Week 3

secondary headaches

-serious underlying cause often warranting urgent attention -occur after age 50 with severe onset and should be ruled out before making dx of primary headache

primary headaches

-without underlying pathology -90% are primary headaches and fall into 4 categories- tension, migraine, cluster, and chronic daily headache

A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. What would the nurse do?

Ask a client to identify scents.

The nurse is caring for a client who knows what to say but cannot produce the speech to communicate it. Which area of the cerebral cortex is dysfunctional?

Broca's area Aphasia that involves the inability to produce the correct words for communication is caused by dysfunction to Broca's area.

The nurse walks into a client's room and finds that the client is disoriented to time and place but is awake and responsive. What term best describes this client?

Confused

The peripheral nervous system is neatly partitioned along dermatomes, whereas the central nervous system is not. Therefore, a sensory deficit along a dermatome, particularly when accompanied by local pain, suggests a peripheral nerve lesion. T/ F

F

Ipsilateral involvement of the spinothalamic tract results in the loss of pain and temperature senses. T/ F

F- contralateral

Contralateral involvement of the corticospinal tract would result in upper motor neuron weakness, increased tone, and positive Babinski's sign. T/F

F- ipsilateral

The nurse is assessing the neurological status of an unconscious client. The nurse should use which assessment scale?

Glasgow An appropriate scale to assess the neurological status of an unconscious client is the Glasgow Coma Scale (GCS). The Norton and Braden scales are used to assess skin. The Morse Fall scale is used to assess the risk for falls.

When performing an assessment of the nervous system, it is most appropriate for a nurse to complete it in which sequence?

Mental status, cranial nerves, motor/cerebellar, sensory, reflexes

Subarachnoid Hemorrhage (thunderclap headache)

Process: Bleeding from a ruptured cerebral saccular aneurysm; rarely from AV malformation, mycotic aneurysm Location: generalized Quality and Severity: Very severe, "the worst of my life" Onset: Sudden onset; can be less than a minute Duration: Variable, usually days Course: Varies according to presenting severity and level of consciousness; worst if initial coma Associated Sx: Nausea, vomiting, loss of consciousness, neck pain. Possible prior neck symptoms from "sentinel leaks" Agg Factors: Rebleeding, ↑ intracranial pressure, cerebral edema All Factors: Subspecialty treatments

Postconcussion Headaches

Process: Follows mild acceleration-deceleration traumatic brain injury. May involve axonal, cerebrovascular autoregulatory, neurochemical injury Location: Often but not always localized to the injured area Quality and Severity: Dull, aching, constant; may have features of tension and migraine headaches Onset: Within 7 days of the injury up to 3 mo Duration: Weeks to up to a year Course: Tends to diminish over time Associated Sx: Drowsiness, poor concentration, confusion, memory loss, blurred vision, dizziness, irritability, restlessness, fatigue Agg Factors: Mental and physical exertion, straining, stooping, emotional excitement, alcohol All Factors: Rest; medication

Brain Tumor

Process: Mass lesion causing displacement of or traction on pain-sensitive arteries and veins or pressure on nerves Location: Variable, including lobes of brain, cerebellum, brainstem Quality and Severity: Aching, steady, dull pain worse on awakening the better after several hours Onset: Variable Duration: Often brief; depends on location and rate of growth Course: Intermittent but may progress in intensity over a period of days Associated Sx: Seizures, hemiparesis, field cuts, personality changes. Also nausea, vomiting, vision change, gait change Agg Factors: May be aggravated by coughing, sneezing, or sudden movements of the head All Factors: Subspecialty treatments

Headache from Sinusitis

Process: Mucosal inflammation of the paranasal sinuses Location: Usually frontal sinuses above the eyes or over the maxillary sinus Quality and Severity: Aching or throbbing, severity variable; consider possible migraine Onset: variable Duration: Often daily several hours at a time, persisting until treatment Course: Often daily in a repetitive pattern Associated Sx: Local tenderness, nasal congestion, discharge, and fever Factors that Aggravate/ Provoke: May be aggravated by coughing, sneezing, or jarring the head Factors that Alleviate: Nasal decongestants, antibiotics

migraine headaches

Process: Neuronal dysfunction, possibly of brainstem origin, involving low serotonin level, spreading cortical depression and trigeminovascular activation; types: with aura; without aura; variants Lifetime Prevalence: 10% of headaches; prevalence 18% of U.S. adults; affects ∼15% of women, 6% of men Location: Unilateral in ∼70%; bifrontal or global in ∼30% Quality and Severity: Throbbing or aching, pain, moderate to severe in intensity; preceded by aura in up to 30% Onset: Fairly rapid, reaching a peak in 1-2 hrs Duration: 4-72 hrs Course: Recurrent—usually monthly, but weekly in ∼10%; peak incidence early to mid-adolescence Associated Sx: Prodrome: nausea, vomiting, photophobia, phonophobia; aura in 30%; either visual (flickering, zig-zagging lines), or motor (paresthesias of hand, arm, or face, or language dysfunction) Triggers/ Factors that Aggravate or Provoke: Alcohol, certain foods, or stress may provoke; also menses, high altitude; aggravated by noise and bright light Factors that Relieve: Quiet, dark room; sleep; sometimes transient relief from pressure on the involved artery

Errors of Refraction (eyesight)

Process: Probably the sustained contraction of the extraocular muscles, and possibly of the frontal, temporal, and occipital muscles Location: Around and over the eyes; may radiate to the occipital area Quality and Severity: Steady, aching, dull Onset: gradual Duration: variable Course: variable Associated Sx: Eye fatigue, "sandy" sensations in eyes, redness of conjunctiva Factors that Aggravate/ Provoke: Prolonged use of the eyes, particularly for close work Factors that Relieve: rest eyes

tension headache

Process: Process unclear—possibly heightened CNS pain sensitivity. Involves pericranial muscle tenderness; etiology also unclear Lifetime Prevalence: Most common headache (40%); prevalence about 50% Location: Usually bilateral; may be generalized or localized to the back of the head and upper neck or to the frontotemporal area Quality and Severity: Steady; pressing or tightening; nonthrobbing pain; mild to moderate intensity Onset: gradual Duration: 30 mi to 7 days Course: episodic- may be chronic Associated Sx: Sometimes photophobia, phonophobia; scalp tenderness; nausea absent Triggers/ Factors that Aggravate or Provoke: Sustained muscle tension, as in driving or typing; stress; sleep disturbances Factors that Relieve: Possibly massage, relaxation

cluster headaches

Process: Process unclear—possibly hypothalamic then trigemino-autonomic activation Lifetime Prevalence: <1%, more common in men Location: Unilateral, usually behind or around the eye or temple Quality and Severity: Sharp, continuous, intense; severe in intensity Onset: Abrupt; peaks within minutes Duration: 15 min to 3 hrs Course: Episodic, clustered in time, with several each day for 4-8 wks and then relief for 6-12 mo Associated Sx: Unilateral autonomic symptoms: lacrimation, rhinorrhea, miosis, ptosis, eyelid edema, conjunctival infection Triggers/ Factors that Aggravate/ Provoke: During attack, sensitivity to alcohol may increase

Giant Cell (Temporal) Arteritis

Process: Transmural lymphocytic vasculitis often involving multinucleated giant cells that disrupts the internal elastic lamina of large-caliber arteries Location: Localized near the involved artery, most often the temporal artery in those > age 50, women > men (2:1 ratio) Quality and Severity: Throbbing, generalized, persistent; often severe Onset: gradual or rapid Duration: variable Course: Recurrent or persistent over weeks to months Associated Sx: Tenderness over temporal artery, adjacent scalp; fever (in ∼50%), fatigue, weight loss; new headache (∼60%), jaw claudication (∼50%), visual loss or blindness (∼15%-20%), polymyalgia rheumatica (∼50%) Agg Factors: Movement of neck and shoulders All Factors: Often steroids

Trigeminal Neuralgia

Process: Vascular compression of CN V, usually near entry to pons leading to focal demyelination, aberrant discharge. 10% with causative intracranial lesion Location:

Meningitis

Process: Viral or bacterial infection of the meninges surrounding the brain and spinal cord Location: generalized Quality and Severity: Steady or throbbing, very severe Onset: Fairly rapid, usually <24 hrs; may be sudden onset Duration: Variable, usually days Course: Viral: usually <1 wk; bacterial: persistent until treatment Associated Sx: Fever, stiff neck, photophobia, change in mental status Alleviating Factors: Immediate antibiotics until diagnosis of bacterial or viral

Acute Glaucoma

Process: sudden increase in intraocular pressure Location: pain in and around one eye Quality and Severity: steady, aching, often severe Onset: often rapid Duration: variable- may depend on treatment Course: variable- may depend on tx Associated Sx: Blurred vision, nausea and vomiting; halos around lights, reddening of eye Factors that Aggravate/ Provoke: Sometimes provoked by mydriatic drops

analgesic rebound

Process: withdrawal of meds Location; previous headache pattern Quality and Severity: variable Onset: variable Duration: depends on prior headache pattern Course: depends on frequency of mini-withdrawals Associated Sx: depends on prior headache pattern Factors that Aggravate or Provoke: Fever, carbon monoxide, hypoxia, withdrawal of caffeine, other headache triggers Factors that Relieve: depends on cause

A nurse is working with a client who is victim of a shooting. The client has an increased pulse rate and pupil dilation and is clearly in stress. The nurse recognizes the "fight-or-flight" response in this client and understands that this represents an activation of which of the following?

SNS

spastic hemiparesis

Seen in corticospinal tract lesions that cause poor control of flexor muscles during swing phase (for example, from stroke). -Affected arm is flexed, immobile, and held close to the side, with elbow, wrists, and interphalangeal joints flexed. -Affected leg extensors are spastic; ankles are plantar-flexed and inverted. -Patients may drag toe, circle leg stiffly outward and forward (circumduction), or lean trunk to contralateral side to clear affected leg during walking.

cerebellar ataxia

Seen in disease of the cerebellum or associated tracts. -Gait is staggering and unsteady, with feet wide apart and exaggerated difficulty on turns. -Patients cannot stand steadily with feet together, whether eyes are open or closed. -Other cerebellar signs are present such as dysmetria, nystagmus, and intention tremor.

steppage gait

Seen in foot drop, usually secondary to peripheral nervous system disease. -Patients either drag the feet or lift them high, with knees flexed, and bring them down with a slap onto the floor, appearing to be walking up stairs. -Patients cannot walk on their heels. -Gait may involve one or both legs. -Tibialis anterior and toe extensors are weak.

sensory ataxia

Seen in loss of position sense in the legs from polyneuropathy or posterior column damage. -Gait is unsteady and wide based (with feet wide apart). -Patients throw their feet forward and outward and bring them down, first on the heels and then on the toes, with a double tapping sound. -Patients watch the ground for guidance when walking. -With eyes closed, patients cannot stand steadily with feet together (positive Romberg sign), and the staggering gait worsens.

scissors gait

Seen in spinal cord disease, causing bilateral lower extremity spasticity, including adductor spasm. -Gait is stiff. Patients advance each leg slowly, and the thighs tend to cross forward on each other at each step. Steps are short. -Patients appear to be walking through water, and there may be compensating sway of the trunk away from the side of the advancing leg. -Scissoring is seen in all spasticity disorders, most commonly cerebral palsy.

Parkinsonian gait

Seen in the basal ganglia defects of Parkinson disease. -Posture is stooped, with flexion of head, arms, hips, and knees. -Patients are slow getting started. -Steps are short and shuffling, with involuntary hastening (festination). -Arm swings are decreased, and patients turn around stiffly—"all in one piece." -Postural control is poor (anteropulsion or retropulsion).

A lesion at the spinal level of the pathway for conscious proprioception (the ability to sense the position and movement of the limbs) and stereognosis (the ability to identify objects by touch) will result in the loss of these senses ipsilaterally, below the level of the lesion. T/ F

T

A lesion of the pain-temperature pathway (spinothalamic tract), whether within the brain stem or spinal cord, will result in loss of pain-temperature sensation contralaterally, below the level of the lesion. T/ F

T

Ipsilateral involvement of the dorsal column-medial lemniscus system results in loss of fine touch, vibration, and proprioception. T/ F

T

In an adult patient, the plantar reflex is found to be extensor on the right. What does this indicate?

abnormal Babinski response

The nurse is doing a brainstem assessment on an unconscious client. Which of the following will the nurse examine during this part of the acute assessment? Select all that apply. a. Corneal Reflex b. Gag reflex c. Oculocephalic reflex (doll's eye maneuver) d. Pupillary assessment e. Level of consciousness assessment via the Glasgow coma scale

a, b, c

Which of the following are TRUE? Choose all that apply. a. Motor neurons above the level of this synapse are considered upper motor neurons (UMN) b. Upper and lower motor neuron injuries produce different clinical signs. c. Peripheral nerve cells and their extensions beyond the synapse are lower motor neurons (LMN). d. The corticospinal tract and related motor pathways synapse in the spinal cord, just before leaving the cord.

a, b, c, d

What important questions guide the approach to physical assessment of the nervous system? (Select all that apply.) a. Where does the lesion lie? b. Is the central nervous system intact? c. Is the mental status intact? d. Are right-sided and left-sided examination findings symmetric?

a, c, d

CN XI

spinal accessory -look for atrophy or fasciculations (small irregular twitching) of trapezius muscles -ask patient to shrug both shoulders against hands =in trapezius muscle paralysis, the shoulder drops and the scapula is displaced downward and laterally -ask patient to turn head against hand =a supine patient with bilateral weakness of SCM muscles has difficulty raising head off pillow

The nurse is preparing to perform the Romberg test on an adult male client. The nurse should instruct the client to

stand erect with arms at the sides and feet together.

An upper motor neuron problem might present with all of the following EXCEPT: a. Spastic weakness b. Flaccid weakness c. No significant muscle atrophy d. No fasciculations e. Hyperreflexia f. Babinski reflex

b -Upper Motor Neuron Defects include any of the following: Spastic weakness No significant muscle atrophy No fasciculations or fibrillations Hyperreflexia Babinski reflex may be present -Lower Motor Neuron Defects include any of the following: Flaccid weakness Significant atrophy Fasciculations and Fibrillations Hyporeflexia No Babinski reflex

Which body functions are related to the hypothalamus? Select all a. withdrawing a hand from a hot stove b. sweating on a hot day c. feeling worried about an exam d. experiencing a regular menstrual cycle e. learning a new dance move

b, c, d The hypothalamus is responsible for regulation of temperature, governing emotions, and secretion of hormones. Withdrawing a hand from a hot stove involves production of sensory impulse; this is the role of the thalamus. Learning a dance move requires coordination of movement; this is the role of the cerebellum.

Which disorders are controlled by the autonomic nervous system? Select all that apply. a. muscle strain b. orthostatic hypotension c. arrhythmia d. gastroparesis (slow stomach emptying) e. hypertension

b, c, d, e Muscle movement is not controlled by the autonomic nervous system. Skeletal muscles are under the control of the somatic nervous system. The somatic nervous system controls the motor and sensory information to and from the central nervous system and is responsible for all voluntary muscle movements as well as processing sensory information.

The nurse performing an admission assessment on an older adult. What would be an expected finding?

decreased vision Decreased vision is part of the aging process and may be a safety concern. Dizziness, delirium, numbness and tingling would not be an expected finding.

Which situation indicates that there is damage to the amygdala? a. An adult cannot say what they are thinking. b. An adult cannot remember what they ate 5 minutes ago. c. A newborn baby has delayed growth despite adequate nutrition and care. d. A child's expression remains the same while the child rides on a roller coaster.

d.

When assessing deep tendon reflexes in an elderly client what finding would the nurse anticipate?

decreased reaction time

CN VII

facial -inspect the face at rest- note asymmetry, often visible in nasolabial folds, and observe any tics or other abnormal movements =flattening of nasolabial fold and drooping of lower eyelid suggests facial weakness =peripheral injury to CN VII (Bell's Palsy) affects both upper and lower face, central lesion affects mainly the lower face. >loss of taste, hyperacusis, and increased/ decreased tearing can also occur in Bell's Palsy -smile, frown, puff out cheeks, raise eyebrows, close eyes tightly against resistance =in unilateral facial paralysis, mouth droops on paralyzed side when patient smiles or grimaces

CN IX and X

glossopharyngeal, vagus -listen to patient's voice- hoarse, nasal? =hoarseness occurs in vocal cord paralysis, nasal voice in paralysis of palate -is there difficulty swallowing =suggests pharyngeal or palatal weakness -ask patient to say ah as you watch movements of soft palate and pharynx -soft palate should rise symmetrically, uvula should remain midline, and each side of posterior pharynx moves medially =palate fails to rise with bilateral lesion of CN X =in unilateral paralysis, one side of the palate fails to rise and, together with the uvula, is pulled toward the normal side

CN XII

hypoglossal -listen to articulation of words -inspect patient's tongue as it lies resting on floor of mouth- look for atrophy or fasiculations =seen with amyotrophic lateral sclerosis and history of polio -with patient's tongue protruded, look for asymmetry, atrophy, or deviation from midline -ask patient to move tongue from side to side and note symmetry of movement =protruded tongue deviates to weak side- away from side of cortical lesion and toward CN XII lesion

A client presents to the health care clinic with a 3-day history of fever, chills, neck pain and stiffness, and headache. The nurse observes an elevated temperature of 102.5°F and pain with rotation of the head side to the side and decreased ability to flex the head forward. The nurse recognizes these findings as most likely the onset of what infectious process?

meningitis Impaired range of motion and neck pain associated with fever, chills, and a headache may be indicative of a serious infection such as meningitis. Arthritis is inflammation or infection within a joint. Spondylitis is an inflammation of the vertebra. Bursitis is an inflammation in the bursa (small sacs) of synovial fluid in the body.

A nurse would like to check a patient's hypoglossal nerve. The nurse will ask the patient to...

move the tongue from side to side The hypoglossal nerve has the motor function of controlling the muscles in the tongue for manipulation of food

CN III, IV, and VI

oculomotor, trochlear, and abducens -test extraocular movements in 6 cardinal directions of gaze =monocular diplopia is seen in issues with glasses or contact lenses, or ocular problems such as cataracts or astigmatism =binocular diplopia occurs in CN III, IV, and VI neuropathy, internuclear ophthalmoplegia, myasthenia gravis, and eye muscle disorders including trauma and thyroid ophtho -identify any nystagmus- involuntary jerking of eyes =seen in cerebellar disease (increases with retinal fixation, may be accompanied by ataxia and dysarthria), vestibular disorders (decreases with retinal fixation), and internuclear ophthalmoplegia -look for ptosis- drooping of eye =seen in CN III palsy, Horner syndrome (ptosis, miosis, forehead anhidrosis), or myasthenia gravis

CN I

olfactory -ask patient to identify odor =defects: sinus conditions, head trauma, smoking, aging, use of cocaine, Parkinson's

CN II

optic -visual acuity- tested with Snellen Chart (distant), with handheld chart (near) -inspect optic fundi with ophthalmascope =bulging/ blurred margins (papilledema), pallor (optic atrophy), cup enlargement (glaucoma) -test visual fields by confrontation- each eye separately =prechiasmal/ anterior defects seen in glaucoma, retinal emboli, optic neuritis =bitemporal hemianopsias from defects at the optic chiasm (usually from pituitary tumor) =homonymous hemianopsias/ quadrantanopsias in postchiasmal lesions usually in occipital, temporal, or parietal lobe w associated findings of stroke

CN II and III

optic, oculomotor -inspect size and shape of pupils =aniscoria- difference of > 0.4 mm in diameter =if the large pupil reacts poorly to light or anisocoria worsens in light, the large pupil has abnormal pupillary constriction, seen in CN III palsy >consider intracranial aneurysm if patient is awake and transtentorial herniation if patient is comatose -check pupillary reactions to light- pupillary constriction (pupillary constrictor muscles), convergence (medial rectus muscles), and accommodation of lens (ciliary muscles) =if anisocoria worsens in darkness, with normal pupillary reaction to light but abnormal pupillary dilation in one eye, this suggests Horner syndrome affecting sympathetic innervation

A 54-year-old man is referred to your hospital with a 5-month history of progressive difficulty in walking and left leg numbness. He first noticed mild gait unsteadiness and, gradually, he later developed right leg weakness. His left leg developed progressive numbness and tingling. His blood pressure is 138/88 mm Hg, heart rate is 72/min and regular, and temperature is 36.7°C (98.2°F). On physical examination, he is alert and oriented x4. The cranial nerves are intact. Muscle strength is 5/5 in the left upper extremity and in the left lower extremity, but 3/5 in the right leg with an increased tone. The plantar reflex is extensor on the right. Pinprick sensation is decreased on the left side below the umbilicus. Vibration and joint position senses are decreased in the right foot and leg. All sensations are normal in the upper extremities. Finger-to-nose and heel-to-shin testing are normal. This patient's lesion is most likely located in which of the following parts of the nervous system?

right hemi-spinal cord The most important clinical features are: -Right leg upper motor neuron weakness (weakness, increased tone, and positive Babinski's sign) -Decreased vibration and joint position sense in the right leg -Decreased pinprick sensation on the left side below the umbilicus Unilateral weakness and upper motor neuron signs (increased tone, weakness, and positive Babinski's sign) in the leg is likely caused by a lesion in the ipsilateral spinal cord. -The associated sensory abnormalities in this case support a right hemi-spinal cord lesion

A client says that an object placed in the hand is a pair of scissors when the object is a paper clip. Which aspect of the client's neurologic system should the nurse identify as being compromised?

sensory

CN V

trigeminal -motor- palpate temporal and masseter muscles while patient clenches teeth =difficulty clenching jaw or moving it to opposite side suggests masseter and lateral pterygoid weakness, respectively =look for unilateral weakness in CN V pontine lesions, bilateral weakness in bilateral hemispheric disease =CNS patterns from stroke include ipsilateral face and body sensory loss from contralateral cortical or thalamic lesions, ipsilateral face, but contralateral body sensory loss in brainstem lesions -sensory- test sensation with dull/ sharp object in 3 divisions of CN V =isolated sensory loss occurs in peripheral nerve disorders, including lesions of trigeminal nerve (CN V)

The patient is having difficulty moving the eyes up and down during a neurological assessment. Which nerve is likely to be involved?

trochlear nerve Controls superior oblique -Responsible for intorsion of the eye and depression of the eye

A lesion in the pons causes cranial nerve deficits (CN V, VI, VII, and VIII) and long tract signs involving the corticospinal tract, spinothalamic, and dorsal column-medial lemniscus system. T/F

true

A nurse is completing a neurological assessment in an adult patient. The plantar reflex is extensor on the left. This is a very important sign that indicates which of the following?

upper motor neuron lesion A positive Babinski reflex is a very important sign that points towards an upper motor neuron lesion.

CN VIII

vestibulocochlear -assess gross hearing with whispered voice test =sensitive and specific test when assessing presence or absence of hearing loss -if hearing loss is present, determine if the loss is conductive (from impaired air through ear transmission) or sensorineural (from damage to cochlear branch of CN VIII) -Weber- lateralization, Rinne- air and bone =excess cerumen, otosclerosis, and otitis media cause conductive hearing loss =presbyacusis from aging is usually from sensorineural hearing loss =disorders that affect the vestibular function of CN VIII may produce nystgmus =vertigo with hearing loss and nystagmus typifies Meniere disesase