Neuro Review
Persistent vegetative state
devoid of cognitive function but has sleep-wake cycles
A client is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the client in preparation for this test?
"You will need to lie still throughout the procedure."
Nursing Process: The Care of the Patient With Altered Level of Consciousness—Planning
1.Maintenance of clear airway 2.Protection from injury 3.Attainment of fluid volume balance 4.Maintenance of skin integrity 5.Absence of corneal irritation 6.Effective thermoregulation 7.Accurate perception of environmental stimuli 8.Maintenance of intact family or support system 9.Absence of complications
Collaborative Problems and Potential Complications
1.Respiratory distress or failure 2.Pneumonia 3.Aspiration 4.Pressure ulcer 5.Deep vein thrombosis (DVT) 6.Contractures
A neurologic nurse is reviewing seizures with a group of staff nurses. How should this nurse best describe the cause of a seizure?
A dysrhythmia in the nerve cells in one section of the brain
A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school?
Absence seizure
While completing a health history on a client who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state?
Confusion
A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the ED. The nurse should gauge the client's LOC on the results of what diagnostic tool?
Glasgow Coma scale
A client is having a "fight or flight response" after receiving bad news about his prognosis. What affect will this have on the client's sympathetic nervous system?
Increase in the secretion of sweat
A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?
Loosen the client's restrictive clothing
The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?
Maintaining a patent airway
A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-related changes that may influence the assessment results. Of what phenomenon should the nurse be aware?
Reduction in cerebral blood flow
A client scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize what action?
Removing all metal-containing objects
Locked-in syndrome
inability to move or respond except for eye movements due to a lesion affecting the pons
LOC is a continuum from
normal alertness and full cognition (consciousness) to coma
Altered LOC is
not the disorder but the result of a pathology
Level of responsiveness and consciousness is
the most important indicator of the patient's condition
Coma
unconsciousness, unarousable unresponsiveness
Akinetic mutism
unresponsiveness to the environment, makes no movementor sound but sometimes opens eyes
An elderly client is being discharged home. The client lives alone and has atrophy of his olfactory organs. The nurse tells the client's family that it is essential that the client have what installed in the home?
A smoke detector
The nurse is caring for a client whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this client?
Assessing the client's verbal response