Neuro pt1
client w/subdural hematoma become restless and confused, with dilation of ipsilateral pupil. the physical orders mannitol for which of the following reasons?
to promote osmotic diuresis to decrease ICP
the nurse is positioning client w/ increased ICP which of the following positions would the nurse avoid?
turn head to side
for client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication?
using a picture board
nurse is assessing client who is experiencing seizure activity. the nurse understands that it is unnecessary to determine info about which of the following items as part of routine assessment of seizures?
what the client ate in 2hrs preceding seizure activity
which of the following signs and symptoms of increase ICP after head trauma would appear first?
restlessness and confusion
nurse caring for client who begins to experience seizure activity while in bed, which of the following action by nurse could be contraindicated?
restraining clients limbs
nurse is caring for male client who begins to experience seizure activity while in bed. which of the following actions by the nurse would be contraindicated?
restraining the client's limbs
male client having lumbar puncture performed. the nurse would plan to place the client in which position?
side lying w/legs pulled up and head bent down into chest
nurse is assessing child diagnosed w/brain tumor, which of the following s/s would nurse expect child to demonstrate ? select all that apply
A. head tilt B vomiting D lethargy
nurse explains that the neural synapse refers to the
space between the axons of one neuron and the dendrites of the next
when preparing to teach a client about phenytoin sodium(Dilantin) therapy, the nurse should urge the client not to stop the drugs suddenly because?
status epileptics may develop
which of the following should the nurse include in the teaching plan for a client w/seizures who is going home w/ a prescription for gabapentin(Neurontin)?
Notify the physical if vision changes occur
pt w/severe head injury begins to assume a posture of flexed upper extremities w/plantar flexed lower extremities. these assessments indicates?
ICP w/ decorticate posturing
most reliable indicator of neuro status is?
LOC
which of the following will nurse observe in client in the ictal phase of a generalized tonic-clonic seizure?
LOC, body stiffening, and violent muscle contractions
male client having a tonic-clonic seizures. What should the nurse do first?
take measures to prevent injury
pt w/migraine headaches has a seizure. After the seizure which action can you delegate to CNA?
take pts vital signs
pt w/generalized convulsive disorder has a nursing diagnosis of deficient knowledge, related to lack of info about side effects of phenytoin(Dilantin). which goal and outcome criteria would be most appropriate?
absence of GI complaint; take meds w/food
priority nursing diagnosis for pt experiencing migraine headache.
acute pain related to biologic and chemical factors
pt should be left with a ny permanent paralysis. in which of the following regions would it be apt to most severe?
arm
nurse witnesses pt w/seizure disorder as the pt suddenly jerks the arms and legs, falls to the floor and regains consciousness immediately. it will be most important for nurse to?
asses pt for possible head injury
Emt transports 27 yr old iron worker to the ER. he fell from 2 story building. has large contusion on left chest and a hematoma in left parietal area. has compound fracture of his left femur and he's comatose. we intubated him and hes maintaining an arterial o2 sat of 92% by pulse ox w/ manual resuscitation bag. which intervention by the nurse has the highest priority?
assessing LOC
nurse explains that the 3 symptoms characteristic of Cushing triad associated w/ ICP are
bradycardia,HTN and widening pulse pressure
nurse is assigned to care for female client w/complete rt sided hemiparesis. nurse plans care knowing that this condition:
the client has weakness on rt side of body including face and tongue
assessing a pt w/head injury, the nurse recognizes that the earliest indication of ICP is?
changes in LOC
female client who's paralyzed on left side has been receiving physical therapy and attending teaching sessions about safety. which behavior indicates that the client accurately understands safety measures rerated to paralysis?
client uses a mirror to inspect skin
when pt falls to floor in a generalized seizure, the nurse should?
cradle the head to prevent injury
neurologic finding that would be considered abnormal in an 88yrold pt would be?
dizziness and problems w/balance
nurse has completed discharged instructions for client w/applications of a halo device. nurse determines that client needs further clarification of instructions if the client stated to
drive during the daytime
pt in ER states that she fell and hit her head and blacked out for a while but became alert again. Suspecting an epidural hematoma, the nurse will be diligent in the assessment of:
drowziness
client w/nursing diagnosis impaired swallowing related to neuro impairment, the nurse should
elevate the HOB 90 degrees during meals
during immediate minutes of trauma your first goal is to
establish an open airway
in caring for unconscious pt who suffered head injury 10 days ago the nurse positions the pt to prevent limbs from
flexion deformities
problems with memory and learning would relate to which of the following lobes?
frontal
20yr old who hit his head while playing football has tonic clonic seizures. upon awakening from the seizure, the client asks the nurse what caused me to have a seizure? I've never had one before. which cause should the nurse include in the response as a primary cause of tonic clonic seizures in adults older than age 20?
head trauma
nurse positioning female client w/ICP which position would nurse avoid?
head turned to the side
nurse is caring for the client with increased ICP. the nurse would note which of the following trends in vital signs if the ICP is rising?
increased temp, decreased pulse, decreasing resp, increase BP
nursing student is teaching pt and family about epilepsy prior to pts discharge, for which statement should you intervene?
its ok to take over the counter meds
to prevent headache after lumbar puncture, the nurse instructs the pt to
lie flat
pt begin to mutter book pointing at water. behavior indicated
motor aphasia
nurse assessing motor function of unconscious male client. nurse would plan to use which plan to use which of the following to test peripheral response to pain?
nail bed pressure
pt with right sided weakness that started 1 hr ago is admitted to ER and all these are diagnostic tests are ordered. which order should the nurse act on first?
non contrast computed tomography (CT) scan
while cooking, your client couldn't feel the temp of a hot oven. Which lobe could be dysfunctional?
parietal
after striking head on tree while falling from ladder a young man age 18 is admitted to emergency dpt. hes unconscious and his pupils are nonreactive. which intervention would be most dangerous for the client?
perform a lumbar puncture
male clientw/suspected ICP most appropriate resp goal is to?
promote carbon dioxide elimination
priority nursing goal of a pt w/sensory alteration is
providing safe environment
when caring for pt who has head injury which assessment info is of most concern to nurse?
pt is more difficult to arouse
most sensitive indicator of unconscious pt w/head injury is the
pupillary changes