NSG 203 CH 78 NERVOUS SYSTEM DISORDERS
The parents of a client who sustained a closed head injury in a motor vehicle accident voice their concerns about the distance and additional cost of the rehabilitation center which will not be covered by health care chosen for their son. Which health care team member can help the parents with their questions and concerns?
Social worker
Which client would be most at risk for secondary Parkinson disease caused by pharmacotherapy?
a 30-year-old client with schizophrenia taking chlorpromazine
The parent of a child with a ventriculoperitoneal shunt calls the nurse saying that the child has a temperature of 101.2° F (38.4° C), a blood pressure of 108/68 mm Hg, and a pulse of 100 beats/minute. The child is lethargic and vomited the night before. Other children in the family have had similar symptoms. Which nursing intervention is most appropriate?
• Tell the parent to bring the child to the primary health care provider's office.
A client is admitted to the facility for investigation of balance and coordination problems, including possible Ménière's disease. When reviewing this client's chart, the nurse expects to find which signs and symptoms?
• Vertigo, tinnitus, and hearing loss
A client was hit in the head with a baseball during practice. Which discharge instructions should the nurse reinforce?
• Wake client every hour and check orientation to person, time, and place.
A client is admitted with cardioembolic stroke. Which vital piece of information in the client's history is strongly associated with this type of stroke?
• atrial fibrillation
The nurse is teaching a client who has facial muscle weakness and has recently been diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by:
• destruction of acetylcholine receptors.
A client had cataract surgery. Which sign or symptom should the nurse tell the client to report immediately to the health care provider?
• eye pain
A client arrives at the emergency department after falling on ice outside of the senior citizens' housing facility and sustaining a right hip fracture. Which finding would be most important for the nurse to evaluate?
• neurovascular compromise
The nurse is caring for a client who underwent a stapedectomy. Which position would have the greatest benefit for prevention of complications and promotion of comfort?
• on the unaffected side
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:
• raccoon eyes and Battle's sign.
Which nursing data should be given the highest priority for a child with clinical findings related to tubercular meningitis?
• signs of increased intracranial pressure (ICP)
A nurse is caring for a client who had a lumbar laminectomy 2 days ago. Which finding should the nurse report to the health care provider?
• urine retention or incontinence
A client with multiple sclerosis who is unable to bathe herself complains that other staff members haven't been bathing her. How should the nurse respond to this client's complaint?
"I'm sorry you haven't been bathed. I'm available to bathe you now."
A nurse is caring for a child with spina bifida. The child's mother asks the nurse what she did to cause the birth defect. Which statement would be the nurse's best response?
"The cause is unknown, and there are many environmental factors that may contribute to it."
A client who sustained an L1 to L2 spinal cord injury in a construction accident asks a nurse if he'll ever be able to walk again. Which response by the nurse is appropriate?
"What has your physician told you about your ability to walk again?"
A hospitalized child is to receive 75 mg of acetaminophen for fever control. How much will the nurse administer if the acetaminophen concentration is 40 mg per 0.4 ml? Record your answer using two decimal places.
0.75 Use the following equations: Dose on hand/Quantity on hand = Dose desired/X 40 mg/0.4 ml = 75 mg/X X = 0.75 ml
A client has an exacerbation of multiple sclerosis accompanied by leg spasticity. The physician prescribes dantrolene sodium, 25 mg by mouth daily. How soon after administration of dantrolene will the nurse anticipate the health care provider to prescribe an appointment to assess for a significant reduction in spasticity?
1 to 2 weeks
laceration
A laceration is tearing of the brain tissue caused by direct impact or penetrating injury. Lacerations are commonly associated with depressed skull fractures.
A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. When reviewing the client's chart, the nurse expects to find which documentation that confirms the client has Myasthenia gravis?
A positive edrophonium (Tensilon) test
seizure
A seizure, also known as a convulsion, is an episode of abnormal motor, sensory, cognitive, and psychic activity caused by erratic and abnormal electrical discharges of brain cells.
subdural hematoma
A subdural (below the dura) hematoma is typically slow forming. It is caused by an accumulation of blood, usually from a torn vein on the brain's surface.
A home health nurse visits a client who's taking pilocarpine, a miotic agent, to treat glaucoma. The nurse notes that the client's pilocarpine solution is cloudy. What should the nurse do first?
Advise the client to discard the drug because it may have undergone chemical changes or become contaminated.
The nurse educator is preparing a lecture on dementia. The educator will include that which is the most most common cause of dementia in an elderly client?
Alzheimer's disease
ALS
Amyotrophic lateral sclerosis, also known as Lou Gehrig disease, is a rapidly progressive, fatal neurologic disorder resulting in destruction of motor neurons of the cortex, brain stem, and spinal cord.
What should the nurse do when administering pilocarpine?
Apply pressure on the inner canthus to prevent systemic absorption.
autonomic dysreflexia
Autonomic dysreflexia (also known as autonomic hyperreflexia), an exaggerated response to stimuli below the level of the lesion in clients with lesions at or above T6, is a medical emergency that requires prompt treatment.
A client experienced a stroke that damaged the hypothalamus and was admitted to an acute unit. Which body function would the nurse anticipate that the client has problems with and assess as needed?
Body temperature control
A client injures his or her spinal cord in a diving accident. Which cerebral vertebral level would the nurse associates the injury site if the client is unable to breathe spontaneously?
C4
A client is thrown from an automobile during a collision. The nurse knows that the client will be able to maintain gross arm movements and diaphragmatic breathing if the injury occurs at what vertebral level?
C5
The nurse is caring for a client diagnosed with a cerebral aneurysm, who reports a severe headache. Which action should the nurse perform first?
Call the physician immediately.
CNS
Central Nervous System infection
LOC
Change in behaviors, mentation, level of consciousness, alertness, and orientation could be subtle but significant.
The nurse is reviewing the medical record for a client in a long-term care facility. The nurse notes an entry by the primary care physician indicating the client is colorblind. The nurse understands this condition results from a problem with which structure(s) of the eye?
Cones
The neurologic unit has identified a 30% occurrence of pressure ulcers in clients admitted with the diagnosis of stroke. Which of the following actions should be included in the unit's performance improvement plan?
Creating a spreadsheet on which nursing staff should document repositioning of clients admitted with a stroke
A young man was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then he became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse would expect to observe which sign first?
Declining level of consciousness
The nurse is collecting data on a geriatric client with senile dementia. When reviewing this client's file, which neurotransmitter condition is the nurse likely to find in the client's history as a contributory factor to his or her cognitive changes?
Decreased acetylcholine level
diplopia
Double vision (diplopia)
The nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)?
Elevate the head of the bed to 30 degrees.
A nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above T5, and blood pressure of 162/96 mm Hg. The client reports a severe, pounding headache. Which nursing intervention would be appropriate for this client? Select all that apply.
Elevate the head of the bed to 90°. Loosen constrictive clothing. Assess for bladder distention and bowel impaction. Administer antihypertensive medication.
A client is admitted into a medical unit confused and agitated. Which nursing measure should the nurse implement first to keep the client safe?
Encourage family, friends, or a sitter to stay with the client.
After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway, attends to the client's immediate needs, and then prepares to perform a neurologic assessment. Because the client is unstable and in critical condition, the examination must be brief but will include which nursing intervention?
Evaluation of the corneal reflex response
Bell palsy is a temporary, partial one-sided facial paralysis and weakness caused by ischemia of inflammation of the 7th cranial nerve and is not a result of a brain lesion.
False
The nurse is caring for a client with stroke in evolution. Which nursing intervention is priority?
Have tracheal suction available at all times.
A client undergoes cerebral angiography to evaluate for neurologic deficits. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings should the nurse notify the physician of because they indicate spasm or occlusion of a cerebral vessel by a clot?
Hemiplegia, seizures, and decreased level of consciousness (LOC)
HD
Huntington's disease, also known as Huntington's chorea, is a chronic, progressive, hereditary condition in which brain cells in the basal ganglia prematurely die.
contusion
In contusion, the brain tissue is bruised.
A client with meningitis is being prepared for a lumbar puncture. In which position should the nurse place the client for this procedure?
Laterally, with knees drawn up to the abdomen and chin touching the chest
A 75-year-old client who was admitted to the hospital with a stroke informs the nurse that he doesn't want to be kept alive with machines. He wants to make sure that everyone knows his wishes. Which action should the nurse take?
Make arrangements for the client to receive information about advance directives.
CSF
Measure pressure of cerebrospinal fluid
A client was admitted with an injury to the occipital lobe. Which nursing action should the nurse perform?
Monitor client for visual disturbances.
A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?
Notify the physician.
An adult client was admitted with myasthenia gravis. While reviewing the client's chart, the licensed practical nurse (LPN)/licensed vocational nurse (LVN) noticed the medication administration record (MAR). Based on the information, what should the nurse do next?
Notify the registered nurse and question the morphine sulfate.
A white female client is admitted to an acute care facility with a diagnosis of stroke. Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for stroke?
Obesity
opisthotonos
Opisthotonos, an acute spasm in which the body is bowed forward, with the head and heels bent backward, is often present. Children have tense or bulging fontanels and a high-pitched cry.
A client is admitted to the emergency department with a suspected overdose of an unknown drug. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?
Prepare to assist with ventilation.
tonic phase
Rigid contraction of body muscles (tonic phase). The tonic-clonic or grand mal seizure is perhaps the most life-threatening type of seizure.
A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes highest priority?
Risk for injury related to neurologic deficit
Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease?
Risk for injury related to vertigo
shingles
Shingles, or herpes zoster, is an acute viral inflammation of a nerve caused by the varicella-zoster virus (the same virus that causes chickenpox).
nuchal rigidity
Signs and symptoms include fever, chills, severe headache, nausea and vomiting, nuchal rigidity (stiff neck), and irritability. A change in LOC is present. Two neurologic signs are present: positive Kernig sign and positive Brudzinski.
status epilepticus
Status epilepticus refers to the occurrences of a single, unremitting seizure that lasts longer than 5 minutes or frequent clinical seizures without an interictal return to baseline.
A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse reviews the client's chart and prepares to administer which neuromuscular blocking agent?
Succinylcholine
When assisting with the education of the family of a client with C4 quadriplegia on how to perform tracheostomy suctioning, which instruction should the nurse be sure to include?
Suction for 10 to 15 seconds at a time.
focal point
Surgery may be performed in certain circumstances in which the seizure's focal point can be clearly identified in the brain.
craniotomy
Surgical entry into the skull (cranium) is called a craniotomy. This invasive procedure is performed for many reasons; one of the most common being a brain tumor.
vertigo
Symptoms include headache, anxiety, fatigue, or vertigo (a sensation of rotation of self or one's surroundings; not true dizziness).
neurology
The medical specialty related to the nervous system is neurology.
A client was admitted with injury to the thalamus. Which manifestation would the nurse observe during data collection?
aching sensation over half of the body
The nurse is discussing the purpose of an electroencephalogram with the family of a client who has massive cerebral hemorrhage and loss of consciousness. Which response by the nurse would be the most accurate in describing what the test measures?
activity of the brain
A client recovering from a spinal cord injury has a great deal of spasticity. What medication administered by the nurse may be used to control spasticity?
baclofen
Which of these medications are given to a client with Parkinson's disease? a. Neostigmine methylsulfate b. Zolmitriptan c. MAO B inhibitors d. Beta-blockers e. Phenytoin
c. MAO B inhibitors Medications given to a client with Parkinson's disease include: -Levodopa (L-dopa, Dopar, Larodopa) -Levodopa plus carbidopa (Sinemet) -Dopamine agonists -MAO B inhibitors -Anticholinergics -Glutamate (NMDA) blocking drugs
A client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from the ears and nose. Which nursing intervention is appropriate?
checking the fluid for glucose with a dipstick
A client is newly diagnosed with myasthenia gravis. When reinforcing education what should the nurse indicate as the cause of this disease?
destruction of acetylcholine receptors, causing muscle weakness
dysphasia
difficulty in speaking
dysphagia
difficulty in swallowing
ptosis
drooping of one or botheyelids
The nurse observes that a comatose client's response to painful stimuli is decerebrate posturing. The client exhibits extended and pronated arms, flexed wrists with palms facing backward, and rigid legs extended with plantar flexion. Decerebrate posturing as a response to pain indicates:
dysfunction in the brain stem.
A client has a cervical spinal cord injury at the level of C5. Which condition would the nurse anticipate during the acute phase?
the need for mechanical ventilation
The nurse is gathering data from a client with Ménière disease. Which symptom does the nurse relate to the disease process?
tinnitus
A client with new-onset seizures of unknown cause is started on phenytoin, 750 mg IV now and 100 mg P.O. t.i.d. Which statement best describes the purpose of the loading dose?
to more quickly attain therapeutic levels
A nurse working on a surgical floor observes an unlicensed assistive personnel (UAP) completing assigned tasks. Which situation requires the nurse to intervene?
turning a client who is 24 hours post-op laminectomy
A client with a subdural hematoma was given mannitol. Which result would best show the effectiveness of the medication?
urine output of 65 ml/hour
A nurse has administered timolol to a client with glaucoma. What symptom would be of greatest concern to the nurse?
wheezing
A client was diagnosed with having right subarachnoid hemorrhage. The nurse should plan to place the client in which position?
with the head of the bed elevated
A client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction?
• "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."
A client with a mild concussion reports a headache. When offered acetaminophen, the client asks for a stronger pain medication. Which response by the nurse is appropriate?
• "Opioids are avoided after a head injury because they may hide a worsening condition."
Which statement by the parent of a child with otitis media indicates an understanding of the nurse's discharge instructions about the use of antibiotics?
"I'll give my child the full course of antibiotics."
The parent of a child with a history of closed-head injury asks the nurse why the child would begin having seizures without warning. Which response by the nurse is the most accurate?
"It's not unusual to develop seizures after a head injury because of brain trauma."
A client is receiving pilocarpine eye drops. Which statement made by the client shows correct understanding of the medication?
"The medication will help decrease pressure in my eyes."
seizure disorder
A Seizure disorder may be associated with birth trauma, meningitis, traumatic injury, and a variety of metabolic or developmental disorders.
concussion
A concussion is the result of any blow to the head. The concussion may not damage any brain structures, but temporary unconsciousness is possible.
A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client? Select all that apply.
Assist the client to the floor. Turn the client to the side. Place a pillow under the client's head.
KEY POINTS
Because the nervous system controls the body's movements, disorders in this system may cause unwanted movement or immobility. Seizure disorders have different manifestations, ranging from generalized tonic-clonic movements to uncontrolled movements without loss of consciousness. Spinal cord injuries can result in a range of physical and mental deficits, including paralysis. Degenerative disorders of the nervous system can cause difficulties in movement, sensory deficits, or varying degrees of alteration in mental status. Inflammatory disorders of the nervous system can quickly become life-threatening. Increased ICP has many causes. It is a significant sign of a brain disorder. One of the first and most important signs of ICP and other disorders of the brain is a change in LOC. Most brain tumors are nonmalignant. Benign tumors, however, cause pressure on the brain and can be fatal.
cephalgia
Cephalgia (headache) is one of the most common symptoms of a neurologic disorder. It is also associated with many other diseases and disorders. Headache is not a disease in itself, but rather it is a symptom of an underlying disorder.
A client who sustained a closed head injury in a skating accident pulls out his feeding tube, I.V. catheter, and indwelling urinary catheter. To ensure this client's safety, a physician prescribes restraints. Which action should a nurse take when using restraints?
Fasten the restraint to the bed frame using a quick-release knot.
A client comes to the emergency department after hitting his or her head in a motor vehicle collision. The client is alert and oriented. Which nursing intervention should be done first?
Immobilize the client's head and neck.
otorrhea
In a basilar skull fracture, rhinorrhea, leakage of CSF from the nose (otorrhea), or leakage of CSF from the ear may occur.
Which nursing diagnosis takes highest priority for a client with Parkinson's crisis?
Ineffective airway clearance
A client is admitted with myasthenia gravis. Which nursing intervention should be priority?
Monitor respiratory status.
MG
Myasthenia gravis is a progressive disorder of weakness of the voluntary muscles. Generally considered an acquired autoimmune disorder, it also can involve genetic factors.
paraplegia
Paraplegia means paralysis of the legs and lower body; it usually results from injury to the cord below the first thoracic vertebra.
parkinsonism
Parkinson disease, also called parkinsonism, is second only to Alzheimer disease as the most common neurologic disease in older adults.
chorea
The disease progresses at different rates. HD usually starts with abnormal involuntary movement, called chorea, as fidgeting, jerking, and spasms.
rhinorrhea
The dye may appear to bulge, and other symptoms of vasodilation are seen, such as edema, lacrimation (tear formation), rhinorrhea (runny nose), diaphoresis (sweating), and flushing of the affected side.
Is the following statement true or false? When caring for a client with cardiovascular accident (CVA) and hemiplegia, the client should be encouraged to use the trapeze bar on the bed.
True Frequent position changes help to prevent disorders caused by immobility-disuse disorders. Use of trapeze bar allows the client to assist with position changes and to reduce the shearing forces that can lead to skin breakdown. Mobility will prevent respiratory complications and will help the client to maintain self-esteem. Splints or high-top sneakers aid in maintaining normal anatomical alignment of the joints.
clonic phase
alternates with rhythmic jerking movements (clonic phase), follows.
A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order:
electromyography (EMG).
When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should:
elevate the head of the bed 90 degrees during meals.
The health care provider prescribes several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question prior to administration?
heparin sodium
The nurse is working on a surgical floor. The nurse must logroll a client following a:
laminectomy.
A client is admitted to an acute care facility with a diagnosis of stroke. The nursing student is reviewing the client's history. Which history findings noted will the student report as risk factors for stroke? Select all that apply.
obesity smoking ½ pack of cigarettes a day hypertension
A client at the eye clinic is newly diagnosed with glaucoma. What should the nurse inform the client might occur if administration of the medication is not closely adhered to?
permanent vision loss
The nurse is teaching a client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:
rest in a room set at a comfortable temperature.
A client with Parkinson disease is receiving selegiline. Which foods should the nurse instruct the client to avoid while taking this medication? Select all that apply.
salami aged cheese soy sauce sauerkraut
The nurse is caring for a client with stroke in evolution. Which nursing intervention is priority?
• Have tracheal suction available at all times.
The nurse is preparing a client for a computed tomography (CT) scan, which requires infusion of radiopaque dye. Which question is important for the nurse to ask?
"Are you allergic to seafood or iodine?"
The nurse is observing pupillary responses from a client. Which method should the nurse use to evaluate pupil accommodation?
• Observe for pupil constriction and convergence while focusing on an object coming toward the client.
A client is scheduled for an electroencephalogram (EEG) after having a seizure for the first time. Which instruction does the nurse provide to the client as preparation for this test?
"Avoid stimulants and alcohol for 24 to 48 hours before the test."
A quadriplegic client is prescribed baclofen, 5 mg by mouth three times daily. The client asks what is the indication for baclofen. How would the nurse respond?
"Baclofen is indicated when there are muscle spasms with paraplegia or quadriplegia from spinal cord lesions."
A nurse is educating the parents of a 1-year-old infant with otitis media. Which statement regarding predisposing factors for otitis media would be most accurate for the nurse to make?
"Eustachian tubes are short, wide, and straight and lie in a horizontal plane."
A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. The client has questions about the paralysis. What information will the nurse tell the client about the paralysis?
"The paralysis caused by this disease is temporary."
A client who sustained a closed head injury in a motor vehicle accident is diagnosed as brain dead by a neurosurgeon. The physician has scheduled a meeting with the client's family about discontinuing life support. Before the meeting, a family member asks the nurse her opinion about life support. Which response by the nurse is appropriate?
"What has the physician explained about the client's prognosis?"
The nurse receives a health care provider's order to administer 1,000 mL of intravenous (IV) normal saline solution over 8 hours to a client who recently had a stroke. What should the drip rate be if the drop factor of the tubing is 15 gtt/mL? Record your answer using a whole number.
31 Explanation: The drip rate is calculated using the following formula: Volume of infusion (in milliliters)/Time of infusion (in minutes 60 MINUTES X 8 HRS =480) × drip factor (in drops/milliliter) = drops/minute. Therefore, 1,000 mL/480 minutes × 15 drops/mL = 31 gtt/minute.
The health care provider prescribed t-PA, a thrombolytic agent. The order is for 0.9 mg/kg over 1 hour. The client weighs 110 lb (50 kg). What is the total dose in milligrams the client will receive? Record your answer using a whole number.
45 Explanation: 0.9 mg/kg × 50 kg = 45 mg
Following an eye examination, a client is given the following prescription: "pilocarpine ophthalmic solution, 0.25%, 1 gtt both eyes qid." Which statements indicate the correct interpretation and procedure for administering the medication? Select all that apply.
Apply pressure to the inner corner of eye for 1 to 2 minutes after application to prevent systemic absorption. Instill one drop of pilocarpine solution into each eye every 4 hours each day. Wash hands before and after instilling eye drops and do not allow dropper to touch the eye or any other surfaces.
A nurse is caring for a group of clients on the neurologic unit. Which task should the nurse perform first?
Arrange an escort for a client who needs to go to the physical therapy department.
For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?
Attaching braces or splints to each foot and leg
A nurse is positioning a client with flaccid left-sided hemiparesis in bed following a cerebral vascular accident (CVA). Which is the nurse's best intervention?
• Position the left arm supported on a pillow.
EEG
Electroencephalography records the brain's electrical impulses as a graph. This test is used frequently in the diagnosis of seizure disorders, brain tumors, intracranial lesions (in Parkinson disease, Alzheimer disease, and narcolepsy), blood clots, infections (meningitis, encephalitis), and sleep disorders.
A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?
Ineffective breathing pattern
The nurse is presenting a lecture on vertigo at a community setting. The nurse will include that the client with vertigo may have a problem with which portion of the ear?
Inner ear
halo sign
Inspect the wet area after a few minutes for a halo sign: if a yellow ring encircles a central ring that is red, the red ring indicates blood, and the yellow ring suggest CSF.
intracranial pressure
Intracranial pressure is the pressure that the brain, blood, and CSF exert inside the cerebrospinal cavity.
MS
Multiple sclerosis is one of the most common nerve disorders in the United States, typically affecting young adults and people living in northern temperature climates.With recurrent episodes, increasingly severe symptoms, such as paralysis, dysphagia (difficulty in swallowing), and bladder and bowel dysfunctions develop.
A nurse is caring for a client with a closed head injury. What is the appropriate action by the nurse?
Notify the health care provider of a blood pressure change from 147/72 mm Hg to 176/70 mm Hg.
During the course of a busy shift, a nurse fails to document that a client's ventricular drain had an output of 150 ml. Assuming that the drain was no longer draining cerebrospinal fluid, the physician removes the drain. When the nurse arrives for work the next morning, she learns that the client became agitated during the night and his blood pressure became elevated. What action should the nurse take?
Notify the physician of the documentation omission.
After striking his head on a tree while falling from a ladder, a young man is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client?
Perform a lumbar puncture.
photophobia
Photphobia (intolerance to light) and pain when the eyes move from side to side occur. The affected person may have seizures. Aptechial purpuric rash is also possible.
The parent of a child with a ventriculoperitoneal shunt calls the nurse saying that the child has a temperature of 101.2° F (38.4° C), a blood pressure of 108/68 mm Hg, and a pulse of 100 beats/minute. The child is lethargic and vomited the night before. Other children in the family have had similar symptoms. Which nursing intervention is most appropriate?
Tell the parent to bring the child to the primary health care provider's office.
tetraplegia
Tetraplegia (also referred to as quadriplegia) means paralysis to the cervical segments of nerves from C1 to C8. resulting from impaired function of the upper extremities, trunk (including respiratory involvement), pelvic organs, and lower extremities.
GCS
The Glasgow coma scale (GCS) is commonly used as a broad indicator of the severity of brain injury.p
LP
The lumbar puncture (LP, spinal tap) involves the insertion of a hollow needle with a stylet (guide) into the subarachnoid space of the lumbar region of the spinal canal.
ataxia
The person has difficulty maintaining balance and coordination (ataxia).
aura
The person may have sensory warnings or premonitions (aura) that a headache will occur. Various auras include mood changes, anorexia, numbness of a body part, or visual symptoms, such as flashing lights or floating spots.
flaccidity
The seizure may commence with the person falling down because of brief loss of muscle tone (flaccidity).
neuralgia
The term neuralgia literally means "pain in a nerve." Neuralgia often applies to fleeting pain in the shoulder and upper arm or pain caused by a herniated intervertebral disk.
bradykinesia
This progressive brain disease is characterized by bradykinesia (slowness of movement) and fine, rhythmic tremors of the hands, arms, legs, jaw, and face. The limbs and trunk become rigid and stiff.
A client accidentally splashes chemicals into his eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first-aid treatment?
To prevent vision loss
A nurse is gathering neurological data from a client. To determine if a Babinski reflex is present, indicate the point where the nurse places the tongue blade to begin stroking the foot.
To test for a Babinski reflex, use a tongue blade to slowly stroke the side of the sole of the foot. Start at the heel and move toward the great toe. The normal response in an adult is plantar flexion of the toes. Upward movement of the great toe and fanning of the little toes—Babinski's reflex—is abnormal in clients over the age of 12 to 18 months.
transection
Transection (severing) of the cord can be incomplete (partial) or complete. If the transection is complete, all sensation and voluntary movements below the site of injury are lost.
A cluster headache occurs suddenly and severely, often affecting only one side and involving the eye, neck, and face on that side
True
A nurse is assisting with the development of a teaching plan for a client who will undergo a stapedectomy for the treatment of otosclerosis. Which instruction should the plan include?
Vertigo and dizziness are common after surgery.
A 58-year-old client complaining of difficulty driving at night states that the "lights bother my eyes." The client wears corrective glasses. The nurse would expect the physician to have the client increase his or her intake of which vitamin because the client is experiencing a deficiency in this vitamin?
Vitamin A
Which of these is a key component of a neurological assessment? a. Signs of increased intracranial pressure and eye signs b. Signs of heightened hearing c. Loss of the sensation of touch d. Loss of appetite e. Loss of hearing
a. Signs of increased intracranial pressure and eye signs Other key components of a neurological assessment include: -Neurologic nursing history, including history given by family and Neurologic status -Speech patterns, Level of consciousness (LOC), changes in LOC -Gross evaluation of muscle tone/strength -Overview of balance, coordination, and protective reflexes and of sensory function -Function of selected cranial nerves
A nurse performs a neurologic data collection on a client reporting headache and dizziness. Which data collection technique helps determine the motor function of cranial nerve VII?
asking the client to frown, smile, and raise the eyebrows
A physician diagnoses a client with myasthenia gravis and prescribes pyridostigmine, 60 mg by mouth every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client's history. Which preexisting condition would contraindicate the use of pyridostigmine?
• Intestinal obstruction
What is the function of cerebrospinal fluid (CSF)?
• It cushions the brain and spinal cord.
A nurse collecting data on a post-craniotomy client finds the urinary catheter bag with 1,500 mL the first hour and the same amount for the second hour. Which complication should the nurse suspect as a cause of this amount of output?
diabetes insipidus
A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What does Brudzinski's sign indicate?
• Meningeal irritation
A client with a spinal cord injury has a neurogenic bladder. When planning for discharge, the nurse anticipates that the client will need which procedure or program?
intermittent catheterization
An older adult client admitted to the hospital with chest pain has difficulty hearing. Which method should the nurse use when collecting data from this client?
lower voice pitch while facing the client
The nurse is making assignments for the day. Which of the following tasks can be safely assigned to unlicensed assistive personnel (UAP)?
measuring the intake of a client with multiple sclerosis
A graduate nurse, working in a long-term facility, is caring for a client who has hearing loss. When observing the graduate, the nurse mentor would intervene if which action is taken by the graduate?
moves around and multitasks when speaking
In caring for a child immediately after a head injury, the nurse notes a blood pressure of 110/60, a heart rate of 78 beats/minute, dilated and nonreactive pupils, minimal response to pain, and slow response to name. Which symptom would cause the nurse the most concern?
nonreactive pupils
The nurse is preparing to administer carbamazepine oral suspension, 150 mg by mouth. The pharmacy has dispensed carbamazepine suspension 100 mg/5 mL. How many milliliters of carbamazepine should the nurse administer to the client? Record your answer using one decimal place.
• 7.5 To calculate the dose, the nurse should use this equation: 100 mg/5 mL = 150 mg/X 100X = 750 X = 7.5 mL
The nurse is scheduled to administer an otic medication. Which action should the nurse perform first?
• Check and verify the proper client's name. When giving medications, a nurse follows the 10 rights of medication administration: right client, right drug, right dose, right route, right time, right documentation, right assessment, right to refuse, right evaluation, and right client education or information. Put the client in the lateral position, not semi-Fowler's position, for 5 minutes to prevent the drops from draining out. The drops may be warmed to prevent pain or dizziness, but this is not the first action. An emesis basin would be used for irrigation of the ear.
A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?.
• Elevated 30 degrees
A client is admitted into a medical unit confused and agitated. Which nursing measure should the nurse implement first to keep the client safe?
• Encourage family, friends, or a sitter to stay with the client.
