Adult Neuro

signs of comminuted skull fracture

"egg shell" appearance

increased ICP diagnostic tests

- ABGs - CBC - coagulation studies - electrolytes - serum osmilarity (270-290) - urinalysis/osmilarity - CT, MRI - EEG, cranial doppler

how to avoid MS attacks

- adequate rest - exercise - staying cool - balanced diet - stress releif

How diagnose Parkinson's?

2 or more cardinal symptoms with asymmetrical presentation (brady/akinesia, resting tremor, rigidity, postural instability)

Multiple sclerosis diagnostics

2 separate symptomatic events or MRI changes in at least 2 separate locations

Cranial nerve names

1. Olfactory 2. Optic 3. Oculomotor 4. Trochlear 5. Trigeminal 6. Abducens 7. Facial 8. Vestibulocochlear 9. Glossopharyngeal 10. Vagus 11. Accessory 12. Hypoglossal

*** Physostigmine must be administered at the exact hour to maintain muscle strength. usually given ___________ before ______

30-60 minutes before meals (to decreased chewing/swallowing difficulty)

A client with myasthenia gravis is receiving pyridostigmine bromide to control symptoms. Recently, the client has begun experiencing increased difficulty in swallowing. Which nursing action is effective in preventing aspiration of food? 1 Place a tracheostomy set in the client's room. 2 Assess respiratory status after meals. 3 Request for the diet to be changed from soft to clear liquids. 4 Coordinate mealtimes with the peak effect of the medication.

4 (Dysphagia should be minimized during peak effect of pyridostigmine bromide, thereby decreasing the probability of aspiration. A tracheostomy set is a treatment for, rather than equipment to prevent, aspiration. Although it is vital that the client's respiratory function be monitored, assessing the client's respiratory status will not prevent aspiration. There are insufficient data to determine whether changing the diet from soft foods to clear liquids is appropriate; also, liquids are aspirated more easily than semisolids.)

A client sustains a crushing injury of the spinal cord above the level of origin of the phrenic nerve. As a result of this injury, the nurse expects to react to which clinical manifestation? 1 Ventricular fibrillation and decreased perfusion 2 Dysfunction of the vagus nerve with hiccups 3 Retention of sensation but paralysis of the lower extremities 4 Respiratory paralysis and cessation of diaphragmatic contractions

4 (The phrenic nerve innervates the diaphragm. A crushing spinal cord injury above the cervical plexuses, the level of phrenic nerve origin, results in respiratory paralysis. Cardiac activity will not be affected; the heart is regulated by the autonomic nervous system fibers originating in the medulla. Activities regulated by the vagus nerve will be unaffected; the vagus nerve originates in the medulla, which is superior to the cervical region; the phrenic nerves originate from the cervical plexuses. In a crushing spinal cord injury, both motor and sensory conduction are affected.)

Normal CCP

60-100 (>70)

A client has a mean arterial blood pressure (MAP) of 97 mm Hg and an intracranial pressure (ICP) of 12 mm Hg. Calculate the cerebral perfusion pressure (CPP) for this client. Record your answer using a whole number. _________ mm Hg

85 (MAP-ICP=CPP)

8. What is the BEST position for a patient experiencing autonomic dysreflexia? A. High Fowler's with legs lowered B. Low Fowler's with legs lowered C. Semi-Fowler's with legs at heart level D. Prone

A (The patient should be in high Fowler's (90 degrees) with the legs lowered. This will allow gravity to cause blood to pool in the lower extremities and help decrease blood pressure.)

most important assessment in ALS

AIRWAY

5. After taking all the necessary steps for a patient who has developed autonomic dysreflexia, what should the nurse assess FIRST as a possible cause of this condition? A. Skin break down B. Blood glucose C. Possible bladder irritant D. Last bowel movement

C

cervical injuries at ___ and ___ are usually fatal

C2, C3

injury above ___ involves respiratory difficulty and quadriplegia

C4

Dementia vs. Alzheimer's

Dementia is a general term for a decline in mental ability severe enough to interfere with daily life. Alzheimer's is the most common cause of dementia. Alzheimer's is a specific disease. Dementia is not.

Signs of subarachnoid hemorrhage

Horner's Sign - pupil constriction (miosis) - eyelid droop (ptosis) - decreased sweating (anhidrosis)

CCP = ____ - ____

MAP, ICP

CCP ex. BP=90/42, ICP=19

MAP: 42x2 = 84 84 + 90 = 174 174 / 3 = 58 (MAP) 58 - 19 = 39 (CCP)

Ocular vs Bulbar myasthenia gravis

Ocular: ptosis, diplopia Bulbar: difficult phonation, swallowing, chewing

first med given in ALS to slow disease progression

Riluzole (Rilutek)

Tensilon Test Antidote

atropine

***______________ with lesions/injuries above T6 and in cervical lesions may occur

autonomic dysreflexia (sweating, bradycardia, HTN)

Huntington's Disease inheritance

autosomal dominant

The cranial vault contains...

brain tissue, blood, CSF

*** earliest symptom of increased ICP

decreased LOC

First symptom of Alzheimer's

forgetfulness

Glascow Coma Scale classifications

mild: 13-15 moderate: 9-12 severe: 3-8

*** because Ach accumulates in the ANS, monitor for ___________ such as _____

muscarinic side effects, diarrhea, bradycardia, and bronchospasm

*** brain tumors are _________ lesions that ______ ICP

space occupying, increase

***visceral distension from noxious stimuli (distended bladder, impacted rectum) may cause ___________

sweating, bradycardia, hypertension, nasal stuffiness

upper v lower motor neuron damage

upper: spasticity lower: flaccidity

Which initial action would the nurse take for a nursing home resident with moderate Alzheimer disease who begins to engage in numerous acting-out behaviors? 1 Assess the client's level of consciousness 2 Identify the stressors that precipitate the client's behavior 3 Observe the client's performance of activities of daily living 4 Monitor the side effects associated with the client's medications

2 (The nurse would initially identify the stressors that precipitate the client's behavior. If the areas that cause stress can be identified, the client would be better able to control the acting-out behavior. These clients may be confused or disoriented, but they usually do not experience an altered level of consciousness; an altered level of consciousness is associated with delirium, not dementia. Although the client's performance of activities of daily living may be observed, this is only one area of function that should be assessed and it is not the initial action. The initial action would focus on the acting-out behaviors. Although monitoring the side effects associated with the client's medications is important, it is not the initial action.)

Which characteristic would a client who has been taught about myasthenia gravis identify as being common to both myasthenic and cholinergic crises? 1 Diarrhea 2 Salivation 3 Difficulty breathing 4 Abdominal cramping

3 (Because of the decrease in tone and strength of the respiratory muscles, difficulty breathing is a prominent feature of both crises. Diarrhea occurs in cholinergic crisis; it is an effect of an overdose of the medications (anticholinesterases) used to treat myasthenia gravis. Salivation occurs in cholinergic crisis; it is an effect of an overdose of the medications (anticholinesterases) used to treat myasthenia gravis. Abdominal cramping occurs in cholinergic crisis; it is an effect of an overdose of the medications (anticholinesterases) used to treat myasthenia gravis.)

Which immunomodulatory agent is beneficial for the treatment of clients with multiple sclerosis? 1 Interleukin 2 2 Interleukin 11 3 Beta interferon 4 Alpha interferon

3 (Beta interferon is an immunomodulator administered in the treatment of multiple sclerosis. Interleukin 11 (IL-11) prevents development of thrombocytopenia after chemotherapy. IL-2 treats metastatic renal cell carcinoma and metastatic melanoma. Alpha interferon treats hairy cell leukemia, chronic myelogenous leukemia, and malignant melanoma.)

The nurse is caring for a client with signs of autonomic hyperreflexia. Which factor would the nurse consider as a possible cause? 1 Positional vertigo 2 Deteriorating myelin sheath 3 Distended large intestine 4 Fluid volume overload

3 (Bowel or bladder distention causes autonomic nerve impulses to ascend via the cord to the point of injury; here the reflex is completed, and autonomic outflow causes piloerection (goose bumps), sweating, and splanchnic vasoconstriction. Splanchnic vasoconstriction causes hypertension and a pounding headache. Positional changes or vertigo is not involved in the autonomic hyperreflexia phenomenon. The myelin sheath deteriorating is not involved in the autonomic hyperreflexia phenomenon. Hypervolemia does not cause autonomic hyperreflexia.)

While assessing the eyes of a client, a health care provider notices there is an obstruction to the outflow of aqueous humor. Which additional finding would be noted to support a diagnosis of glaucoma? 1 Blurred central vision 2 Increased opacity of the lens 3 Elevated intraocular pressure 4 Changes in retinal blood vessels

3 (In glaucoma, there is an obstruction of the outflow of aqueous humor due to an intraocular structural damage, which may result from elevated intraocular pressure. Blurred central vision is seen in macular degeneration. Increased opacity of the lens may be seen in cataracts. Retinopathy may result from the changes in retinal blood vessels.)

Which treatment goal would the nurse emphasize when teaching a client with a diagnosis of open-angle glaucoma? 1 Dilate the pupil. 2 Rest the eye muscles. 3 Control intraocular pressure. 4 Prevent secondary infections

3 (Individuals with glaucoma have increased intraocular pressure that must be returned to the expected range, or blindness will result. Resting the eye muscles has no effect on this condition because it will not decrease the pressure. Dilation of the pupils may increase the pressure further by obstructing flow; increased pressure reduces the visual field and leads to blindness. Glaucoma does not lead to secondary infections.)

A client is diagnosed with Parkinson disease and receives a prescription for levodopa therapy. Which mechanism of action would the nurse identify for this medication? 1 Blocks the effects of acetylcholine 2 Increases the production of dopamine 3 Restores the dopamine levels in the brain 4 Promotes the production of acetylcholine

3 (Levodopa is a precursor of dopamine, a catecholamine neurotransmitter; it increases dopamine levels in the brain that are depleted in Parkinson disease. Blocking the effects of acetylcholine is accomplished by anticholinergic medications. Increasing the production of dopamine is ineffective because it is believed that the cells that produce dopamine have degenerated in Parkinson disease. Levodopa does not affect acetylcholine production.)

A health care provider prescribes mannitol for a client with a head injury. Which mechanism of action is responsible for therapeutic effects of this medication? 1 Decreasing the production of cerebrospinal fluid 2 Limiting the metabolic requirements of the brain 3 Drawing fluid from brain cells into the bloodstream 4 Preventing uncontrolled electrical discharges in the brain

3 (Mannitol, an osmotic diuretic, pulls fluid from the brain to relieve cerebral edema. Mannitol's diuretic action does not decrease the production of cerebrospinal fluid. Mannitol does not affect brain metabolism; rest and lowered body temperature reduce brain metabolism. Preventing uncontrolled electrical discharges in the brain is the action of phenytoin sodium, not mannitol.)

Which finding in a client's history would likely be a precipitating factor for myasthenic crisis? 1 Getting too little exercise 2 Taking excess medication 3 Omitting doses of medication 4 Increasing intake of fatty foods

3 (Myasthenic crisis often is caused by undermedication and responds to the administration of cholinergic medications, such as neostigmine and pyridostigmine. Too little exercise is not a factor. Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Fatty food intake is incorrect.)

A client has a partial loss of peripheral vision. The client's eye examination report shows an intraocular pressure of 24 mm Hg. Which condition would the nurse suspect is causing these findings? 1 Reduced elasticity of the lens 2 Unevenness in the cornea 3 Excess production of aqueous humor 4 Nontransparent substances in the vitreous humor

3 (Partial loss of peripheral vision and a high intraocular pressure of 24 mm Hg (normal is 10-21 mm Hg) are indicative of glaucoma. Glaucoma is typically caused by an excess production of aqueous humor. Reduced elasticity of the lens due to aging may result in loss of accommodation and presbyopia. Unevenness in the cornea may cause astigmatism. The presence of nontransparent substances in the vitreous humor may block light passing through the vitreous membrane and affect vision.)

A client is scheduled to have a Tensilon test. Which response to the test would confirm the diagnosis of myasthenia gravis? 1 Brief exaggeration of symptoms 2 Prolonged symptomatic improvement 3 Rapid but brief symptomatic improvement 4 Symptomatic improvement of only the ptosis

3 (Tensilon acts systemically to increase muscle strength; it lasts several minutes. Tensilon produces a brief increase in muscle strength; with a negative response the client will demonstrate no change in symptoms. Tensilon may intensify muscle weakness in a cholinergic crisis. Tensilon does not cause lasting effects. Tensilon acts systemically on all muscles, rather than selectively on the eyelids.)

The nurse plans to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level. Which statement explains the nurse's rational? 1 Deep tendon reflexes have been lost. 2 There is partial transection of the cord. 3 There is damage above the sixth thoracic vertebra. 4 Flaccid paralysis of the lower extremities has occurred.

3 (The T6 level is the sympathetic visceral outflow level, and any injury above this level may result in autonomic dysreflexia. The reflex arc remains after spinal cord injury. It is important to know the level at which the injury occurs, not whether the cord is transected. Flaccid paralysis of the lower extremities is not related to autonomic dysreflexia. All cord injuries result in flaccid paralysis during the period of spinal shock; as the inflammation subsides, spasticity gradually increases.)

A client is undergoing diagnostic testing for myasthenia gravis. Which test would the nurse identify as the most specific for this diagnosis? 1 Electromyography 2 Pyridostigmine test 3 Edrophonium chloride test 4 History of physical deterioration

3 (The edrophonium chloride test uses a medication that is a cholinergic and an anticholinesterase; it blocks the action of cholinesterase at the myoneural junction and inhibits the destruction of acetylcholine. Its action of increasing muscle strength is immediate for a short time. The results of electromyography will be added to the database, but they are nonspecific. Pyridostigmine is a slower-acting anticholinesterase medication that is commonly prescribed to treat myasthenia gravis; edrophonium chloride is used instead of pyridostigmine to diagnose myasthenia gravis because, when injected intravenously, it immediately increases muscle strength for a short time. The results of a history and physical are added to the database, but the data collected are not as definitive as another specific test for the diagnosis of myasthenia gravis.)

Which is the priority assessment for the client who has Guillain-Barré syndrome with rapidly ascending paralysis? 1 Monitoring urinary output 2 Assessing nutritional status 3 Monitoring respiratory status 4 Assessing communication needs

3 (The most serious complication of Guillain-Barré syndrome is respiratory failure caused by respiratory muscle paralysis. Urinary retention is common in Guillain-Barré, but monitoring urinary output is of lower priority than monitoring respiratory status. If ascending paralysis impairs the gag reflex, clients may require tube feedings or parenteral nutrition. Assessing nutritional status, however, is of lower priority than monitoring respiratory status. If ascending paralysis impairs cranial nerve functioning or if the client is intubated, verbal communication abilities are lost.)

Which intervention is the priority for a client in myasthenic crisis? 1 Performing plasmapheresis 2 Administering intravenous atropine 3 Maintaining adequate respiratory function 4 Administering intravenous immunoglobulins

3 (The priority nursing management of a client with myasthenic crisis is maintaining adequate respiratory function to promote gas exchange. Plasmapheresis is used as a short-term management of an exacerbation, but it is not the priority nursing intervention. Atropine is administered after maintaining adequate respiratory function. Intravenous immunoglobulins are administered as a long-term option for disease refractory to other treatment.)

A client arrived in the emergency department with a posttraumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. Which score on the Glasgow Coma Scale (GCS) would the nurse document? Record your answer using a whole number. _______ Total GCS score

3 (The score is 3. The score on the GCS ranges from 3 to 15. The client's lack of response earns the minimum of 1 point in each of the categories: eye opening response, best verbal response, and best motor response.)

A client who has experienced a subarachnoid hemorrhage would be maintained in which position? 1 Supine 2 On the unaffected side 3 In bed with the head of the bed elevated 4 With sandbags on either side of the head

3 (With the head of the bed elevated, the force of gravity helps prevent additional intracranial pressure (ICP), which will intensify the ischemic manifestations of hemorrhage. The supine position will not facilitate drainage of cerebral fluid; this position promotes accumulation of fluid, which increases ICP. Lying on the unaffected side will not facilitate drainage of cerebral fluid; this position promotes accumulation of fluid, which increases ICP. Vomiting can occur with increased ICP, and placing sandbags to immobilize the head can result in aspiration.)

Which priority intervention would the nurse perform immediately for a client with a spinal cord injury? 1 Monitor the urinary output. 2 Assess for other injuries. 3 Infuse lactated Ringer solution. 4 Immobilize and stabilize the cervical spine.

4 (A client with a spinal cord injury should first have the cervical spine immobilized and stabilized. Monitoring urinary output should be performed during ongoing assessments, after providing initial treatment. The client should be assessed for other injuries after immediate interventions are performed. Ringer solution should be infused after stabilizing oxygen levels and the cervical spine.)

A client with a head injury has a computed tomography (CT) scan that shows a subdural hematoma. How would the nurse interpret this finding? 1 Blood within the brain tissue 2 Blood in the subarachnoid space 3 Blood between the dura and the skull 4 Blood between the dura mater and the arachnoid layer

4 (A subdural hematoma refers to blood between the dura mater and the arachnoid layer of the meninges. Blood within the brain tissue is an intracerebral hematoma. Blood in the subarachnoid space is below the arachnoid and is called a subarachnoid hematoma. Epidural hematoma refers to blood between the dura and the skull.

The nurse administers carbidopa-levodopa to a client with Parkinson's disease. Which activity describes the mechanism of action of this medication? 1 Increase in acetylcholine production 2 Regeneration of injured thalamic cells 3 Improvement in myelination of neurons 4 Replacement of a neurotransmitter in the brain

4 (Carbidopa-levodopa is used because levodopa is the precursor of dopamine. It is converted to dopamine in the brain cells, where it is stored until needed by axon terminals; it functions as a neurotransmitter. Regeneration of injured thalamic cells is not an action of this medication; neurons do not regenerate. Increase in acetylcholine production and improvement in myelination of neurons are not actions of this medication.)

Pyridostigmine is prescribed for a client with myasthenia gravis. Why would the nurse instruct the client to take pyridostigmine about 1 hour before meals? 1 This timing limits first pass metabolism. 2 Taking it on an empty stomach increases absorption. 3 Taking it before meals decreases gastric irritation. 4 Taking it before meals improves the ability to chew.

4 (Peak action of the medication will occur during meals to promote chewing and swallowing and prevent aspiration. It should be given with a small amount of food to prevent gastric irritation. First pass metabolism is a process of metabolism, which is not affected by medication timing. Absorption is not affected significantly by the presence of food in the stomach. Gastric irritation is reduced best by the administration of medications with food, not on an empty stomach.)

While assessing the airway patency of a client after a bomb blast, which intervention is most appropriate when the nurse suspects the client has severe brain injury and gives the client a score of 7 using the Glasgow Coma Scale (GCS)? 1 Performing the jaw-thrust maneuver 2 Maintaining vascular access using a large-bore catheter 3 Observing for chest wall trauma or other physical abnormalities 4 Preparing for endotracheal intubation and mechanical ventilation

4 (The most appropriate intervention for a client with a GCS score of 7 is preparing for endotracheal intubation and mechanical ventilation. The jaw-thrust maneuver is performed in a client if there is any risk of spinal injury. The use of large-bore catheters to maintain vascular access is done to perform resuscitation in traumatic conditions. Observing for chest wall trauma or other physical abnormalities may not be the appropriate intervention for a client with brain injury.)

7. A patient is receiving treatment for a complete spinal cord injury at T4. As the nurse you know to educate the patient on the signs and symptoms of autonomic dysreflexia What signs and symptoms will you educate the patient about? Select all that apply: A. Headache B. Low blood glucose C. Sweating D. Flushed below site of injury E. Pale and cool above site of injury F. Hypertension G. Slow heart rate H. Stuffy nose

A, C, F, G, H (The answers are A, C, F, G and H. All of these are signs and symptoms of autonomic dysreflexia. The patient will have flushing above site of injury due to vasodilation from parasympathetic activity, BUT will be pale and cool below site of injury due to vasoconstriction occurring below the site of injury for the sympathetic response reflex.)

9. In autonomic dysreflexia, the nurse would expect what finding below the site of the spinal cord injury? A. Flushed lower body B. Pale and cool lower extremities C. Low blood pressure D. Absent reflexes

B

4. You're providing an in-service to a group of new nurse graduates on the causes of autonomic dysreflexia. Select all the most common causes you will discuss during the in-service: A. Hypoglycemia B. Distended bladder C. Sacral pressure injury D. Fecal impaction E. Urinary tract infection

B, C, D, E (Anything that can cause an irritating stimulus below the site of the spinal injury (T6 or higher) can lead to autonomic dysreflexia, which causes an exaggerated sympathetic reflex response and the parasympathetic system is unable to oppose it. This will lead to severe hypertension. The most common cause of AD is a bladder issue (full/distended bladder, urinary tract infection etc). Other common causes are due to a bowel issue like fecal impaction or skin break down (pressure injury/ulcer, cut, infection etc.).)

3. You're performing a head-to-toe assessment on a patient with a spinal cord injury at T6. The patient is restless, sweaty, and extremely flushed. You assess the patient's blood pressure and heart rate. The patient's blood pressure is 140/98 and heart rate is 52. You look at the patient's chart and find that their baseline blood pressure is 106/76 and heart rate is 72. What action should the nurse take FIRST? A. Reassess the patient's blood pressure. B. Check the patient's blood glucose. C. Position the patient at 90 degrees and lower the legs. D. Provide cooling blankets for the patient.

C (Based on the patient findings and how the patient has a spinal cord injury at T6, they are experiencing autonomic dysreflexia. Patients with this condition may have a blood pressure that is 20-40 mmHg higher than their baseline and may experience bradycardia (heart rate less than 60). The FIRST action the nurse should take when AD is suspected is to position the patient at 90 degree (high Fowler's) and lower the legs. This will allow gravity to cause the blood to pool in the lower extremities and help decrease the blood pressure. Then the nurse should try to find the cause of the autonomic dysreflexia, which could be a full bladder, impacted bowel, or skin break down.)

2. Your patient, who has a spinal cord injury at T3, states they are experiencing a throbbing headache. What is your NEXT nursing action? A. Perform a bladder scan B. Perform a rectal digital examination C. Assess the patient's blood pressure D. Administer a PRN medication to alleviate pain and provide a dark, calm environment.

C (This is the nurse's NEXT action. The patient is at risk for developing autonomic dysreflexia because of their spinal cord injury at T3 (remember patients who have a SCI at T6 or higher are at MOST risk). If a patient with this type of injury states they have a headache, the nurse should NEXT assess the patient's blood pressure. If it is elevated, the nurse would take measures to check the bladder (a bladder issue is the most common cause of AD), bowel, and skin for breakdown.)

unilateral tremor, "pill rolling" motion, shuffling/wide gait are signs of ___________

Parkinson's disease

Traumatic Brain Injury Coup v Countrecoup

coup: primary injury (wreck) countrecoup: inflammation, hypoxia

Guillian-Barre Syndrome symptoms

demyelination of peripheral nerves - numbness/tingling (starts in toes) - muscle weakness, paralysis - reparatory compromise

Parkinson's disease involves the loss of _______

dopamine producing brain cells

spinal cord injury meds

dopamine, levophed, neo-synephrine, vasopressin, dobutamine

amyotrophic lateral sclerosis (ALS) symptoms

muscle cramps/stiffness on one part of the body --> slurred speech, dysphagia --> respiratory failure

Myasthenia Crisis vs. Cholinergic Crisis

myasthenia crisis: low dose of meds = RESP. EMERGENCY increased RR/pulse rise in BP Anorexia Cyanosis Unable to cough or swallow Cholinergic crisis: too much Ach Small pupils Salvation Diarrhea N/V Abdominal cramps Increased bronchial secretions, sweating Lacrimation: tears SOB-->bronchospasms Bradycardia Facial muscle twitching

Parkinson's medical management

- anticholinergic meds (decreases tremors, can cause intraocular pressure, dry mouth, constipation) * congentin, artane - dopamine receptor agonists (NOT for cardiac, renal, or psych patients) * mirapex, requip - COMT inhibitors (inhibit dopamine metabolism, late stages) * Entacapone (avoid MAOI, B6, high protein meals) - Levodopa/Carbidoa * used with COMPT

Signs of myasthenia gravis

- drooping eyelids - double vision, eye strain - weakness (trunk and limb) - respiratory involvement

Normal ICP

0-15 mmHg

Which assessment findings alert the nurse that the client who has a spinal cord injury is developing autonomic hyperreflexia (autonomic dysreflexia)? 1 Hypertension and bradycardia 2 Flaccid paralysis and numbness 3 Absence of sweating and pyrexia 4 Escalating tachycardia and shock

1 (Hypertension and bradycardia occur as a result of exaggerated autonomic responses. If autonomic hyperreflexia is identified, immediate intervention is necessary to prevent serious complications. Paralysis is related to transection, not autonomic hyperreflexia; the client will have no sensation below the injury. Profuse diaphoresis occurs above the level of injury. Bradycardia occurs rather than tachycardia.)

Which nursing action has the highest priority when the nurse is providing care to a trauma client whose primary survey indicates a Glasgow Coma Scale (GCS) score of 7? 1 Preparing for intubation 2 Observing for chest wall trauma 3 Covering the client with a blanket 4 Applying direct pressure to the client's wound

1 (If the Glasgow Coma Scale (GCS) score is 8 or less, the priority action by the nurse is to prepare for endotracheal intubation because the client is at risk for airway compromise. Observing for chest wall trauma, covering the client with a blanket, and applying direct pressure to a bleeding wound are all appropriate actions but not the priority.)

A client with Parkinson disease is admitted to the hospital. Which medication is prescribed to improve the physical manifestations of Parkinson disease? 1 Carbidopa-levodopa 2 Isocarboxazid 3 Dopamine 4 Pyridoxine (vitamin B6)

1 (Levodopa crosses the blood-brain barrier and converts to dopamine, a substance depleted in Parkinson disease. Isocarboxazid is a monoamine oxidase inhibitor used for the treatment of psychological symptoms associated with severe depression, not physiological symptoms of Parkinson disease. Dopamine is not prescribed for this purpose because it does not cross the blood-brain barrier. Pyridoxine can reverse the effects of some antiparkinsonian medications and is contraindicated.)

Which assessment is priority after checking airway for a client with a cervical spinal cord injury? 1 Level of consciousness 2 Sensory perception in all extremities 3 Presence and location of diaphoresis 4 Vital sign assessment and oxygen assessment

1 (Only after the airway is secured will a client's level of consciousness be assessed as part of the Glasgow Coma Scale. Then vital signs and oxygen are assessed, sensory perception is assessed for impairment, and diaphoresis is assessed if looking for autonomic dysreflexia.)

A client newly diagnosed with myasthenia gravis voiced concerns about fluctuations in physical condition and generalized weakness. When providing care for this client, which nursing intervention would the nurse implement? 1 Preplan the spacing of activities throughout the day. 2 Restrict activities and encourage bed rest. 3 Teach the client about limitations imposed by the disorder. 4 Have a family member stay at the bedside to give the client support.

1 (Spacing activities encourages maximum functioning within the limits of the client's strength and endurance. Bed rest and limited activity may lead to muscle atrophy and calcium depletion. Teaching the limitations imposed by the disorder is necessary for lifelong psychologic adjustment but does not address the client's concerns at this time. Staff should permit the client to have a member of the family stay and give the client support if requested by the client or family, but this intervention does not address the concerns voiced by the client.)

A client is admitted to the hospital with a tentative diagnosis of Guillain-Barré syndrome. Which question by the nurse will elicit information consistent with this diagnosis? 1 "Have you experienced an infection recently?" 2 "Is there a history of this disorder in your family?" 3 "Did you receive a head injury during the past year?" 4 "What medications have you taken in the past several months?"

1 (Symptoms usually appear 1 to 3 weeks after an acute infection; this syndrome is linked to diseases such as viral hepatitis, the Epstein-Barr virus, and infectious mononucleosis. There is no known familial tendency that exists in the development of Guillain-Barré syndrome. This syndrome is unrelated to head trauma. Medication therapy is not implicated as a contributing factor in Guillain-Barré syndrome.)

Alzheimer's medications

1) Donepezil (Aricept) - anticholinergic 2) Galantamine (Razadyne) - anticholinergic 3) Rivastigmine (Exelon) - anticholinergic 4) Memantine (Namenda) - glutamate inhibitor 5) Vitamin E

Huntington Disease meds

1) antipsychotics (can make pt drowsy) - haloperidol - risperidone - clozapine 2) muscle relaxers - baclofen

When a client is admitted to the emergency department with a possible spinal cord injury, the nurse would monitor for which clinical manifestations of spinal shock? Select all that apply. One, some, or all responses may be correct. 1 Bradycardia 2 Hypotension 3 Spastic paralysis 4 Urinary retention 5 Increased pulse pressure

1, 2, 4 (Bradycardia occurs with spinal shock because the vascular system below the level of injury dilates and the cardiac accelerator reflex is suppressed. Initially there is a loss of vascular tone below the injury, resulting in vasodilation and hypotension. Urinary retention may occur in spinal shock because of autonomic nervous system dysfunction. Initially, flaccid paralysis is associated with spinal shock; as spinal shock subsides, spastic paralysis develops. There is a decreased, not increased, pulse pressure associated with hypotension and shock.)

The nurse performed a neurological assessment on a client, which included the Glasgow Coma Scale (GCS). Which components does the GCS assessment tool include? Select all that apply. One, some, or all responses may be correct. 1 Best verbal response 2 Best pupillary response 3 Best motor response 4 Best eye-opening response 5 Best cognitive response

1, 3, 4 (The GCS is a common way of determining and documenting level of consciousness that scores verbal response, motor response, and eye-opening response. The lowest score is 3, which indicates a totally unresponsive client; a normal GCS score is 15. Pupillary and cognitive responses are not part of the GCS assessment.)

Which physical assessment findings would the nurse document on a client who is experiencing Cushing triad? Select all that apply. One, some, or all responses may be correct. 1 Bradycardia 2 Tachycardia 3 Irregular respirations 4 Systolic hypertension 5 Diastolic hypertension 6 Widening pulse pressure

1, 3, 4, 6 (A client experiencing Cushing triad presents with bradycardia (with a full and bounding pulse), irregular respirations, systolic hypertension, and a widening pulse pressure. These clients do not experience tachycardia or diastolic hypertension.)

For which clinical manifestations would the nurse assess the client diagnosed with Alzheimer disease? Select all that apply. One, some, or all responses may be correct. 1 Loss of recent memory 2 Focused attention span 3 Perceptual disturbances 4 Willingness to accept change 5 Difficulty learning something new

1, 3, 5 (Neurofibrillary tangles attack the hippocampus, impairing recent memory. As dementia progresses, sensory-perceptual alterations occur, such as hallucinations. Alzheimer disease is associated with a global intellectual impairment that affects learning, thinking, and language. Progressive deterioration of the regions of the brain results in cognitive deficits, such as a decreased, not focused, attention span. Clients with Alzheimer disease are easily confused or disoriented. They require familiar routines that provide a sense of security.)

Which therapeutic effect would the nurse expect to identify when mannitol is administered to a client? 1 Improved renal blood flow 2 Decreased intracranial pressure 3 Maintenance of circulatory volume 4 Prevention of the development of thrombi

2 (As an osmotic diuretic, mannitol helps reduce cerebral edema. Although there may be a transient increase in blood volume as a result of an increased osmotic pressure, which increases renal perfusion, this is not the therapeutic effect. Prevention of the development of thrombi is not the reason for giving this medication.)

The nurse assesses a client admitted with suspected Guillain-Barré syndrome who reports numbness, which began in the hands and feet and now involves the arms, legs, and lower trunk. For which related clinical manifestations would the nurse assess in this client? 1 Ptosis and dysphagia 2 Paresthesias and paralysis 3 Atrophy and fasciculations 4 Muscle weakness and drooling

2 (Guillain-Barré syndrome includes the clinical manifestations of paresthesia and paralysis result from patchy demyelination of the peripheral nerves, nerve roots, root ganglia, and the spinal cord. Ptosis and dysphagia relate to myasthenia gravis. Atrophy and fasciculations relate to amyotrophic lateral sclerosis. Muscle weakness and drooling relate to Parkinson disease.)

Which assessment finding reflects increased intracranial pressure (ICP)? 1 Tachycardia 2 Unequal pupil size 3 Decreasing body temperature 4 Decreasing systolic blood pressure

2 (Increased ICP causes unequal pupils as a result of pressure on the third cranial nerve. It causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. ICP increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.)

Which early sign of increased intracranial pressure (ICP) would the nurse monitor in a client who sustained a head injury while playing soccer? 1 Nausea 2 Lethargy 3 Sunset eyes 4 Hyperthermia

2 (Lethargy is an early sign of a changing level of consciousness; a changing level of consciousness is one of the first signs of increased ICP. Nausea is a subjective symptom, not a sign, potentially present with increased ICP. Sunset eyes is a late sign of increased ICP that occurs in children with hydrocephalus. Hyperthermia is a late sign of increased ICP that occurs as compression of the brainstem increases.)

Which assessment would the nurse perform specific to the safe administration of intravenous mannitol? 1 Body weight daily 2 Urine output hourly 3 Vital signs every 2 hours 4 Level of consciousness every 8 hours

2 (Mannitol, an osmotic diuretic, increases the intravascular volume that must be excreted by the kidneys. The client's urine output should be monitored hourly to determine the client's response to therapy. Although mannitol results in an increase in urinary excretion that is reflected in a decrease in body weight (1 L of fluid is equal to 2.2 pounds [1 kg]), a daily assessment of the client's weight is too infrequent to assess the client's response to therapy. Urine output can be monitored hourly and is a more frequent, accurate, and efficient assessment than is a daily weight. Vital signs should be monitored every hour considering the severity of the client's injury and the administration of mannitol. Although the level of consciousness should be monitored with a head injury, conducting assessments every 8 hours is too infrequent to monitor the client's response to therapy.)

Which autoimmune disease is directly related to the client's central nervous system? 1 Rheumatic fever 2 Multiple sclerosis 3 Myasthenia gravis 4 Goodpasture syndrome

2 (Multiple sclerosis is a central nervous system-specific autoimmune disease. Rheumatic fever is related to the heart. Myasthenia gravis is a muscle-related autoimmune disease. Goodpasture syndrome is a kidney-related autoimmune disease.)

During the neurological assessment of a client with a tentative diagnosis of Guillain-Barré syndrome, which clinical finding would the nurse expect the client to manifest? 1 Diminished visual acuity 2 Increased muscular weakness 3 Pronounced muscular atrophy 4 Impairment in cognitive reasoning

2 (Muscular weakness with paralysis results from impaired nerve conduction because the motor nerves become demyelinated. Diminished visual acuity usually is not a problem; motor loss is greater than sensory loss, with paresthesia of the extremities being the most frequent sensory loss. Demyelination occurs rapidly early in the disease, and the muscles will not have had time to atrophy; this can occur later if rehabilitation is delayed. Only the peripheral nerves are involved; the central nervous system is unaffected.)

A client with myasthenia gravis has been receiving neostigmine and asks about its action. Which information would the nurse consider when formulating a response? 1 Stimulates the cerebral cortex 2 Blocks the action of cholinesterase 3 Replaces deficient neurotransmitters 4 Accelerates transmission along neural sheaths

2 (Neostigmine, an anticholinesterase, inhibits the breakdown of acetylcholine, thus prolonging neurotransmission. Neostigmine's action is at the myoneural junction, not the cerebral cortex. Neostigmine prevents neurotransmitter breakdown, but it is not a neurotransmitter. Neostigmine's action is at the myoneural junction, not the sheath.)

Which nursing intervention is correct for a client in skeletal traction? 1 Add and remove weights as the client desires. 2 Assess the pin sites at least every shift and as needed. 3 Ensure that the knots in the rope are tied to the pulley. 4 Perform range of motion to joints proximal and distal to the fracture at least once a day.

2 (Nursing care for a client in skeletal traction may include assessing pin sites every shift and as needed. The needed weight for a client in skeletal traction is prescribed by the primary health care provider, not as desired by the client. The nurse also would ensure that the knots are not tied to the pulley and move freely. The performance of range of motion is indicated for all joints except the ones proximal and distal to the fracture because this area is immobilized by the skeletal traction to promote healing and prevent further injury and pain.)

Pyridostigmine bromide is prescribed for a client with myasthenia gravis. The nurse evaluates that the medication regimen is understood when the client makes which statement? 1 "I will take the medication on an empty stomach." 2 "I need to set an alarm so I take the medication on time." 3 "It will be important to check my heart rate before taking the medication." 4 "I should monitor for an increase in blood pressure after taking the medication."

2 (Pyridostigmine is a vital medication that must be taken on time; a missed or late dose can result in severe respiratory and neuromuscular consequences or even death. Pyridostigmine should be taken with a small amount of food to prevent gastric irritation. It is unnecessary to take the pulse rate before taking pyridostigmine. Pyridostigmine may cause hypotension, not hypertension, which is a sign of cholinergic crisis.)

Signs of basilar skull fracture

1. Raccoon eyes 2. Battle sign 3. leaking of CSF

Alzheimer's safety/interventions

1. SAFE ENVIRONMENT 2. weight, I/Os 3. bowel/bladder/skin 4. ADLs, coping 5. label toxic substances, monitoring devices

increased ICP management

1. airway 2. ventilation (PEEP) - PaO2 >80 - PaCO2 35-45 3. adequate hematocrit 4. avoid hyperventilation (unless suctioning)

Huntington's disease interventions

1. bed rail padding, clean skin, upright HOB 2. ROM to prevent contractures 3. lifestyle changes

4 types of incomplete spinal cord injuries

1. central cord syndrome (lesion) - motor loss greater in arms than legs - bladder dysfunction - loss of sensation 2. Anterior cord syndrome - compression from bony fragments/disk herniation - loss of pain, temp, crude touch - preserved proprioception, vibration, fine touch 3. posterior cord syndrome - grey and white matter of spinal cord damage - opposite of anterior 4. brown-sequard syndrome - hemisection from penetration injury, ischemia, infection, or hemorrhage - ipsilateral loss of motor function, proprioception, and vibration - contralteral pain and temperature

Hormones effected in Huntington's Disease

- excess dopamine - GABA and Acetylcholine decreased

Stages of Guillain-Barre Syndrome

- Acute: 1-4 weeks * edema, inflammation - Plateau: days-weeks * demyelination ceases - Recovery: gradual * regeneration begins

Increased ICP medications

- Diuretics (mannitol, lasix) FILTER NEEDLE - corticosteroids (dexamethasone) - antihypertensives (labetolol, enalapril ) - antiepileptics (dilantin, fosphenytoin) - sedatives (morphine, versed)

increased ICP nursing interventions

- HOB 30-35 - neurtral head/hip position - suction only as needed (10-15 sec, hyperventilate prior) - neuro assessment q1-2hr - vital signs

myasthenia gravis teaching

- HOB elevated, - keep meds with them always - flu/pneumonia vaccine - rest periods

Guillian Barre meds

- IV antibodies, immunoglobulin (IVIg) - plasmapheresis

Symptoms of Huntington's Disease

- Puppet gait - facial grimacing - jerking movements ** antidepressants dont work

Diagnostic tests for Myasthenia Gravis

- Repetitive nerve stimulation & electromyography - Single fiber electromyography - Tensilon test (keep atropine on hand) - Chest CT

*** complications of spinal cord injury

- Spinal shock * complete, temporary loss of motor, sensory, reflex, and autonomic function after an injury lasting 48hrs-weeks * hypotension, bradycardia - Neurogenic shock * injuries above T6 * vasodilation, bradycardia, instable body temp * fluid, vasopressors, atropine - Autonomic shock*** * severe hypertension, bradycardia, headache, nasal stuffiness, flushing * after spinal shock, visceral distension (full bladder/rectum)

MS meds

- beta interferons - immunosuppressants - corticosteroids, plasma exchange - muscle relaxants (Baclofen, Tizanidine)

Parkinson's safety interventions

- fall precautions - nutrition - suctioning available - stool softeners

traumatic brain injury nursing interventions

- keep HOB >30 - loosely apply gauze to collect CSF - avoid NG tube placement - start enteral nutrition - maintain temp - seizure precautions - SCD/stockings, anticoagulants

*** Guillian-Barre diagnostic tests

- lumbar puncture for CSF (***elevated protein, normal WBC) - electromyography (slowed nerve conduction)

Traumatic brain injury assessments

- neuro assessments q1-2 hr - ECG and cardiac biomarkers - VS (BP) - seizure activity

*** medications for myasthenia gravis

- pyridostigmine (increases ACh) * always administer on time (30-60 min before meals) - neostigmine (short acting IV version) *** monitor for N/D, bradycardia, bronchospasm - immunotherapy (inhibits T cell proliferation) - IV immunoglobulins - plasmapheresis

The nurse is caring for an older adult client with dementia. Which client need would the nurse prioritize while providing care? 1 Safety 2 Self-esteem 3 Self-actualization 4 Love and belonging

1 (An older adult client with dementia has impaired cognition. The nurse would make arrangements such as applying bedside rails to ensure that the client's safety needs are met first. At this stage, self-esteem or factors that enhance confidence and self-worth are not as important as safety. Self-actualization is the ability to solve problems and being able to cope realistically, which is beyond the capacity of the client with dementia. All clients need to feel love and belonging; however, safety is the first priority for this client.)

Which action would the nurse take when caring for a client who has a possible skull fracture as a result of trauma? 1 Monitor the client for signs of brain injury. 2 Check for hemorrhaging from the oral cavity. 3 Elevate the foot of the bed if the client develops symptoms of shock. 4 Observe for indicators of decreased intracranial pressure and temperature.

1 (Head injuries can cause trauma to the brain, and the client should be monitored for symptoms of increased intracranial pressure (e.g., headache, dizziness, and visual disturbances). Checking for hemorrhaging from the oral cavity is not indicated in this situation. Elevating the lower extremities should be avoided because it will increase intracranial pressure. The intracranial pressure may increase after trauma because of bleeding and edema. The temperature may increase because of injury to or pressure on the hypothalamus.)

1. Which patient below is at MOST risk for developing a condition called autonomic dysreflexia? A. A 24-year-old male patient with a traumatic brain injury. B. A 15-year-old female patient with a spinal cord injury at C7. C. A 35-year-old male patient with a spinal cord injury at L6. D. A 42-year-old male patient recovering from a hemorrhagic stroke.

B (Patients who are at MOST risk for developing autonomic dysreflexia are patients who've experienced a spinal cord injury at T6 or higher...this includes C7. L6 is below T6, and traumatic brain injury and hemorrhagic stroke does not increase a patient risk of AD.)

10. Which statements are TRUE about autonomic dysreflexia? Select all that apply: A. "Autonomic dysreflexia is an exaggerated reflex response by the parasympathetic nervous system that results in severe hypertension due to a spinal cord injury." B. "Autonomic dysreflexia causes a slow heart rate and severe hypertension." C. "Autonomic dysreflexia is less likely to occur in a patient who has experienced a lumbar injury." D. "The first-line of treatment for autonomic dysreflexia is an antihypertensive medication."

B, C

*** late symptoms of increased ICP

Cushing's Triad - increased systolic BP, decreased diastolic - bradycardia - irregular RR -- Babinski reflex Cheyne-stokes respirations Cranial nerve changes - double vision - optic nerve swelling (papiloedema) - constricted/dilated pupils - abnormal doll's eye Decerebrate posturing - straight Decorticate posturing - to the body

6. The physician orders Nitropaste for a patient who has developed autonomic dysreflexia. Which finding would require the nurse to hold the ordered dose of Nitropaste and notify the physician? A. The patient's blood pressure is 130/80. B. The patient reports a throbbing headache. C. The patient's lower extremities are pale and cool. D. The patient states they took Sildenafil 12 hours ago.

D (A patient should not receive a dose of Nitropaste if they have taken a phosphodiesterase inhibitor within the past 24 hours (Sildenafil or Tadalafil). This will cause major vasodilation and severe hypotension that will not respond to medication. Another medication should be used. All the other findings are expected with autonomic dysreflexia.)

*** Glascow Coma Scale

EYE OPENING 4 - spontaneous 3 - open to speech 2 - open to pain 1 - no response VERBAL 5 - alert and oriented 4 - disoriented conversation 3 - inappropriate words 2 - nonsensical sounds 1 - no response MOTOR 6 - spontaneous 5 - localizes pain 4 - withdraws to pain 3 - decorticate posturing 2 - decerebrate posturing 1 - no movement