Neuro/Muscle-Skeletal Exam 4

Tonic-Clonic Seizures (Grand Mal Seizures) Recovery Phase

-On their side -Prevent aspiration if vomiting

A nurse is caring for a 2-year-old child who has seizures and is receiving phenytoin in suspension form. Which of the following actions should the nurse take before administering each dose?

Shake the container vigorously

Teaching for myasthenia gravis

Slowing down with meals/Smaller bites/Extra chewing

A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed?

Supplements via nasogastric tube

Prednisone MS meds

Given when MS pt is having flair up or exacerbation to calm nerve endings if the client is getting weaker and weaker the MS is progressing. No good :(

A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching?

I'll be glad when I can stop taking this medication

Cervical spine C1, C2, C3

If severed pt will die instantly In accident Stabilize the neck

A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client's plan of care?

Obtain IV access

Cranial Nerve VII facial

facial nerve

A nurse is assessing a client that has parkinson's disease. Which of the following manifestations should the nurse expect?

Bradykinesia

Surgical procedure for traumatic brain injury

Burr holes- drill holes in skull to release pressure. If mannitol npt working

Ischemic Stroke Assessment

"Does anyone know when the Sx started" Internal bleeding and shock -Hypotension, increased HR, Increased RR.

Guillain-Barre syndrome

-Autoimmune disease -Typically seen around swine flu usually asked if you have GB before flu shot. -Mentally aware until last breath -End up on ventilator

A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review?

-Avoid overwhelming fatigue -Remove caffeinated products from the diet -Limit looking at flashing lights

A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.)

-Provide a suction setup at the bedside is correct. -Elevate the side rails near the head when the client is in bed is correct. -Place the bed in the lowest position is correct. -Keep an oxygen setup at the bedside is correct.

ALS lifespan

2 to 6 years 10 yr mark w/c bound Will eventually pass away Make sure patient has all legal items completed (nurse is looking out for people pt will leave behind)

A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed selegiline, an MAOI. Which of the following foods should the nurse eliminate?

A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed selegiline, an MAOI. Which of the following foods should the nurse eliminate?

Nurse interventions in traumatic brain injury (concussion)

Give pt IV mannitol while intubated this is a specific neuro diuretic If seeing urine - 1st sign its working will be uptake in urine

A nurse is caring for a child who is having a seizure. Which of the actions should the nurse take (Select all that Apply)

Assess the client's airway patency. Remove objects from the client's bed. Place the client in a side-lying position.

1st Priority with Cervical Spine Injury

C-Collar over paten airway

Internal Pressure from concussion

Central line probe that measures the cerebral spinal pressure. This is the only way to know.

A nurse is caring for a client who ingested a poison and is now experiencing a seizure. Which of the following is the priority action the nurse should take?

Check the patency of the client's airway.

Meningitis Sx

Contagious - Droplet precautions Main Sx: Neck stiffness, not able to rotate neck, painful, N/V, fever

Thoracic Spinal Nerves T1-T12

Controls upper body Assessment: GI function Bowel Bladder

Meds for MS

Corticosteroids - Cause insulin production Increase in blood glucose.

A nurse is teaching a client who is taking benztropine to treat Parkinson's disease. The nurse should instruct the client to report which of the following adverse effects?

Difficulty voiding

A nurse is teaching a client who has multiple sclerosis about a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching?

Do not take antihistamines with this medication

Lumbar Puncture (spinal tap) MS diagnostic test

Draws CSF from subarachnoid space between two lumbar vertebrae.

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?

Encourage the client to take small bites

Traumatic Brain Injury (Concussion)

Eyes- Pupil check for swelling on brain Does not mean brain death or brain damage

Meningitis 3 types

Fungal Viral Bacterial

Ischemic Stroke Diagnostic

Head CT with contrast

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate?

Implement a schedule to include periods of rest

Myasthenia Gravis Assessment

Important is ASPIRATION Pt is fatigued/Swallowing problems/Chewing problems

A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

Inability to recognize family members

Parkinson's Nursing interventions

Keep head of bed at 30 degrees all the time. MAKE SURE TO LET PT DO AS MUCH AS THEY CAN ON THEIR OWN.

A nurse is providing teaching to a client who has a new diagnosis of Parkinson's disease. On which of the following medications should the nurse prepare to instruct the client?

Levodopa/Carbidopa

Meningitis Procedure

Lumbar Puncture CSF from spine between columns Nurse walks down directly Tx: Broad septum of antibiotic and steroids May be antiviral or antifungal

A nurse is caring for a client who has a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

Manifestations preceded by severe headache.

A nurse is teaching the family of a client who has a new diagnosis of epilepsy about the actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?

Move object away from client.

Alzheimer's Sx

No cure, but tx Difficulty solving 1+1= Progressively damaging neuro disease process

Glascow Coma Scale Performed for

Performed for individuals coming out of a coma For individual under general anesthesia for long period of time *Higher the number the better

A nurse is caring for a client who has AD and falls frequently. WHich of the following actions should the nurse take first to keep the client safe?

Place client in a room close to the nurse's station

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

Place the client on his side

MRI Scan (brain Scan) MS diagnostic test

Plaque in brain = MS

Seizure Interventions

Possible lobe resection Only if seizure coming from one part of lobe

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?

Provide client supervision

Tonic-Clonic Seizures (Grand Mal Seizures) Postical Phase

Pt could wake up swinging

A nurse is developing a plan of care for the nutritional needs of a client who has stage IV Parkinson's disease. Which of the following actions should the nurse include?

Record diet and intake Offer cold fluids such as milkshakes Offer nutritional supplements between meals

A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?

Remind the client to look for food on the left side of the tray.

ALS meds

Riluzole: only med approved, disease modifying Has properties to slow ALS progression, but DOES NOT cure it or stop it.

Viral Meningitis

Self-limiting Found in freshmen dorms Meds given for full recovery

Seizure Meds

Valium/Ativan - Immediate intervention given during seizure phase. Relaxes muscles & helps eliminate the seizures. Tegretol - Limits production of WBC'S RISK FOR INFECTION! Depakote - LIVER DAMAGE Phenytoin - Hyplasia (Increase in # of cells in organ or tissue *Teach pt early liver S/Sx - Gen aching, Gen RUQ pain.

C-Spine Clearance test

X-ray

EMG (electromyography) MS diagnostic test

a measurement technique that records the electrical activity of a muscle or group of muscles.

A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level?

a self report pain rating scale.

Ischemic Stroke

a stroke where the blood loss is caused by a blockage or clot.

Bacterial Meningitis

most common form of suppurative CNS infection

Cranial XII (Hypoglossal)

muscles of the tongue

Hemorrhagic stroke

occurs when a blood vessel in the brain leaks or ruptures; also known as a brain bleed.

A nurse is making a home visit to a client who has AD. The client's partner states the client is often disoriented to time and place, is unsteady, and has a Hx of wandering. Which of the following safety measures should the nurse review with the partner. (Select all that apply)

remove rugs provide increased lighting in stairwell install handrails in the bedroom

Absent Seizures consist of.

-Adolescents or school-aged children. -Sitting with blank stare -Keto (Atkins) diet used for those w/ absent seizures -HARD ON KIDNEYS (Kidney Function)

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?

-Loosen restictive clothing -Place a pillow underneath client's head

Tonic-Clonic Seizures (Grand Mal Seizures) Aura Phase

-Patient knows about to have seizure -10 sec - Several minutes -Do not touch patient unless it's safety aspect & medically -necessary. -PUT ON FLOOR

Multiple Sclerosis(MS) S/Sx Assessments

1) Bladder retention and constipation GI/GU "Are you urinating and having a BM" if yes = Tx working

Gullian-barre syndrome Assessments

ALL ABOUT RESPIRATORY!

Plasmapheresis (plasma exchange)

Abnormal Igg bands = MS

Neuro Consists of

Brain Function Spinal Cord Peripheral Nervous system

Ischemic stroke Intervention

Can give TPA (Massive clot buster) ONLY IF ONSET WAS WITHIN 4.5 HOURS. PAY ATTENTION TO VITAL SIGNS

Hemorragic stroke Assessment

Cranial nerves VII and XII Facial and Hypoglossal nerves Smile = Facial droop VII (7) Stick out tongue = Deviation XII (8)

Fungal meningitis

Deadly (AIDS Patients) Spreads rapidly Immunosupressed

A nurse is caring for a client who has Parkinson's disease and is taking diphenhydramine 25 mg PO TID. Which of the following therapeutic outcomes should the nurse expect to see?

Decreased temors

Amyotrophic Lateral Sclerosis (ALS) (Lou Gehrig's Disease)

Degenerative disorder with lack of motor neurons in the spinal cord and brain stem. Rare progressive neuro disease.