Lesson 8C Neurological System
A client is seen in the emergency department with a left hemiplegia. To determine if the stroke is ischemic or hemorrhagic, the nurse anticipates that the health care provider will request which diagnostic procedure? a. CT scan b. Lumbar puncture c. Cerebral arteriogram d. Positron emission tomography (PET)
a. CT scan A CT scan is the most commonly used diagnostic test to determine the size and location of the lesion and to differentiate a thrombotic stroke from a hemorrhagic stroke. Positron emission tomography (PET) will show the metabolic activity of the brain and provide a depiction of the extent of tissue damage after a stroke. Lumbar punctures are not performed routinely because of the chance of increased intracranial pressure causing herniation. Cerebral arteriograms are invasive and may dislodge an embolism or cause further hemorrhage; they are performed only when no other test can provide the needed information.
A client is admitted with the diagnosis of meningitis. Which finding should the nurse expect when assessing this client? a. Flexion of the hips and knees with passive flexion of the neck b. Hyperextension of the neck with passive flexion of the hips and knees c. Straightening of the leg with passive flexion of the hip d. Hyperextension of the neck with passive shoulder flexion
a. Flexion of the hips and knees with passive flexion of the neck Severe neck stiffness in meningitis causes flexion of hips and knees with passive flexion of the neck, known as Brudzinski's sign. The inability to straighten the legs when the hip is flexed to 90° due to hamstring stiffness, is Kernig's sign another physical finding in meningitis.
A nurse is caring for a newly admitted client with a concussion due to a helmet to helmet hit to the head during the client's football game. The nurse performs an assessment. Which assessment data would call for an immediate nursing intervention? a. Client complains of contusion pain b. Client exhibits signs of confusion c. Client's Glasgow score is 15 d. Client exhibits even bilateral muscle strength
b. Client exhibits signs of confusion When your client has been admitted with a head injury and the client has confusion and/or restlessness and/or the level of consciousness (LOC) is altered, this is an early sign of increased intracranial pressure and a nursing action is required. Contusion pain is common with a head injury but remember not to give a narcotic because it may alter the LOC. A Glasgow score of 15 indicates the client is alert and oriented however a score between three and eight indicates severe head trauma. Monitoring muscle strength is an assessment and implementation the nurse will follow however unless the muscle strength is week or uneven it is normal.
A nurse is performing a neurological assessment on a client following a right cerebrovascular accident (CVA). Which finding, if observed by the nurse, would warrant immediate attention? a. Emotional lability b. Decrease in level of consciousness c. Loss of bladder control d. Altered sensation of stimuli
b. Decrease in level of consciousness Stroke or CVA can cause paralysis, sensory disturbances, problems understanding or using language and emotional disturbances. But a further decrease in the level of consciousness would be indicative of progression of the CVA and would require immediate intervention.
The nurse is caring for a client who has hearing loss. Which of the following actions should be implemented by the nurse to improve communication? (Select all that apply.) a. Keep the client lights down to decrease stimulation b. Speak to the client at eye level c. Speak at a slower rate than usual d. Use short sentences e. Know basic sign language techniques f. Speak in a loud voice toward the client's ear
b. Speak to the client at eye level d. Use short sentences Important actions to improve communication between the nurse and a client who has hearing loss is for the nurse to be sure they speak to the client at eye level and use short sentences. It is not necessary to turn the lights down, speak at a slower rate or speak loudly. Further, not all clients with hearing loss understand sign language and it is not a requirement for the nurse to learn.
Which assessment data would make the nurse suspect that the client has ALS? a. History of GI upset in the last month b. Complaints of double vision and light sensitivity c. Fatigue, progressive muscle weakness and twitching d. Loss of sensation in the extremities
c. Fatigue, progressive muscle weakness and twitching ALS typically has a gradual onset, which is generally painless. Progressive muscle weakness is the most common initial symptom in ALS. Other early symptoms vary but can include tripping, dropping things, abnormal fatigue of the arms and/or legs, slurred speech, muscle cramps and twitches and/or uncontrollable periods of laughing or crying.
Which of the following is a priority action for a client having a seizure? a. Restrain the client to prevent injury b. Assess the family's reaction to the seizure c. Maintain the client's airway d. Administer an antiepileptics as ordered
c. Maintain the client's airway During a seizure, the client may not be able to maintain their own airway. Many times they will aspirate their secretions. Having suction available is important. Assessing the family's reaction, coping skills and teaching will be initiated however it is not the priority in during the seizure event. Further, antiepileptics will be administer as ordered but not during seizure activity.
A nurse enters the room as a 3-year-old child is having a generalized seizure. Which intervention should the nurse perform first? a. Restrain the child b. Place a padded tongue blade in the mouth c. Place the child on his or her side d. Give the prescribed anticonvulsant
c. Place the child on his or her side Protecting the airway is the top priority in a seizure, and the first action should be to roll the client on their side to open the airway and prevent aspiration in case of vomiting. If a child is actively convulsing, a patent airway and oxygenation must be assured. Nothing should be placed in the mouth when the client is having a seizure. Administration of the prescribed anticonvulsant would be another appropriate intervention for a prolonged seizure and to prevent further seizure activity during the post-ictal phase.
The nurse is working with a client who is diagnosed with MS. The nurse is teaching the client about how to reduce muscle spasticity. Which of the following statements by the client indicate the need for further teaching? a. Daily exercise, including weight bearing can help relieve spasticity b. My stretching routine can help with the spasms c. Taking Baclofen may help relieve these painful spasms in my legs d. At the end of a day, taking a nice hot bath may relieve the muscle spasms
d. At the end of a day, taking a nice hot bath may relieve the muscle spasms The client with MS should never use hot water for a bath due to sensory deficits. All other answers can help with muscle spasms. Warm compresses can be used to relieve muscle spasms.
The nursing is caring for a client who is suffering from spinal shock. What finding might the nurse expect? a. Spasticity of the muscles b. Hypertension c. Hyperreflexia d. Bradycardia
d. Bradycardia A client with spinal shock with be hypotensive, have bradycardia, a decrease is visceral reflexes and flaccid paralysis of the skeletal muscles.
The nurse is providing discharge information to a client with glaucoma. Which of the following instructions would the nurse include? a. Decrease intake to control the intraocular pressure b. Avoid overuse of the eyes c. Decrease the amount of salt in the diet d. Eye medications will need to be administered lifelong
d. Eye medications will need to be administered lifelong The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of his or her life.
The home health nurse makes a scheduled visit to provide wound care and finds the client lethargic and confused. The client's partner states the client fell down the stairs two hours ago. What action should the nurse take next? a. Place a call to the client's health care provider for instructions b. Reassure the client's partner that the symptoms are transient c. Instruct the client's partner to call the health care provider if symptoms return d. Send the client via ambulance to the emergency department for evaluation
d. Send the client via ambulance to the emergency department for evaluation This client requires immediate evaluation. Possible causes of the findings include intracranial bleeding, concussion or other head injury. A delay in treatment could result in further deterioration of the client's condition and possibly permanent injury. Home care nurses must prioritize interventions based on assessment findings that are in the client's best interest. After emergency care is implemented, the nurse should also inform the client's health care provider about the event.
