68C Phase II Exam 16 Review
Sit upright and check blood pressure
A patient with a spinal cord injury at T1 complains of stuffiness of the nose and a headache. The nurse notes a flushing of the neck and "goose flesh." What should be the primary nursing intervention based on these assessments?
areflexia
A period of flaccid paralysis following a cord injury is called ___________________, or spinal shock, and may be temporary.
herniation
A supratentorial shift can result in __________.
Cushing response
A widened pulse pressure, increased systolic blood pressure, and bradycardia are together called _________________________________. It is considered an important diagnostic sign of late-stage brain herniation.
nystagmus
Involuntary rhythmic movement of the eyes, with oscillations that may be horizontal, vertical, or mixed movements, is called ___________________
decreased reflexes
Physiological changes in the nervous system in regards to age include decreased ability to regulate body temperature, decreased blood supply to the spinal cord resulting in _________ ________.
viral
The most common causes of meningitis are meningococccus, pneumococcos, streptococcus, staphylococcus, hemophilius influenza, and ____________ agents
patient teaching aimed at decreasing painful stimuli and enhancing proper positioning/improved function
The most important nursing intervention with neurological pain is?
Place the neck in a neutral position (not flexed or extended) to promote venous drainage.
The newly admitted patient to the emergency room 30 minutes ago after a fall off a ladder has gradually decreased in consciousness and has slowly reacting pupils, a widening pulse pressure, and verbal responses that are slow and unintelligible. What is the most appropriate position for the patient?
Hypotension
The nurse assures an anxious family member of a 92-year-old patient, who is demonstrating signs of dementia, that many causes of dementia are reversible and preventable. What is one example?
high-fiber
The nurse caring for a patient with neurological pain should offer prune juice and a ____-_____ diet and encourage up to 2000ml a day or more of fluids.
gas
The nurse explains that a pneumatic retinopexy is a repair of a retinal detachment using a bubble of_________ to put pressure on the damaged retina.
shuffle with arms flexed.
The nurse is aware that the characteristic gait of the person with Parkinson disease is a propulsive gait, which causes the patient to:
40
The nurse is aware that the patient has 20/40 vision. This means that the patient can see at 20 feet what the normal eye can see at _______ feet.
As individual scores in each category
The nurse is aware that when assessing a patient by the FOUR score coma scale, the patient is assessed in four categories: eye response, brainstem reflexes, motor response, and respiration. How are these results reported?
feed self with setup and adaptive equipment.
The nurse is caring for a home health patient who had a spinal cord injury at C5 three years ago. The nurse bases the plan of care on the knowledge that the patient will be able to:
louder in his affected ear.
The nurse takes into consideration that the Weber test indicated a conductive hearing loss in a patient because the patient reported hearing the tone:
The nurse would need to determine how this patient's visual impairment affects normal functioning.
The patient tells the nurse that he is legally blind. How would this information impact the nurse's plan of care for this patient?
Parkinson disease
The patient with ________________________________ can improve the activity level by sleeping on a firm mattress without a pillow to prevent spinal curvature, hold hands clasped behind to keep better balance, and keep the arms from hanging stiffly at the side. Walk with a lifting of the feet to avoid tripping and "freezing."
feeding
The patient with dyaphagia often requires prefeeding and ________ exercises.
myringotomy
The surgical incision into the eardrum with either a knife or a heated wire loop to relieve pressure in the middle ear is a(n) ___________.
myelin
The waxy substance that covers the neuron fibers and increases the rate of transmission of impulses is the ________.
Parkinson's
Tremor, rigidity, and bradykinesia are the triad that make up the signs of __________________ disease.
Comatose
Unable to respond to painful stimuli ; cornea and Papillary reflexes are absent
CN VIII Acoustic/Vestibulocochlear
What Cranial Nerve conducts impulses from ear to brain providing the function of hearing and equilibrium?
CN V Trigeminal Nerve
What Cranial Nerve conducts impulses from skin & mucous membranes of the head to the brain, teeth to brain, and from brain to chewing muscles providing the function of sensations of the face, scalp, teeth, and chewing movements?
CN VII Facial Nerve
What Cranial Nerve conducts impulses from taste buds of the tongue to brain and brain to facial muscles providing the function of sense of taste (anterior 2/3rds) and contraction of facial muscles for expression?
CN IV Trochlear Nerve
What Cranial Nerve conducts impulses from the brain to external eye muscles providing the function of down and inward movement of the eyes?
CN I Olfactory Nerve
What Cranial Nerve conducts impulses from the nose to brain providing the function of sense of smell?
12
What Glasgow Coma Scale rating would a patient receive who opens the eyes spontaneously, but has incomprehensible speech and obeys commands for movement?
Computerized devices that guide the surgeon
What are surgical navigational systems?
Lipofuscin, Decrease in oxygen use, Reduction of cerebral blood flow, Loss of neurons
What are the effects of normal aging on the nervous system?
Increased systolic blood pressure; Bradycardia; Widened pulse pressure
What are the three signs of Cushing response?
Can understand the spoken word, but cannot speak
What does the nurse know about the stroke patient who has expressive aphasia?
Overaccentuating words
What is a common mistake that hinders communication when communicating with the hearing impaired?
an extreme hyperextension neck and arching of the back
What is opisthotonos?
hiccup
What is singultus?
Memory loss that disrupts daily life
What is the basic problem that prompts most of the early signs of Alzheimer disease?
Decrease in the level of consciousness
What is the cardinal sign of increased intracranial pressure in a brain injured patient?
Vagus nerve
What is the cranial nerve that supplies most of the organs in the thoracic and abdominal cavities and also carries motor fibers to glands that produce digestive juices and other secretions?
Inability to wrinkle forehead and pucker lips on affected side
What is the first sign of Bell's palsy?
herpes simplex virus and the Eastern and Venezuelan equine virus
What is the highest mortality for encephalitis caused by?
Fund of knowledge
What is the nurse assessing when asking the patient, "Who is the president of the United States?" during a level of consciousness assessment?
Signs and symptoms may not occur until several days after the trauma
What is the nurse aware of when assessing a person with a craniocerebral injury?
Restart drugs at a lower dosage with favorable results
What is the purpose of a "drug holiday" in the treatment of Parkinson disease?
Attention, Wakefulness, Concentration, & Introspection
What is the reticular activating system (RAS) essential to?
Avoid alcoholic beverages
What should the nurse advise the 20-year-old to do who has been put on cefaclor (Ceclor) for a resistant otitis media?
Place the child in respiratory isolation
What should the nurse do when the child arrives on the floor with the diagnosis of bacterial meningitis?
Checking the affected side of mouth for food accumulation; Offering small bites of food; Adding a thickening agent to liquids
What techniques are necessary for safely feeding a hemiplegic patient?
Leave the bed flat; Medicate immediately on the complaint of nausea; position with the operated side facing up; patient is not turned; dressing is not changed by the nurse
What would a nurse do when the patient arrives in the PACU after a left stapedectomy?
until the pathogen can no longer be cultured from the nasopharynx, this is usually accomplished after 24 hours of effective antibiotic therapy
When a patient is diagnosed with meningitis, how long should they be placed in respiratory isolation?
pain on one side of the head usually around or behind one eye
Where is the pain felt with cluster headaches?
"Can you describe the sensations you are having?"
Which question is likely to elicit the most valid response from the patient who is being interviewed about a neurologic problem?
They are preceded by an aura
Which symptom is specific to migraine headaches?
Promotes nerve impulse transmission
Why are the drugs neostigmine (Prostigmin) and pyridostigmine (Mestinon) helpful to the person with myasthenia gravis?
Eustachian tubes in children are shorter and straighter.
Why is otitis media found more frequently in children 6 to 36 months?
The disease can rapidly progress into respiratory failure
Why is the patient with suspected Guillain-Barre Syndrome (GBS) hospitalized immediately?
memory loss
With Alzheimer's disease ______ ____ is the classic symptom is confined at first to recent events.
impairment reduces
With MS, sensory __________ _______ sensation of discomfort.
affected
With motor function disturbance, paralysis may be seen, the _______ side should be protected.
a CT scan takes 20-30 minutes if done without contrast medium
Your patient needs official diagnosis for meningitis and has been ordered for a CT scan, when the patient asks how long it will take, what is your answer?
Doll's Eyes
_____ ____ test is a test for brain stem damage in a comatose patient.
Postmyelogram
_______________________ care includes the assessment to ensure there is no leakage of CSF, sensation and strength of the lower extremities, or headache. To avoid a headache, the patient should be flat for a few hours
Disorientation
disoriented; unable to follow simple commands; Thinking slowed; inattentive, flat affect
Apraxia
impairment in the ability to perform purposeful Acts or to use objects properly
Agnosia
total or partial loss of the ability to recognize Familiar objects or people through sensory stimuli
Ipsilateral
when the lesion is in one hemisphere
Obtain an allergy history before the test
A patient, age 45, is to have a myelogram to confirm the presence of a herniated intervertebral disk. Which nursing action should be planned with respect to this diagnostic test?
Parkinson's
A slowing down in the initiation and execution of movement (bradykinesia) is known as __________, increased muscle tone, tremor and impaired postural reflexes.
CN XI Spinal Accessory Nerve
What Cranial Nerve conducts impulses from the brain to certain shoulder and neck muscle providing the function of shoulder movements (trapezius) and turning movements of head (sternocleidomastoid)?
CN VI Abducens Nerve
What Cranial Nerve conducts impulses from the brain to external eye muscles providing the function of outward movement of the eyes?
CN III Oculomotor Nerve
What Cranial Nerve conducts impulses from the brain to eye muscles providing the function of eye movements, extraoccular muscles, and pupillary control (contraction)?
CN XII Hypoglossal Nerve
What Cranial Nerve conducts impulses from the brain to muscles of tongue providing the function of tongue movements?
CN II Optic Nerve
What Cranial Nerve conducts impulses from the eye to brain providing the function of vision?
CN IX Glossopharyngeal Nerve
What Cranial Nerve conducts impulses from throat and taste buds of tongue to brain and from brain to throat muscles & salivary glands providing the function of sensations of throat, taste (posterior 1/3rd), swallowing movements, gag reflexes, & secretion of saliva?
CN X Vegas Nerve
What Cranial Nerve conducts impulses from throat, larynx, and organs in thoracic and ABD cavities to brain and from brain to muscles of the throat and to organs in thoracic and ABD cavities providing the function of sensations of throat, larynx, thoracic and ABD organs, swallowing, voice production, slowing of HR and acceleration of peristalsis?
Onset is gradual and insidious: Mild tremor, slight limp, decreased arm swing, change in handwriting
What are initial onset clinical manifestation of Parkinson's?
Later stages show Shuffling, propulsive gait with arms flexed Loss of postural reflexes. Slight change in speech patterns
What are later signs of Parkinson's?
Disorientation, Restlessness, and lethargy (Change in LOC)
What are often the first signs of increased intracranial pressure (IICP)?
Central and the peripheral
What are the two divisions of the nervous system?
early signs and symptoms of a developing condition or disease
What does prodromal mean?
known as aching of the head
What is cephalalagia?
inflammation of the brain and or spinal cord (central nervous system) characterized by pathological changes in the gray and white matter with nerve cell destruction
What is encephalitis?
involuntary, rhythmic movements of the eye
What is nystagmus?
Patient positioning on side with knee and head flexed
What is the position a patient must be in if they will be having a lumbar puncture performed?
because it can stimulate contractions of the uterine smooth muscle
Why should ergot preparations be avoided with pregnant women?
Alzheimer's
____________ disease is a degenerative disorder that affects the cells of the brain and causes impaired intellectual functioning.
Ataxic
_____________ breathing is an irregular, and unpredictable breathing pattern with random, shallow and deep breaths and occasional pauses.
Neurotransmitters
_________________ is/are responsible for the transmission of impulses between
Cushing's Triad
a widening pulse pressure (increased systolic), irregular breathing, and bradycardia
Aphasia
an abnormal neurological condition where in which the language function is defective or absent
Great Lakes
Multiple Sclerosis can affect those in prevalent it temperate climates in areas such as the ____ ____, the Pacific Northwest and the North Atlantic states.
central pain tract
Neurological pain may arise from lesions involving the peripheral cutaneous nerves, the sensory nerve roots, the thalamus and the _______ ____ _____ at some level.
Nerve Block
Non-surgical pain control for neurological pain includes: TENS, spinal cord stimulation, acupuncture, _____ _____, medications and counseling.
30-45
Nursing management for IICP include elevate HOB __-__ degrees, prevent hyperextension, flexion or rotation of the head, avoid flexion of the hips, wrists and neck, limit suctioning and avoid valsalva.
lasix
Osmotic diuretic used for IICP is mannitol and may also include loop diuretics such as _____, bumex and edecrin.
pruritis
Pain receptors can be activated by cellular damage, certain chemicals such as histamine, heat, ischemia, muscle spasms and sensations of cold and _____________ that go beyond a specific level of intensity.
year
Patients with MS often have remission that may last for a ____ or more.
Lie immobile and hold the head in one position until the vertigo lessens.
How should the nurse advise a patient who has severe vertigo from labyrinthitis?
Agnosia
How would a nurse record the behavior when a patient with Alzheimer disease attempts to eat using a napkin rather than a fork?
To walk with hands clasped behind back to help balance
How would the nurse instruct a patient with Parkinson disease to improve activity level?
Schwann
IN GBS, the antibodies attack the _______ cells, causing the sheath to break down, a process called demyelination.
subdural hematoma
If a patient who has been conscious for several days after head injury loses consciousness or develops neurologic signs and symptoms, a ___________________________________ should be suspected.
acyclovir due to fewer side effects
If encephalitis is caused by HSV, what is the preferred medical management?
neurological eamination
Since there is no diagnostic test for Parkinson's, diagnosis is made solely on the history, a thorough ___________ _____ and clinical features.
plasmapheresis
Medical management for GBS depends on the signs and symptoms, it has been found that therapeutic ______________ leads to decreased severity and length of symptoms.
valium, dantrium
Medications used for the spasticity with MS are ______, ________ and lioresal.
myelogram
A ___________ is a diagnostic procedure used to identify lesions by observing the flow of radiopaque dye through the subarachnoid space of the spinal cord.
louder
A conductive hearing loss can be diagnosed by the Weber test. A person with a conductive loss will hear the noise _______________ in his affected ear.
Postictal period
A family member of a patient who has just suffered a tonic-clonic seizure is concerned about the patient's deep sleep. What is this behavior called?
It is possibly a temporary condition and will clear.
A frantic family member is distressed about the flaccid paralysis of her son following a spinal cord injury several hours ago. What does the nurse know about this condition?
Tuck chin when swallowing
A patient has recently suffered a stroke with left-sided weakness and has problems with choking, especially when drinking thin liquids. What nursing interventions would be most helpful in assisting this patient to swallow safely?
Second Stage
A patient is in which stage of Alzheimer disease when she demonstrates "sundowning"?
migraine headaches
A patient who suffers from ________________________ should avoid vinegar, chocolate, yogurt, alcohol, fermented or marinated foods, ripened cheese, cured sandwich meat, caffeine, and pork because they may cause or worsen symptoms.
autonomic dysreflexia
A patient with a spinal cord injury at T1 complains of stuffiness of the nose and a headache. The nurse notes a flushing of the neck and "goose flesh." These are indicators of ____________________________________________________ or hyperreflexia. It is a medical emergency. The patient should be placed in an upright position to decrease blood pressure and the blood pressure should be checked. Assessments for impaction, full bladder, or a urine infection can help to evaluate this condition.
Proprioception
As the result of a stroke, a patient has difficulty discerning the position of his body without looking at it. In the nurse's documentation, which would best describe the patient's inability to assess spatial position of his body?
velocity
As the person ages, normal age-related changes occur such as loss of neurons, reduction of cerebral blood flow, appearance of lipofuscin, a decrease in oxygen use and brain metabolism, and a decline in ____________ of nerve impulses.
proprioception
Alteration is sensory or perceptual function can cause a loss, decrease or increase in sensation of pain, temperature, touch, ___________________and agnosia.
from the left side.
An 83-year-old patient has had a stroke. He is right-handed and has a history of hypertension and "little" strokes. He presents with right hemiplegia. To afford him the best visual field, the nurse should approach him:
entropion
An entropion is the abnormal turning in of the eyelid, causing irritation and tearing of the eye.
ticks and mosquitos/ as a complication of measles, chicken pox or mumps
How is epidemic encephalitis transmitted? What can nonepidemic encephalitis be complications of?
atenolol
Beta blockers used for vascular headache suppressants are propranolol, timolol and _____________.
meningitis
Brudzuski's sign is seen with __________ and is the inability to extend the leg when the thigh is flexed on the abdomen with extreme pain.
cerebrovascular
Causes of Parkinson's include possible genetic link, encephalitis lethargica or type A encephalitis, intoxication with a variety of chemicals, drug-induced parkinsonism, patients with _______________ disease often have parkinsonism-like symptoms.
CSF
Causes of increased intracranial pressure are: space occupying lesions (tumors), trauma, excess _________, and cerebral edema.
motor function disturbane
Cerebral palsy is an example of _____ ________ __________.
papilledema
Choked disk is also known as ___________.
Muscle Weakness
Classic signs of GBS include ______ ________, tingling and numbness, which begin in the legs or feet and work their way upward.
2-10
Cluster headaches last 30-minutes to 2 hours with the occurring in clusters with __ to __ headaches per day.
CT Scan
Diagnostic procedures for a client suspected of having a brain abscess would include: WBC, MRI, x-rays, CSF, and _____________
Brain Absces
Direct extension from the ear, tooth, mastoid or sinus infection are primary causes for _____ ________.
bromocriptine mesylate (Parlodel), levodopa (Larodopa, Dopar), tolcapone (Tasmar), phenytoin (Dilantin), amantadine (Symmetrel).
Drugs used in the treatment of Parkinson's disease include?
Prevent
Ergotamine tartrate preparations should be taken early in the attack may _______________ progression of the headache.
sensation in lower extremities.
Following a myelogram the nurse should include in the postprocedure care assessment for:
Hearing will not return until edema subsides
Four hours after a stapedectomy the patient complains that hearing has not improved at all. What knowledge would the nurse use to shape a response?
acute inflammatory polyradiculopathy
Guillain-barre' syndrome is AKA ________________ __________________ ___________________ or postinfectious polyneuritis
vascular, tension and traction-inflammatory
Headaches are classified in 3 categories, what are they?
widening pulse pressures
Late signs of IICP include a rise in Systolic pressure and an unchanged diastolic pressure, resulting in a ________ _____ ________, bradycardia and irregular respiration and indicate that the brain is about to herniate.
headaches
MSG, tyramine, nitrates, glutamate, vinegar, chocolate, yogurt, alcohol, fermented of marinated foods, ripened cheese, cured sandwich meat, caffeine and pork are foods that may cause or worsen _________________.
Folic Acid
Research shows that the simple addition to a normal diet of large doses of _____ _____ and vitamin B will substantially reduce homocysteine levels in AD.
Alert
Responds appropriately to auditory, tactile and Visual stimuli
acute migraine
Selective serotonin receptor agonists are indicated to treat ______________________ (with or without aura) in adults. These medications include medications such as axert, frova, amerge, maxalt, imitrex and zoming.
malnutrition
Some forms of dementia are reversible. Dementia caused by hypotension, anemia, drug toxicity, metabolic disturbance, and _______________ can all be corrected to abolish the dementia.
neurectomy
Surgical methods of pain control for neurological pain include __________, rhizotomy, cordotomy and percutaneous cordotomy.
tumors
Surgical navigational systems are computerized devices that guide the surgeon and make possible the resection of ________________ that were once thought to be inoperable.
False
T or F Normal changes in the nervous system are the same as senility, organic brain disease or Alzheimer's.
False
T or F Pain is common with MS.
True
T or F The incidence of bacterial meningitis is higher in fall and winter when upper respiratory tract infections are common.
True
T or F The skull and brain tissues are not able to feel sensory pain, pain arises from the scalp, its blood vessels and muscles, and from the dura mater and its venous sinuses.
fixed position
Tension headaches develop in response to: emotional stress, eyestrain, maintaining a ______ ________.
reticular activating system (RAS)
The ___________________________, located on the brainstem, is essential to wakefulness, attention, concentration, and introspection.
propulsive gait
The ______________________________ causes the patient to shuffle with his arms flexed and with a loss of postural reflexes.
neurons
The effects of aging on the nervous system are variable. The changes include a loss of brain weight and a substantial loss of _______________, with the cortex loosing cells faster than the brainstem.
entropion
The home health patient complains of tearing and a feeling of dryness in the right eye. The nurse assesses that the eyelid is turned inward and the sclera is red. The nurse documents the presence of a(n)_________________.
Semi-comatose
is in impaired state of consciousness, characterized by obtundation and stupor
Aneurysm
localized dilation of the wall of a blood vessel Usually caused by atherosclerosis and HTN
Supratentorial shift
pressure is exerted on surrounding structures Where the pressure is lower
Stupor
responds to verbal commands with moaning or Groaning, if at all
Gently wipe nose with absorbent gauze
The newly admitted patient to the emergency room after a motorcycle accident has serosanguineous drainage coming from the nose. What is the most appropriate nursing response to this assessment?
3
The nurse is aware that the drug t-PA (Activase), a tissue plasminogen activator, must be given in____hours of the onset of symptoms to have maximum benefit.
Parkinson's
Tremor- pill rolling motion is seen with ___________ where the thumb and forefinger appear to move in a rotary fashion.
mensuration
Triggering factors associated with severe and recurring headaches may include fatigue, alcohol, stress, seasonal climate changes, hunger , allergies and ___________________.
