Med surg II exam 2
A patient is suspected of having a brain tumor. The signs and symptoms include memory deficits, visual disturbances, weakness of right upper and lower extremities, and personality changes. The nurse recognizes the tumor is most likely located in the
Frontal lobe
A patients eyes jerk while the patient looks to the left. You all record this finding as
Nystagmus
Information provided by the patient that would helpful differentiate a hemorrhagic stroke from a thrombotic stroke includes
Sudden onset of severe headache
During neurologic testing, the patient is able to perceive pain elicited by pinprick. Based on this finding, the nurse may omit testing for
Temperature perception
Amyotrphic lateral sclerosis teaching
This is a progressive disease that eventually results in permanent paralysis, though you will not lose any cognitive function
Paralysis of lateral gaze indicated a lesion of cranial nerve
VI
Abnormal intracranial pressure, ICP
above 20 mm HG
Bacterial meningitis
acute inflammation of meningeal tissue surrounding brain and spinal cord, fall, winter, and early spring. medical emergency. mortality near 100% if untreated. Steptococcus pneumonia or Neisseria meningitidis
Seizure treatment
anti epileptic drugs, non cure, MOA- stabilizes nerve cell membranes and prevents spread of epileptic discharge
Phenytoin, dilantin
anti seizure agent, one of oldest and most commonly used. lots of side effects, notable toxicity, can do drug level for therapeutic range, pt must be on cardiac monitor during administration- dysrhythmias can occur, only mix in NS, gingival hyperplasia
Valproic acid, depakene
anticonvulsant
Gabapentin, fanatrex
anticonvulsant, mood stabilizer, adjunct for analgesia, for neuro pain, stable for diabetic neuropathies, or shingles pain, increase in CNS depression postop
Complications of increased ICP
change in LOC, change in VS, dilation of pupils, decrease in motor function, headache, vomiting, inadequate cerebral perfusion, cerebral herniation
Complex focal
change or loss of consciousness, dreamlike experience, lip smacking, loss memory during seizure
Parkinsons disease
chronic, progressive neurodegenerative disorder. Triad- tremor, bradykinesia, cogwheel. lack of dopamine
Intracranial pressure
hydrostatic force measured in the brain cerebrospinal fluid compartment. exerted by 3 components within skull- brain tissue, blood, and CSF
Most important modifiable risk factor for stroke
hypertension
Causes of subarachnoid hemorrhage
rupture of cerebral aneurysm, arteriovenous malformation, trauma, or drug abuse, cocaine, meth, sudden emotional distress
Atypical absence
staring spell that often goes unnoticed, can occur up to 100 times a day
Topiramate, topamax
sulfamate, prevention of migraine headaches, freaky hallucigenic side effects
Transient Ischemic attack, TIA
transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction of the brain. symptoms occur within an hour. most resolve. 1/3 progress to ischemic stroke
Nursing management of a patient with a brain tumor includes
Assisting and supporting the family in understanding any changes in behavior. Planning for seizure precautions and teaching the patient and the caregiver about antiseizure drugs
Drugs or diseases that impair the function of the extrapyramidal system may cause a loss of
Automatic movements associated with skeletal muscle activity
A client with cancer is scheduled for a bone scan to determine the presence of metastasis. The nurse evaluates that the teaching before the scheduled bone scan is effective when the client states:
"A substance of low radioactivity will be injected into my vein and my body inspected by an instrument to detect where it is deposited."
Subacute subdural hematoma
2-14 days of the injury, altered mental status
Normal intracranial pressure, ICP
5-15 mm HG
A patient with intracranial pressure monitoring has a pressure of 12 mm HG. The nurse understands this pressure reflects
A normal balance between brain tissue, blood, and cerebrospinal fluid
Assessment of muscle strength of older adults cannot be compared with that of younger adults because
Aging leads to a decrease in muscle bilk and strength
Vasogenic cerebral edema increases intracranial pressure by
Altering the endothelial lining of cerebral capillaries
Recurring headaches. Sharp, stabbing, and located around left eye. Left eye seems to swell and get teary when they occur
Cluster headaches
A result of stimulation of the parasympathetic nervous system is
Constriction of the bronchi, dilation of skin blood vessels, increased secretion of insulin, and relaxation of the urinary sphincters
A nursing measure that is indicated to reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is
Controlling fever with prescribed drugs and cooling techniques
The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the
Degree of collateral circulation
Common psychosocial reactions of the stroke patient to the stroke include
Depression, disassociation, and denial of severity of stroke.
The nurse is alerted to a possible acute subdural hematoma in the patient who
Develops decreased level of consciousness and a headache within 48 hours of a head injury
A nurse completes an admission assessment on a client who is diagnosed with myasthenia gravis. Which clinical finding is the nurse most likely to identify?
Difficulty swallowing saliva
what can you do drug levels on to check therapeutic range?
Dilantin, tegretol, and valproic acid
The nurse is caring for a patient with peripheral neuropathy who is going to have EMG studies tomorrow morning. The nurse should
Instruct the patient that there is no risk of electric shock
An obstruction of the anterior cerebral arteries will affect functions of
Judgement, insight, and reasoning
A patient with right sides hemiplegia and aphasia resulting from a stroke most likely has involvement of the
Left middle cerebral artery
Data regarding mobility, strength, coordination, and activity tolerance are important for the nurse to obtain because
Many neurologic diseases affect one or more of these areas
In a patient with a disease that affects the myelin sheath of nerves, such as multiple sclerosis, the glial cells affected are the
Oligodendrocytes
Angiography test determines the
Patency of the cerebral blood vessels
Cerebral endarterectomy is done to
Prevent a stroke by removing the atherosclerotic plaques blocking cerebral blood flow
Just diagnosed with parkinsons disease. Priority nursing intervention is
Promoting physical exercise and a well-balanced diet
BATS
berry aneurysm, arteriovenous malformation disease, adult polycystic kidney, trauma, stroke
Subdural hematoma
bleeding between dura mater and arachnoid, from veins, usually asymptomatic, higher incidence of death
Epidural
bleeding between the dura and inner surface of the skull caused by trauma, neurological emergency
Focal seizure
caused by focal irritations, unilateral manifestations, arise from localized brain involvement
A client has had a carotid endarterectomy. To monitor for the complication of cranial nerve dysfunction, the nurse assesses the client for:
difficulty swallowing
Carbudopa, Levodopa
dopamine antagonist, parkinsons disease, relief of tremor and rigidity, side effect impulse control disorder
Embolic stroke
embolus lodges in and occludes a cerebral artery, resulting in infarction and edema of the area supplied by the involved vessel. commonly rapid occurrence of severe clinical symptoms
FAST
face- asymmetry, arms- left side neglect, speech- slurred/strange, time- call 911, TPA <3hrs ischemic stroke
A client is admitted with paresis of the ciliary muscles of the left eye. What function should the nurse expect to be affected?
focusing the lens on near objects
Thrombotic stroke
from injury to blood vessel wall and formation of a blood clot. lumen of blood vessel becomes narrowed and it is becomes occluded infarction occurs. large % asymptomatic
What can cause an increase in ICP?
head trauma, stroke, subarachnoid hemorrhage, brain tumor, inflammation, hydrocephalus, or brain tissue damage from other cause. cerebral edema
Multiple sclerosis
heterogenous with variable clinical features. demyelination, chronic inflammation, gliosis, scarring in CNS, damage to myelin sheath of neurons in the brain and spinal cord,
3% normal saline
hypertonic solution, osmotic effect used to combat cerebral edema, can control ICP, staple in neurosurgical ICUs, go to for severe cerebral edema, give slowly, monitor, check labs often, osmosis- draw fluid back into vasculature from brain tissue
Ischemic stroke
inadequate blood flow to the brain from partial or complete occlusion of an artery. 80% of all strokes. Thrombotic and embolic
When performing a neurological check on a client with a head injury, the nurse identifies a diminished corneal reflex in the left eye. Appropriate nursing care for a client with an absent corneal reflex includes:
instilling artificial tears frequently
Subarachnoid Hemorrhage, SAH
internal bleeding into cerebral spinal fluid space, surface of brain, caused by rupture of cerebral aneurysm
Stroke
interruption of blood flow into the brain from ischemia or hemorrhage that results in death of brain cells. Blood supplied to brain by internal carotid arteries and the vertebral arteries
Subarachnoid hemorrhage SAH
intracranial bleeding into the cerebrospinal fluid-filled space between the arachnoid and pia mater membranes on the surface of the brain. silent killer.
Generalized seizures
involve both sides of the brain and are characterized by bilateral synchronous epileptic discharges in the brain, no warning or aura
Chushings triad, increased intracranial pressure
irregular respirations, systolic hypertension with widened pulse pressure, and bradycardia
A nurse is assessing a client with Parkinson disease. Which assessment finding indicates the presence of bradykinesia?
lack of spontaneous movement
Increase in intracranial pressure
life-threatening, diminished CPP, increases risk of brain ischemia and infarction, associated with poor prognosis
Tonic clonic seizures
loss of consciousness, stiffness- tonic 10-20 sec, subsequent jerking- clonic 30-40 sec, dilated pupils, hyperventilation, apnea, cyanosis, tongue or cheek biting
Tension
most common, bilateral, pressing and tightening, stress, headband, mild/moderate intensity. treatment- aspirin, acetaminophen, or NSAID alone or with sedative, muscle relaxant, or tranquilizer
Mannitol, Osmiltrol
osmotic diuretic, renal failure, edema, ICP, toxic overdose, emergency drug for acute herniation, monitor serum osmolarity levels, crystallization- big problem. ICP patients, must be given with a filter
An older adult who was in a motor vehicle collision is brought to the emergency department via ambulance. The client exhibits a decreased level of consciousness, and the nurse identifies serosanguinous drainage from the client's left ear. What should the nurse do?
place a sterile pad over the external ear
General manifestations of seizures
proximal, uncontrolled electrical discharge of neurons in the brain that interrupts normal function, often symptoms of an underlying illness
Cluster
rare, sharp or stabbing pain, repeatedly for weeks to months, periods of remission. treatment- drug therapy not as useful, prophylactic drugs
Migraine
recurring, unilateral or bilateral throbbing pain, triggering event or factor, neurologic and autonomic nervous system dysfunction. treatment- anaglesics, triptans, and preventative treatment
Simple focal
remains unconscious with unusual feelings and sensations
Hemorrhagic stroke
result from bleeding into the brain tissue itself or into the subarachnoid space or ventricles
Absence, mal petit
usually occurs only in children, precipitated by flashing lights and hyperventilation, daydreaming face, altered consciousness
Gold standard for monitoring ICP
ventriculostomy. specialized catheter inserted into right lateral ventricle and coupled to an external transducer
Intracerebral hemorrhage
bleeding within the brain caused by a rupture of a vessel. sudden onset of symptoms with progression over mins to hours
number one cause of CVA
hypertension
The nurse is performing a neurological assessment on a client and is completing the Glasgow Coma Scale (GCS). What components make up this assessment tool? Select all that apply
verbal, motor, and eye opening
Chronic subdural hematoma
weeks to months after injury
Vagal nerve stimulants
when surgery not feasible, exact mechanism unknown, thought to interrupt the synchronization of epileptic brain wave activity and excessive discharge of neurons
Acute subdural hematoma
within 24-48 hours of injury, immediate deteriotation, cerebral edema,
epidural
arterial
Bacterial meningitis diagnosis
blood culture, CT scan, X rays of skull, MRI, verified by lumbar puncture and analysis of CSF
Atherosclerosis
hardening and thickening of the arteries, major cause of ischemic stroke. can lead to thrombus formation and contribute to emboli
Imetrex, Sumatriptan
migraine and cluster headache. staple for migraine treatment. teach pt to not run out, could save from ER trip
subdural
venous
Tergetol, carbamazepine
anticonvulsant, tonic clonic, more common
Levetiracem, Keppra
anticonvulstant, tonic-clonic, complex partial, mixed seizures, common
Glasgow coma scale
assessing degree of impaired consciousness and cranial nerve assessment, pupil evaluation, and motor sensory testing
A client who sustained a severe head injury remains unconscious. During the client's assessment, the nurse observes bleeding from the left ear and rhinorrhea. The nurse concludes that drainage from the ear and nose indicates a:
basilar fracture