Neuro Nurselab notes

Hemorrhagic stroke symptoms:

- "Worst headache of my life" - Decreased LOC - Seizure

Decorticate posturing

- Abnormal flexion - Arms flexing inwards - Cortical spinal, lower spinal cord and brain stem

Seizures

- Abnormal motor, sensory, autonomic or psychic activity - Causes: sudden, abnormal, uncontrolled electrical discharge from cerebral neurons Focal: one hemisphere Generalized: engage bilaterally Unknown: epilepsy spasms "Provoked": acute, reversible conditions

Causes for seizures

- Allergies - Brain tumor - Cerebrovascular disease - CNS infections - Drug/alcohol - Fever (childhood) - HTN - Hypoxemia - Vascular insufficiency

Intracerebral hemorrhage

- Bleeding into the brain tissue - Most common in pts with: HTN Cerebral atherosclerosis Degenerative changes from changes

Preventive Treatment for TIA and Stroke

- Carotid endarterectomy (CEA)for carotid stenosis - Carotid artery stent (CAS) - Anticoagulant for a-fib - Antiplatelet therapy - Statins - HTN meds - Thrombolytics (Ischemic stroke) After stroke - ACE inhibitors - Diuretics

Hemorrhagic Stroke

- Caused by bleeding into brain tissue, ventricles, or subarachnoid space - Related to HTN = caused by a ruptured aneurysm - Brain metabolism disrupted by exposure to blood - ICP increases caused by blood in subarachnoid space

Early manifestations of Increased ICP

- Changes of LOC - Pupillary changes and impaired extraocular movements - Weakness in one extremity or on one side of body - Constant headache

Communication loss: stroke is the most common cause of aphasia

- Dysarthria: difficulty speaking - Dysphasia: impaired speech - Expressive aphasia: Broca's area - Receptive aphasia: (Wernicke's) inability to understand language - Global: mixed aphasia - Apraxia: inability to perform previously learned action

Decerebrate posturing

- Extreme extension - Flex outward - Usually worse than decorticate - Higher on brain stem

Motor loss: stroke is an upper motor neuron lesion * opposite side damage = decussate (cross)

- Hemiplegia: paralysis of one side of the body - Hemiparesis: weakness of one side of the body

Hemorrhagic stroke causes:

- Intracerebral hemorrhage - Subrachnoid hemorrhage - Cerebral aneurysm - Arteriovenous malformation

Nursing care after a seizure

- Keep patient on one side to prevent aspiration - Patent airway - Reorient patient to environment - If agitated after a seizure, keep distance until fully aware

Ischemic Stroke causes:

- Large artery thrombosis - Small artery thrombosis - Cardiogenic embolic - Cryptogenic (unknown)

Cushing's Triad

- Late of Increased ICP - High BP - High temperature - Low respiratory rate - Low heart rate

Late manifestations of Increase ICP

- Level of consciousness continues to deteriorate until comatose - HR and RR decrease - BP and temperature increases - Altered respiratory, Cheyne-Stokes - Projectile vomiting - Hemiplegia - Loss of brain stem reflexes (gag, pupillary, corneal = omnious sign of approaching death)

Increased Intercranial Pressure (ICP)

- Normal ICP: 10 to 20 mmHg - ICP increases with disease/injury - Increased ICP causes: Decreased cerebral perfusion Ischemia Edema (late) Shift brain tissue = herniation

Ischemic Stroke symptoms:

- Numbness/weakness to face, arm or leg - Aphasia - Vision loss/disturbances - Confusion - Severe headache

Craniotomy

- Opening skull to assess intracranial structures - Remove tumor - Relieve increase ICP - Evaluate blood clot or hemorrhage

Management of Increased ICP

- Osmotic diuretics (mannitol) - Restrict fluids (I&O) - Draining CSF - Controlling fever - Maintaining BP and oxygenation Avoid (Will increase ICP more) - Hip flexion - Valsalva maneuver - Abdominal distension

Nursing Care during a seizure

- Provide privacy - Ease patient to floor - Protect the head - Loosen constrictive clothing and remove glasses - Push aside furniture - Do not try to pry open jaws that are clenched

Transient Ischemic Attack (TIA)

- Temporary neurological deficit resulting from impairment of blood flow ** Warning of impending stroke"

Diagnosis:

1. CT 2. MRI (Type of stroke, size, and location of hematoma) 3. Cerebral angiography (confirms intracranial aneurysm of AVM) 4. Lumbar puncture only if: - CT negative - No Increased ICP

GCS Eye opening Response

4 spontaneously 3 to speech 2 to pain 1 no response

GCS Verbal response

5-Oriented 4-Confused conversation 3-Inappropriate words 2-Incomprehensible sounds 1-None

GCS Motor response

6-Obeys commands 5-Moves to localizes pain 4-Flex to withdraws 3-Abnormal flexion (decorticate) 2-Abnormal extension response (decerebrate) 1-None

Which of the following values is considered normal for ICP? A. 0 to 15 mm Hg B. 25 mm Hg C. 35 to 45 mm Hg D. 120/80 mm Hg

A. 0 to 15 mm Hg

Which of the following symptoms would you expect to a client with a phenytoin level of 35 mg/dL? A. Ataxia B. Potassium deficit C. Neglect syndrome D. Tetraplegia

A. Ataxia 35 indicates toxicity = ataxia, tremor, slurred speech, nausea, and vomiting

Which of the following symptoms may occur with a phenytoin level of 32 mg/dl? A. Ataxia and confusion B. Sodium depletion C. Tonic-clonic seizure D. Urinary incontinence

A. Ataxia and confusion Normal phenytoin level: 10-20 32 indicates toxicity

Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? A. Hemorrhagic skin rash B. Edema C. Cyanosis D. Dyspnea on exertion

A. Hemorrhagic skin rash

Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene? A. Placing the client on the back with a small pillow under the head. B. Keeping portable suctioning equipment at the bedside. C. Opening the client's mouth with a padded tongue blade. D. Cleaning the client's mouth and teeth with a toothbrush.

A. Placing the client on the back with a small pillow under the head. A helpless client should be positioned on the side

The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure? A. Side-lying, with legs pulled up and head bent down onto the chest. B. Side-lying, with a pillow under the hip. C. Prone, in a slight Trendelenburg's position. D. Prone, with a pillow under the abdomen.

A. Side-lying, with legs pulled up and head bent down onto the chest.

A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment? A. Time of onset of current stroke B. Complete physical and history C. Current medications D. Upcoming surgical procedures

A. Time of onset of current stroke Administration within 3 hours after a stroke has better outcomes to dissolve blood clots

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? A. Urine output increases. B. Pupils are 8 mm and nonreactive. C. Systolic blood pressure remains at 150 mm Hg. D. BUN and creatinine levels return to normal.

A. Urine output increases.

CN VI

Abducens

CN VIII

Acoustic

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: A. A negative Kernig's sign. B. A positive Brudzinski's sign. C. Absence of nuchal rigidity. D. A Glascow Coma Scale score of 15.

B. A positive Brudzinski's sign.

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? A. Vomiting continues. B. Intracranial pressure (ICP) is increased. C. The client needs mechanical ventilation. D. Blood is anticipated in the cerebrospinal fluid (CSF).

B. Intracranial pressure (ICP) is increased. LP is contraindicated with increased ICP

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? A. Cholesterol level B. Pupil size and pupillary response C. Bowel sounds D. Echocardiogram

B. Pupil size and pupillary response To indicate changes around the cranial nerves

A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present? A. Abnormal flexion of the upper extremities and extension of the lower extremities. B. Rigid extension and pronation of the arms and legs. C. Rigid pronation of all extremities. D. Flaccid paralysis of all extremities

B. Rigid extension and pronation of the arms and legs.

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? A. A blood glucose level of 480 mg/dl. B. A right-sided carotid bruit. C. A blood pressure of 220/120 mmHg. D. The presence of bronchogenic carcinoma.

C. A blood pressure of 220/120 mmHg. Uncontrolled hypertension is a risk factor for hemorrhagic stroke

A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has: A. A cerebral lesion B. A temporal lesion C. An intact brainstem D. Brain death

C. An intact brainstem

During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client's: A. Pulse B. Respirations C. Blood pressure D. Temperature

C. Blood pressure

The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. This test assesses which of the following? A. Cerebellar function B. Intellectual function C. Cerebral function D. Sensory function

C. Cerebral function

What is the expected outcome of thrombolytic drug therapy? A. Increased vascular permeability B. Vasoconstriction C. Dissolved emboli D. Prevention of hemorrhage

C. Dissolved emboli Dissolve cot and reestablish cerebral perfusion

A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to: A. Tolerate the pain. B. Decrease the perception of pain. C. Escape the source of pain. D. Divert attention from the source of pain.

C. Escape the source of pain.

During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute? A. Limiting conversation with the child. B. Allowing the child to play in the bathtub. C. Keeping extraneous noise to a minimum. D. Performing treatments quickly.

C. Keeping extraneous noise to a minimum.

After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client? A. Give him a barbiturate. B. Place him on mechanical ventilation. C. Perform a lumbar puncture. D. Elevate the head of his bed.

C. Perform a lumbar puncture.

A client is admitted to the emergency room with a spinal cord injury. The client is complaining of lightheadedness, flushed skin above the level of the injury, and headache. The client's blood pressure is 160/90 mm Hg. Which of the following is a priority action for the nurse to take? A. Loosen tight clothing or accessories B. Assess for any bladder distention C. Raise the head of the bed D. Administer antihypertensive

C. Raise the head of the bed

Which of the following signs and symptoms of increased ICP after head trauma would appear first? A. Bradycardia B. Large amounts of very dilute urine C. Restlessness and confusion D. Widened pulse pressure

C. Restlessness and confusion First sign of elevated ICP is a change in mental status.

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? A. Prepare to administer recombinant tissue plasminogen activator (rt-PA). B. Discuss the precipitating factors that caused the symptoms. C. Schedule for A STAT computer tomography (CT) scan of the head. D. Notify the speech pathologist for an emergency consultation.

C. Schedule for A STAT computer tomography (CT) scan of the head. CT will determine if having a stroke or has a brain tumor or another neurological disorder

The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? A. The assistant places a gait belt around the client's waist prior to ambulating. B. The assistant places the client on the back with the client's head to the side. C. The assistant places her hand under the client's right axilla to help him/her move up in bed. D. The assistant praises the client for attempting to perform ADL's independently.

C. The assistant places her hand under the client's right axilla to help him/her move up in bed. This action is inappropriate because pulling on a flaccid shoulder joint could cause shoulder dislocation

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? A. To reduce intraocular pressure. B. To prevent acute tubular necrosis. C. To promote osmotic diuresis to decrease ICP. D. To draw water into the vascular system to increase blood pressure.

C. To promote osmotic diuresis to decrease ICP.

Anticonvulsant medications

Carbamazepine Clonazepam Diazepam Ethosuximide Felbamate Gabapentin Lamotrigine Levetiracetam Phenobarbital Phenytoin Topiramate Valproic acid

Which client would the nurse identify as being most at risk for experiencing a CVA? A. A 39-year-old pregnant female. B. A 67-year-old Caucasian male. C. An 84-year-old Japanese female. D. A 55-year-old African American male.

D. A 55-year-old African American male. Hypertension most prevalent in African-Americans

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? A. A thrombolytic medication B. A beta-blocker medication C. An anti-hyperuricemic medication D. An oral anticoagulant medication

D. An oral anticoagulant medication Indicated for a-fib or other sources of cardioembolic sources of TIA

A client who had a stroke is seen bumping into things on the side and is having difficulty picking up the beginning of the next line of what he is reading. The client is experiencing which of the following conditions? A. Visual neglect B. Astigmatism C. Blepharitis D. Homonymous Hemianopsia

D. Homonymous Hemianopsia

The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? A. Sternal rub B. Pressure on the orbital rim C. Squeezing the sternocleidomastoid muscle D. Nail bed pressure

D. Nail bed pressure (Basic peripheral response)

A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure the client to ensure client safety? A. Speak loudly to the client. B. Test the temperature of the shower water. C. Check the temperature of the food on the delivery tray. D. Provide a clear path for ambulation without obstacles.

D. Provide a clear path for ambulation without obstacles.

Intracranial (Cerebral) Aneurysm

Dilation of the walls of a cerebral artery that develops as a result of weakness in the arterial wall * May be due to HTN

Which of the following medical treatments should the nurse anticipate administering to a client with increased intracranial pressure due to brain hemorrhage, except? A. acetaminophen (Tylenol) B. dexamethasone (Decadron) C. mannitol (Osmitrol) D. phenytoin (Dilantin) E. nitroglycerin (Nitrostat)

E. nitroglycerin (Nitrostat)

Craniectomy - ec = exterior

Excision on the outer portion of the skull

CN VII

Facial

CN IX

Glossopharyngeal

CN XII

Hypoglossal

Cerebral Perfusion Pressure (CPP)

Normal: 70 to 100 mm HG MAP - ICP = CPP * CPP if <50 = irreversible brain damage

CN III

Oculomotor

CN I

Olfactory

CN II

Optic

Cranioplasty

Repair of cranial defect resulting from trauma, malformation, or previous surgical procedure. Artificial material used to replace damaged or lost bone.

CN XI

Spinal accessory

Akinetic mutism

State of unresponsiveness to environment = No voluntary movement (Sometimes open eyes)

CN V

Trigeminal

CN IV

Trochlear

Coma

Unarousable, unresponsiveness no purposeful responses to internal or external stimuli

Persistent Vegetative State (PVS)

Unresponsive resumes sleep-wake cycle after coma

CN X

Vagus