Neuro Level 2 EAQ

Damage to Upper Motor Neurons

A Babinski response (dorsiflexion of the first toe and fanning of the other toes) is a reaction to stroking the lateral sole of the foot with a blunt object; it is indicative of damage to the corticospinal tract when seen in adults. Hyperreflexia , Increased muscle tone (spasticity)

Facial Nerve Damage

A nurse is assessing a client whose mouth is drawn over to the left. The nurse should consider damage to which cranial nerve to be the most likely explanation for this clinical finding? Left facial nerve The facial nerve (seventh cranial) has motor and sensory functions. The motor function is concerned with facial movement, including smiling and pursing the lips. Nonconduction of the trigeminal nerve (5) will cause problems in mastication.

Arthritis: Prevent deformities

Exercise of involved joints is important to maintain optimal mobility and prevent buildup of calcium deposits. Functional alignment places the least strain on joints, muscles, and tendons.

Early Sign of ICP and Late Signs

Lethargy is an early sign of a changing level of consciousness; it is one of the first signs of increased intracranial pressure. Nausea is a subjective symptom, not a sign, that may be present with increased intracranial pressure. Sunset eyes are a late sign of increased intracranial pressure that occurs in children with hydrocephalus. Hyperthermia is a late sign of increased intracranial pressure that occurs as compression of the brainstem increases.

Increased ICP

Low PCO2 benefit the client because it reduces intracranial pressure by preventing cerebral vasodilation; Usual S/S restlessness, confusion and lethargy, pupillary and oculomotor dysfunction, hemiparesis or hemiplegia of the contralateral side, projectile vomiting without nausea, increased systolic pressure, widening pulse pressure and bradycardia, and altered breathing pattern.

trigeminal neuralgia (tic douloureux)

Severe, constant pain, emotional stress, muscle tensing, and diminished nutritional intake can lead to exhaustion and fatigue. The movements associated with chewing and swallowing may precipitate a painful attack. The afferent sensory branch of the trigeminal nerve (cranial nerve V) innervates the cornea.

Steroid Therapy for MS

Steroids decrease the inflammatory process around the optic nerve, thus improving vision; visual impairment is the most common physiological manifestation of multiple sclerosis. Steroids are associated with increased emotional lability.

Best indicator of Acceptance

The best indicator of acceptance is when the client begins to participate in self-care.

Myasthenic Crisis and Cholinergic Crisis

The client in cholinergic crisis usually is overmedicated with an anticholinesterase medication that intends to reduce excessive cholinergic activity in the brain (prevents the decrease of Ach by the enzyme ChE). Muscle weakness, Respiratory distress and Difficulty swallowing occurs with both myasthenic and cholinergic crises.

Total Hip Arthroplasty

Using a pillow to keep the legs abducted ensures abduction of the leg to maintain position of the prosthesis and avoid dislocation.

Mobility- Cane Walking

i.e. residual hemiparesis. To help achieve the goal of safe walking with a cane, the nurse should teach the client to: Advance the cane and the affected extremity simultaneously Advancing the cane and the affected extremity simultaneously supports stability. The body is supported partially on the affected limb and partially on the cane as the unaffected limb moves forward.

A client is admitted to the emergency department with head trauma resulting from an accident. The client opens both eyes and withdraws appropriately, but has no verbal response to the stimulus. Using the Glasgow Coma Scale, the nurse determines the client's score is:

7

Tractions Bucks, Skeletal, Halter, and Balance

Buck's extension is an example of traction applied directly to the skin (cutaneous) by tape or by a foam boot. (i.e: fracture of the head of the femur. The health care provider places the client in Buck's extension. What explanation does the nurse give the client for why the traction is being used? Reduces muscle spasms) Buck's extension is used to reduce the fracture, align the bone, and temporarily reduce muscle spasm. Skeletal traction is applied directly to the bony skeleton. A halter (strap) may be used with cervical or pelvic traction. Balanced suspension traction keeps the affected extremity elevated off the bed.

Meals for Osteoporosis

Chicken Breast and Boiled Beef Steak

Fat Embolism r/to hip and femur fracture

Confusion is an early sign

Dry Age Related to Macular Degeneration

Dry age-related macular degeneration. Which ocular symptom should the nurse expect the client to report? Loss of central vision The main characteristic of dry age-related macular degeneration is loss of central vision, which is gradual. Primary closed-angle glaucoma causes pain. Blurred vision may be caused by a refractive error.

Which assessment finding supports the nurse's conclusion that a prosthesis for a client with an above-the-knee amputation fits correctly?

Evenly darkened skin, hemosiderin (iron-rich pigment) in the tissue in response to pressure of the prosthesis indicates a proper fit.

Common sign with Radiation Therapy

Fatigue is a major problem caused by an increase in waste products because of catabolic processes.

Receives a prosthesis: think of the PT Functionality, affects emotion

Improved functioning relates best to improved body image, even if the prosthesis is not at all like the original body part. Slight improvement in self-image occurs with a "normal" look, but a "normal" look usually occurs only when the prosthesis is covered by clothing.

Cranial Nerve Eye Lids Facial.

Lesions that affect the seventh cranial (facial) nerve cause paralysis of eyelids. The oculomotor (nerve 3) nerve is concerned with pupillary constriction and eye movements; lesions result in ptosis, strabismus, and diplopia. The trochlear (nerve 4) nerve is concerned with eye movements; lesions result in diplopia, strabismus, and head tilt to the affected side. The optic (nerve 2) nerve is concerned with vision; lesions result in visual field defects and loss of visual acuity.

Alzheimers Disease Clinical Manifest Loss of recent memory Perceptual Disturbance Difficulty learning something new

Neurofibrillary tangles attack the hippocampus, which impairs recent memory. As dementia progresses sensory-perceptual alterations occur, such as hallucinations. Alzheimer disease is associated with a global intellectual impairment that affects learning, thinking, and language. Progressive deterioration of the temporoparietal regions of the brain result in cognitive deficits, such as a decreased, not focused, attention span. Clients with Alzheimer disease are easily confused or disorientated. They require familiar routines that provide a sense of security.

Range of Motion Definitions Opposition (thumb to tip of other fingers) Eversion (turn sole of foot in and out) Supination (forarm palm up and down) Circumduction (distal circle)

Opposition occurs when the thumb, a saddle joint, sequentially touches the tip of each finger of the same hand; the thumb joint movements involved are abduction, rotation, and flexion. Strengthening the thumb facilitates grasping and holding objects in the hand. Eversion involves turning the sole of the foot outward by moving the ankle joint, which is a gliding joint. Supination involves moving the bones of the forearm so that the palm of the hand faces upward when held in front of the body. Circumduction involves movement of the distal part of the bone in a circle while the proximal end remains fixed; circumduction is used with ball-and-socket joints, such as the shoulder and hip.

left total hip replacement

Protect affected hip by sitting in a firm armchair, the left foot should be flat on the floor's surface

A teenager is brought to the emergency department exhibiting slurring speech, a slight right-sided facial droop, and an inability to close the right eyelid. Bell's palsy is diagnosed. List the following concerns in priority order for this client. 1. Risk for malnutrition because of facial droop Incorrect 2. Chance of falls because of altered vision 3. Low self-esteem because of appearance 4. Risk for dental caries because of retained food particles 5. Difficulty communicating because of slurred speech

Self-esteem is a primary concern of adolescents, who are experiencing the developmental stage of identity versus role confusion. Paralysis of one side of the face affects the ability to speak clearly; communication is essential, particularly with peers. Paralysis of one side of the face affects the ability to chew; nutrition is a basic need. Food particles tend to be retained on the affected side of the oral cavity because of impaired mastication. Oral hygiene helps prevent this occurrence. Falling should not be a problem; the client is capable of seeing clearly with the unaffected eye. (3, 1, 4, 5, 2)

chronic osteomyelitis: infection of the bone should remain at bed rest.

The infected bone is placed at rest and may be in a cast or splint to reduce pain and limit motion, which promotes spread of the infection. Frequent range-of-motion exercises will increase pain and promote spread of the infection. Osteomyelitis usually is caused by a microorganism traveling through the bloodstream to the bone, not the reverse; the client is already septic. Early ambulation may facilitate the spread of the infection.

Meniere Syndrome Labyrinthectomy affects? no pain involved, no serum (wax)

The labyrinth is the inner ear and consists of the vestibule, cochlea, semicircular canals, utricle, saccule, cochlear duct, and membranous semicircular canals. A labyrinthectomy is performed to alleviate the symptom of vertigo but results in deafness, because the organ of Corti and cochlear nerve are located in the inner ear. Permanent Irreversible Deafness

Glasgow Coma Scale Measures:

The scale measures best motor response (6). The scale measures best verbal response (5). The scale measures eye opening response (4).

Drainage Qty based on procedure (expected versus unexpected)

Two portable drainage catheters with hemovacs attached for a hemiglossectomy and right radical neck dissection. Six hours after the catheters were placed, the nurse empties 180 mL of serosanguineous drainage from one of the drainage catheters. The priority nursing intervention is to: Notify the health care provider immediately Serosanguineous drainage of 80 to 120 mL is expected during the first 24 hours; more than this amount of drainage should be reported. Drainage of 180 mL in six hours is excessive and should be reported.

total hip arthroplasty with an uncemented prosthesis

Weight-bearing on the operative side may be permitted for those with an uncemented prosthesis. Full weight-bearing usually is permitted before this time. Partial weight-bearing beginning the day after surgery may be true for cemented, not uncemented, prostheses.