath sounds. Respiratory being compromised is the leading cause of death in cervical cord injury

instructions on taking seizure medication. Taking divalproex sodium, instruct client about the importance of returning to the clinic for monitoring of which laboratory study

Liver function this medication causes fatal hepatotoxicity

Caring for a client with a spinal cord injury to minimize complications

Log roll a client onto a firm mattress

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions would the nurse take

Loosening restrictive clothing, Removing the pillow and raising padded side rails, Positioning the client to the side, if possible, with the head flexed forward

The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect?

Meningitis is an infectious process of the central nervous system caused by bacteria and viruses. The inability to extend the leg when the thigh is flexed anteriorly at the hip is a positive Kernig's sign, noted in meningitis. Kernig's sign is not seen specifically with spinal cord injury, intracranial bleeding, or decreased cerebral blood flow.

Diagnosis of A L S which initial clinical manifestations of this disorder would the nurse expect to see documented in the record

Mild clumsiness usually the distal portion of one extremity. Client may complain of tripping or dragging one leg, mental an intellectual are usually normal,

Patient treated in E R for a concussion. Family needs further teaching if they verbalize to call the primary health care provider (PHCP) for which client sign or symptom?

Minor headache concussion after head injury is a temporary loss of consciousness (from After concussion, the family is taught to monitor the client and call or return the to E R for confusion, difficulty awakening or speaking, one-sided weakness, vomiting,

A thymectomy is performed on a patient with myasthenia gravis. What would be included in the post operative plan

Monitor the clients chest tube drainage

Evaluating use of a cane for a stroke patient who has residual left sided weakness, intervene if you see the patient performing what action

Moving the cane when the right leg is moved, cane should be held on the stronger side to minimize stress on affected side, an provides a wide suppirt base

Caring for a client with.a herniated intervertebral herniated disk, who is complaining about stabbing pain radiating to the lower back and left right buttocks. Signs an symptoms are most likely due to

Muscle spasms int he area of the herniated disk. Compression leads to inflammation, which irritates the muscle putting them into spasms

Monitoring a client with a suspected intervertebral disc problem who returned to unit after myelogram, which complaint would prompt you to notify the providers

Neck stiffness especially on flexion, a pain reported. They are signs of meningeal irritation

Caring for a client who was in a motor vehicle accident who sustained blunt head injuries. On assessment the nurse notes presence of bloody drainage from the nose.

Notify provider, bloody or clear drainage from nose or ear after head trauma is a sign of a cerebral spinal fluid leak which requires immediate interventions

Assessing dressing for a patient who had transsphenoidal resection of the pituitary gland. You see a small amount of serosaguineous drainage that is surrounded with clear fluid, what's the most appropriate action

Notify the provider this could be possible cerebral spinal fluid

The nurse is caring for a client with bacterial meningitis. The nurse would anticipate that an antibiotic with which characteristics will be prescribed for the client?

One that is able to cross the blood-brain barrier if didn't cross it wouldn't be effective

Seizure precautions for a patient. Which e measure would you take for safety

Pad side rails, airway at the bedside, 02 an suction, flushing catheter to make sure the site is patient for medication

nursing student needs to institute full seizure precautions. Which item if noted in the client's room would need to be removed

Padded tongue blade full seizure precautions include bed rest with padded side rails in a raised position, a suction machine at the bedside, having diazepam or lorazepam available, and providing an oxygen source.

Caring for a client with trigeminal neuralgia, client ask why do I have so much pain. How would you respond

Pain is related to stimulation of affected nerve by pressure and temperature

Client with traumatic brain injury is able, with eyes closed, to identify a set of keys placed in their hands. Nurse determines that there is appropriate function of which lobe of the brain

Parietal it's responsible for spatial orientation and awareness of size an shape

client placed on aneurysm precautions, what interventions will be included in the plan of care

Place blood pressure cuff at clients bedside, close shades. include rest an quiet, dimmed lighting, prevent stimuli, monitoring Blood pressure noting changes that could indicated rupture. No pushing pulling sneezing or straining that would increase blood pressure

The nurse is administering oral care to an unconscious client . What would you perform

Position client on side, brush the teeth with small soft tooth brush, cleanse mucous membrane with soft sponges

assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse would use which technique to test the client's peripheral response to pain?

Pressure on nail beds

caring for a client with increased intracranial pressure as a result of a head injury. The nurse would note which trend in vital signs if the intracranial pressure is rising?

Pressure on nail beds. A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature, widening pulse pressure, increased systolic blood pressure, and decreasing pulse and respirations. Respiratory irregularities also may occur.

Preparing admission of a client with Gillian barre syndrome. What's a hallmark manifestation of this syndrome

Progressive muscle weakness that develops rapidly

client with a subarachnoid hemorrhage secondary to aneurysm rupture. What would you do to control the environment.

Prohibit or limit the use of a radio or television and reading. Stimuli should be kept to a minimum to minimize I C P

Nurse is preparing to care for a client with a lumbar puncture, place the client i which position following the procedure

Prone with small pillow under abdomen, reduces cerebral fluid leak an post lumbar puncture headache

ALS the client is severely dysphasia. Which intervention would be included in the plan of care

Provide oral hygiene after each meal Assess swallowing ability frequently Allow the client sufficient time to eat Maintain a suction at the bedside

aneurysm precautions

Provide physical aspects of care, prevent pushing or straining activities, maintain the head of the bed at 25 degrees

Caring for a client who is displaying confusion secondary to a stroke. What wold be helpful in assisting this client

Provide sensory cues, giving simple, clear directions, stable environment, keep families photos near by

A child is diagnosed with Reye's syndrome. The nurse creates a nursing care plan for the child and would include which intervention in the plan?

Providing a quiet atmosphere with dimmed lighting Reye's syndrome, acute encephalopathy, follows a viral illness, characterized by cerebral edema and fatty changes in liver. supportive care, monitoring and managing cerebral edema. Decreasing stimuli providing quiet, dimmed lighting, decrease the stress on the cerebral tissue and neuron responses

Caring for a client following a lumbar laminectomy procedure. The client reports numbness and tingling down the left lateral thigh and knee. What is the next action for the nurse to take?

Question the client about preoperative symptoms. Spinal cord surgery requires frequent assessment. Movement of the arms and the legs and assessment of sensation would be unchanged when compared with the preoperative status.

The nurse is providing care to a client with increased intracranial pressure (ICP). Which approach is beneficial in controlling the client's ICP?

Reduce room noise.

An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period?

Reposition the infant frequently. Hydrocephalus It results in head enlargement, increased I C P , the head grows at an abnormal rate, if not repositioned frequently, pressure ulcers can occur on the back and side of the head. An egg crate mattress under the head is can help prevent skin breakdown.

The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease?

Respiratory or gastrointestinal infection during the previous month. Guillain-Barré syndrome, unknown origin. Many report history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. On occasion, the syndrome can be triggered by vaccination or surgery.

Plan of care after a lumbar puncture, which intervention is in correct

Restrict fluid intake for a period of 2 hours, that isn't correct fluid is encouraged after lumbar puncture to replace fluid that was removed

Assessing the client L O C and documents patient is experiencing delirium. What damage has been done to the nervous system

Reticular activating system and cerebral hemispheres, Insomnia, agitation, mania, and delirium are caused by excessive arousal of the reticular activating system in conjunction with the cerebral hemispheres.

Patient with herniated lumbar intervertebral disk is on bed rest, in Williams position to minimize pain, what position is the bed in

Semi Fowler with the knees slightly flexed, this relaxes lower back muscles an relieves pressure on the spinal root

following craniotomy who has a supratentorial incision, client would most likely be maintained in which position?

Semi-Fowler's position 30 degrees to promote venous outflow

Suspecting cerebrospinal fluid (CSF) leakage, the nurse would look for drainage that is of which characteristic?

Serosanguineous, surrounded by clear to straw-colored fluid that of a halo, verify drainage also by testing for glucose

Nurse is teaching an client with paraplegia form spinal cord injury measure to maintain skin integrity. Which instruction is most helpful

Shift weight in wheel char every 2 hours while in wheel chair and use a pressure relief pad

Patient with herniated disk who has had a spinal fusion and insertion of hardware is extremely concerned with perceived lengthy rehabilitation period. Concerned about finances an the ability to return back to work, what referral of the health care team does this client need a referral for

Social worker

Reviewing discharges plan for a post craniotomy, prepared by student intervene if you observe what

Sounds will not be heard clearly unless they are loud

Observation for tonic clonic seizures, what is the manifestation not likely noted in the clonic phase

Spasms of entire body momentary muscular relaxation of the entire body, accompanied by strenuous hyperventilation. The face is contorted and the eyes roll. Excessive salivation results in frothing from the mouth. The tongue may be bitten, the client sweats profusely, and the pulse is rapid. The clonic jerking subsides by slowing in frequency and losing strength of contractions over a period of 30 seconds. Body stiffening, sudden loss of consciousness, and brief flexion of the extremities are associated with the tonic phase of a seizure.

A client who had Brian attack stroke has suffered damage to brocas area of the brain, what's the priority assessment

Speech coordination of muscular activity of the tongue, mouth an larynx. Aphasia

spinal cord injury patient, whos on a bowel training program, what would you promote

Stimulation of the parasympathetic reflex, which is most active after the first meal of the day, sufficient fluids an roughage with the valsalva maneuver

A client is anxious about a diagnosis procedure. The clients pupils are dilated, and the respiratory rate, and blood pressure are increased from baseline. Manifestation is due to what type of physiological response

Sympathetic nervous system which is responsible for fight or flight

Discussing interventions to prevent constipation in client with multiple sclerosis. There using information correctly if they report

Take high fiber bulk formers an stool softeners. 2000ml fluid intake recommended, client needs to initiate bowel movements every other day 45 minutes after largest meal.

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective?

Taking medications as scheduled. Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength as well

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition

The client is aphasic, the client has weakness on the right side of the body, The client has weakness on the right side of the face and tongue

The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?

The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.

Developing a plan of care for a patient to address interventions to prevent hypothermia. The nurse would document which desired outcome in the plan of care

The clients hands and feet are warm to the touch

The nurse is caring for a client with a head injury The I C P reading is 8mg. What condition would you document

The intracranial reading is normal, normal I C P is 5 to 15

Closed head injury from assault with a baseball bat, what motor responses would be a deficit in this area

The left side of the body, deficits are seen in the opposite side of the injury

client with dysphasia following a stroke, what would you include in the plan of care

Thickened liquids, assist with eating, assess presence of swallowing reflex, provide time for client to chew

Caring for a client with intracranial pressure (ICP) monitoring. Which intervention is appropriate to include in plan of care?

Use strict aseptic technique when monitoring system. There is a foreign body embedded in the client's brain, vigilant aseptic technique implemented. With a client who has increased ICP, the head of the bed elevated at least 30 degrees to improve jugular outflow. Drainage tubing should not be routinely changed.

Client is experiencing a inferior myocardial infarction has had a drop in heart rate, also complain of nausea. With these finding the client is experiencing parasympathetic stimulation of which cranial nerve?

Vagus (CN X)

Suffering a head injury affecting the occipital lobe of the brain, what is the focus of the immediate assessment

Vision

To promote cerebral tissue perfusion in a postoperative phase following cranial surgery, the nurse would place the client client in bed

With the head of the bed elevated at least 30 degrees to avoid increased I C P

The nurse is testing the spinal reflexes of a client during neurological assessment, which help to determine the adequacy of the spinal reflex

Withdrawal reflex. It is an abrupt withdrawal of a body part in response to painful or injurious stimuli

vagus nerve X

is responsible for sensations in the thoracic and abdominal viscera. It also is responsible for the decrease in heart rate because approximately 75% of all parasympathetic stimulation is carried by the vagus nerve.

Activities that increase ICP

isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose.

Client begins seizure activity while in bed

lossen restrictive clothing, remove pillows raise padded rails, position client on there side

caring for a client with trigeminal neuralgia. What's the best snack

room temperature water, mild tactile stimulation of the face can trigger pain, client needs to eat an drinnk room temperature water nutritious foods that are soft an easy to chew. Extreme temps can cause pain