Evolve: Neuro

The nurse uses the Glasgow Coma Scale to assess a client with a head injury. Which Glasgow Coma Scale score indicates that the client is in a coma?

6 A score of 8 or below indicates coma. The Glasgow Coma Scale is used to assess the extent of neurologic damage; it consists of three assessments: eye opening, response to auditory stimuli, and motor response. Consciousness exists on a continuum from full consciousness to coma. A score can be from 3 to 15; the lower the score the more indicative of coma. To achieve the ratings of 9, 12, or 15 the client must be exhibiting some meaningful responses.

A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure?

Lowered level of consciousness Altered consciousness is the first sign of increased intracranial pressure. An increase in intracranial pressure causes impaired cerebral blood flow affecting the cells of the cerebral cortex, which results in a decreased level of consciousness. As the intracranial pressure increases, it places pressure on the thalamus, hypothalamus, pons, and medulla, resulting in a slow pulse. A widening pulse pressure occurs because of an increase in the systolic pressure. As the intracranial pressure increases, it places pressure on the thalamus, hypothalamus, pons, and medulla, resulting in irregular respirations that progress to deep, rapid breathing alternating with periods of apnea (Cheyne-Stokes respirations).

Which visual system assessment technique provides a magnified view of the retina and optic nerve head?

Ophthalmoscopy Ophthalmoscopy provides a magnified view of the retina and optic nerve head. Keratometry measures corneal curvature. Visual acuity testing determines distance and near vision acuity. The confrontation visual field test determines if a client has a full field of vision without obvious scotomas.

While walking in the hall, a hospitalized client has a tonic-clonic seizure. To protect the client during the seizure, what should the nurse do?

Protect the client's head from injury Rhythmic contraction and relaxation associated with a tonic-clonic seizure can cause repeated banging of the head. Holding extremities firmly is contraindicated because it can cause broken bones. Inserting an airway between the client's teeth is contraindicated because damage to the teeth can occur if force is used to insert an airway. Moving during a seizure can result in physical injuries; the client should be moved after the seizure.

A nurse enters the room of a client with myasthenia gravis and identifies that the client is experiencing increased dysphagia. What should the nurse do first?

Raise the head of the bed Raising the head of the bed allows gravity to assist in the swallowing of saliva, thus decreasing the risk for aspiration. Oxygen will not assist in the management of dysphagia [1] [2] or the prevention of aspiration. Performing tracheal suctioning may become necessary if the upright position does not allow the client to manage secretions. Alerting the healthcare provider to the problem is necessary, but only after client safety is ensured. STUDY TIP: Focus your study time on the common health problems that nurses most frequently encounter.

A nurse determines that a client exhibits the characteristic gait associated with Parkinson disease. How should the nurse describe this gait when documenting on the client's progress report?

Shuffling Steps are short and dragging (shuffling); this is seen with defects of the basal ganglia. Spastic gait, short steps with dragging of foot, is associated with neurogenic causes like cerebral palsy. Steppage gait is when foot slaps down and is associated with peroneal nerve injury or paralyzed dorsiflexor muscles. Scissoring gait is associated with bilateral spastic paresis of the legs as occurs in cerebral palsy or hemiplegia.

A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. Which assessment is priority?

The respiratory center in the medulla oblongata can be affected with acute Guillain-Barré syndrome because the ascending paralysis can reach the diaphragm, leading to death from respiratory failure. Although urinary output, sensation to touch, and neurologic status are important, none of them are the priority.

The spouse of a client who had a brain attack (cerebrovascular accident) tells the home health nurse that the client cries easily and without provocation. The spouse asks why the client is so emotionally fragile. What is the nurse's best response?

This behavior is a common response over which the client has very little control. If the client exhibits emotional instability, this usually is caused by lesions that affect the thalamic area in the part of the neural system most responsible for emotions. Attention-getting behavior requires cognitive thinking, and lability of mood is unrelated to this. The client may have remote memory, but there is no selective process that determines which events are remembered. There are no data to come to the conclusion that the client is experiencing feelings of guilt.

A nurse is caring for a client with Guillain-Barré syndrome. The nurse should prepare the client for what essential care related to rehabilitation?

physical therapy Rehabilitation needs for a client with Guillain-Barré syndrome focus on physical therapy and exercise for the lower extremities because of muscle weakness and discomfort. A client with Guillain-Barré syndrome does not need speech or swallowing exercises. A client with Guillain-Barré syndrome does not need vertebral support. Problems with cataracts are not associated with Guillain-Barré syndrome. Test-Taking Tip: Monitor questions that you answer with an educated guess or changed your answer from the first option you selected. This will help you to analyze your ability to think critically. Usually your first answer is correct and should not be changed without reason.

A nurse is caring for an anxious, fearful client. Which client response indicates sympathetic nervous system control?

skin pallor The sympathetic nervous system constricts the smooth muscle of blood vessels in the skin when a person is under stress, thereby causing skin pallor. The sympathetic system stimulates, rather than inhibits, secretion by the sweat glands. Constriction of pupils is not under sympathetic control; the parasympathetic system constricts the pupils. The parasympathetic system (vagus nerve) slows the pulse, and the sympathetic system increases it.

Which client eye movement does the superior oblique muscle control?

Pulls the eye downward The superior oblique muscle contracts alone and pulls the eye downward. The inferior oblique muscle helps in pulling the eye upwards. The medial rectus muscle contracts alone and turns the eye towards the nose. The lateral rectus muscle turns the eye towards the side of the head.

A client with the diagnosis of multiple sclerosis experiences a sudden loss of vision and asks the nurse what caused it to happen. The nurse considers the common clinical findings associated with multiple sclerosis before responding. Which is the most probable cause of the client's sudden loss of vision?

optic nerve inflammation Optic nerve inflammation is a common early effect of multiple sclerosis caused by lesions in the optic nerves or their connections (demyelization). This effect may resolve during periods of remission. At present there is no evidence of viral infection of the eyes in multiple sclerosis. Tumors of the brain and cerebral edema, not multiple sclerosis, cause increased intracranial pressure because the skull cannot expand. Closed-angle glaucoma causes blindness as a result of increased intraocular pressure, not inflammation of the optic nerve, which is commonly associated with multiple sclerosis. Closed-angle glaucoma is unrelated to multiple sclerosis.

A client is admitted to the emergency department with head and chest injuries sustained in a motor vehicle accident. What clinical findings indicate that the client is responding to medical intervention and is ready to be transferred from the emergency department to a critical care unit?

stable vital signs and pain Stable vital signs are the major indicators that transfer will not jeopardize the client's condition. Although complaints of pain are a concern, they do not place the client in physiological jeopardy. Restlessness and pallor may be early signs of shock; the client needs further assessment. An increasing temperature is a sign of increasing intracranial pressure; the client should not be transferred at this time. The vital signs are not stabilized; therefore transfer at this time is contraindicated.

What is the middle layer of the eyeball?

uveal tract The uveal tract (which consists of the iris, choroid, and ciliary body) is considered the middle layer of the eyeball. The sclera is a part of the tough outer layer of the eyeball. The retina is the innermost layer of the eyeball. The outermost layer of the eyeball consists of the transparent cornea.

A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client?

Space activities throughout the day Spacing activities will encourage maximum functioning within the limits of strength and fatigue. Bed rest and limited activity may lead to muscle atrophy and calcium depletion. Strengths, rather than limitations, should be stressed. Having one of the client's relatives stay at the bedside is unnecessary. It is the nurse's responsibility to maintain client safety and meet client needs. Test-Taking Tip: Practicing a few relaxation techniques may prove helpful on the day of an examination. Relaxation techniques such as deep breathing, imagery, head rolling, shoulder shrugging, rotating and stretching of the neck, leg lifts, and heel lifts with feet flat on the floor can effectively reduce tension while causing little or no distraction to those around you. It is recommended that you practice one or two of these techniques intermittently to avoid becoming tense. The more anxious and tense you become, the longer it will take you to relax.

Which clinical indicator is the nurse most likely to identify when assessing a client with a ruptured cerebral aneurysm?

Sudden severe headache Bleeding into the enclosed cavity of the skull creates pressure, causing pain. Seizures are not directly related to the hemorrhage; they result from abnormal electrical charges that may eventually develop as a consequence of tissue ischemia. Decerebrate posturing (extension posturing) indicates caudal deterioration with damage to the midbrain and pons. As the systolic pressure increases, widening of the pulse pressure occurs because of compression of vasomotor centers.

A client exhibits blurred and double vision and muscular weakness, and diagnostic tests are prescribed. The client is informed that a diagnosis of multiple sclerosis (MS) has been made. The client becomes visibly upset. How should the nurse respond?

"That must have really shocked you. Tell me what the healthcare provider told you about it." The response "That must have really shocked you. Tell me what the healthcare provider told you about it" acknowledges the effect of the diagnosis on the client and explores what is known. There is no evidence of ineffective coping, so a referral to a psychiatrist is not necessary. The statement "Don't worry; early treatment often alleviates symptoms of the disease" provides false reassurance. The statement "You should be glad we caught it early so it can be cured" does not address the client's current emotional state, and it is inaccurate; MS is a chronic autoimmune disease.

A client with hemiparesis is reluctant to use a cane. How does the nurse explain the cane's purpose to the client?

Maintain balance to improve stability Hemiparesis creates instability. Using a cane provides a wider base of support and, therefore greater stability. Hemiparesis affects muscle strength on one side of the body; the joints are not directly affected. Activity should strengthen, not injure, weakened muscles. The use of a cane will not prevent involuntary movements if they are present. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = low-fat, high-protein, low-calorie diet).

A client comes into the emergency department with neurologic deficits after falling off a ladder. Which client assessment will the nurse perform for the Glasgow Coma Scale?

The three areas of assessment to determine the level of consciousness using the Glasgow Coma Scale are motor response to verbal commands, eye opening in response to speech, and verbal response to speech. Assessing breathing patterns, deep tendon reflexes, and eye accommodation are not included in the Glasgow Coma Scale.