neuro ?s
Which of the following is the earliest sign of increasing ICP? a) Posturing b) Vomiting c) Change in level of consciousness d) Headache
Change in level of consciousness Correct Explanation: The earliest sign of increasing ICP is a change in LOC. Other manifestations of increasing ICP are vomiting, headache, and posturing.
The ED nurse is receiving a patient-handoff report at the beginning of the nursing shift. The departing nurse notes a patient with a head injury has Battle's sign. The nurse will expect which of the following clinical manifestation? a) An area of bruising over the mastoid bone b) Escape of CSF from the patient's nose c) Escape of cerebrospinal fluid (CSF) from the patient's ear d) A blood stain surrounded by a yellowish stain on the head dressing
An area of bruising over the mastoid bone Explanation: Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign). Basilar skull fractures are suspected when CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea). Drainage of CSF is a serious problem, because meningeal infection can occur if organisms gain access to the cranial contents via the nose, ear, or sinus through a tear in the dura. A blood stain surrounded by a yellowish stain on the head dressing is referred to as a halo sign and is highly suggestive of a CSF leak.
A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the medical treatment to include which of the following? a) Monthly prothrombin levels b) Anticoagulant therapy c) Cholesterol-lowering drugs d) Carotid endarterectomy
Anticoagulant therapy Explanation: Anticoagulant or antiplatelet therapy can prevent clot formation associated with cardiac dysrhythmias such as atrial fibrillation. Cholesterol-lowering drugs can be ordered if indicated to manage atherosclerosis. Prothrombin and international normalized ratio (INR) levels may be ordered to monitor therapeutic effects of anticoagulant therapy. Carotid endarterectomy would be anticipated only when the carotids have narrowing from plaque
The nurse is aware that burr holes may be used in neurosurgical procedures. Which of the following is a reason why a neurosurgeon may choose to create a burr hole in a patient? a) To assess visual acuity b) Visualization of a hemorrhage c) Aspiration of a brain abscess d) Access for intravenous (IV) fluid
Aspiration of a brain abscess Correct Explanation: Burr holes may be used in neurosurgical procedures to make a bone flap in the skull, to aspirate a brain abscess, or to evacuate a hematoma.
An unresponsive patient is brought to the ED by a family member. The family states, "We don't know what happened." Which of the following is the priority nursing intervention? a) Assess for a patent airway. b) Assess vital signs. c) Assess pupils. d) Assess Glasgow Coma Scale.
Assess for a patent airway. Correct Explanation: A patient with altered LOC may be unable to protect his or her airway and therefore the priority nursing intervention should be to assess for a patent airway. The nurse should assess pupils, vital signs, and Glasgow Coma Scale, but only after ensuring the patient has a patent airway.
For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? a) To increase cerebral perfusion pressure b) So that the patient will not have a respiratory arrest c) Because hypoxemia can create or worsen a neurologic deficit of the spinal cord d) To prevent secondary brain injury
Because hypoxemia can create or worsen a neurologic deficit of the spinal cord Correct Explanation: Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2), because hypoxemia can create or worsen a neurologic deficit of the spinal cord.
A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode? a) Recent weight gain and loss b) Recent stress level c) Compliance with the prescribed medication regimen d) The type of anticonvulsant prescribed to manage the epileptic condition
Compliance with the prescribed medication regimen Correct Explanation: The most common cause of status epilepticus is sudden withdraw of anticonvulsant therapy. The type of medication prescribed, the client's stress level, and weight change don't contribute to this condition.
Which of the following types of posturing is exhibited by abnormal flexion of the upper extremities and plantar flexion of the feet? a) Flaccid b) Normal c) Decerebrate d) Decorticate
Decorticate Explanation: Decorticate posturing is an abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities, internal rotation of the lower extremities, and plantar flexion of the feet. Decerebration is an abnormal body posture associated with a severe brain injury, characterized by extreme extension of the upper extremities and plantar flexion of the feet. Flaccidity occurs when the patient has no motor function, is limp, and lacks motor tone.
A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? a) Administer morning dose of anticonvulsant. b) Complete a head-to-toe assessment. c) Elevate the head of the bed. d) Administer Percocet as ordered.
Elevate the head of the bed. Correct Explanation: The first action would be to elevate the head of the bed to promote venous drainage of blood and CSF. Then, a neurological assessment would be completed to determine if any other assessment findings are significant of increasing ICP. The administering of routine ordered drugs is not a priority, and narcotic analgesics would be avoided in clients with ICP issues
A nurse is caring for a client with deteriorating neurologic status. The nurse is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate? a) Weak muscular tone b) Flaccidity c) Decorticate posturing d) Abnormal posture
Flaccidity Correct Explanation: The nurse would document flaccidity when the client makes no motor response to stimuli. Abnormal posturing and weak motor tone would be documented specifically as the nurse would assess. Decorticate posturing is when a client is stiff with bent arms and clenched fists with legs straight out
Which of the following cerebral lobes is the largest and controls abstract thought? a) Parietal b) Temporal c) Frontal d) Occipital
Frontal Correct Explanation: The frontal lobe also controls information storage or memory and motor function. The temporal lobe contains the auditory receptive area. The parietal lobe contains the primary sensory cortex, which analyzes sensory information and relays interpretation to the thalamus and other cortical areas. The occipital lobe is responsible for visual interpretation.
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? a) Prone b) Semi-Fowler's c) Supine d) High-Fowler's
Semi-Fowler's Correct Explanation: The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.
The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring? a) Infection b) Exacerbation of uncontrolled hypertension c) Increased ICP d) Increase in cerebral perfusion pressure
Increased ICP Correct Explanation: Increased ICP and bleeding are life threatening to the patient who has undergone intracranial surgery. An increase in blood pressure and decrease in pulse with respiratory failure may indicate increased ICP. (less)
A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following nursing diagnoses would be the first priority for the plan of care? a) Risk of injury related to decreased LOC b) Risk for impaired skin integrity related to prolonged immobility c) Deficient fluid volume related to inability to take fluids by mouth d) Ineffective airway clearance related to altered LOC
Ineffective airway clearance related to altered LOC Explanation: The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.
A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? a) 9 b) 6 c) 3 d) 12
LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response (Barlow, 2012). The patient's responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive (see Chapter 68). (less)
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? a) Bradycardia b) Lethargy and stupor c) Hypertension d) A bounding pulse
Lethargy and stupor Correct Explanation: As ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli. At this stage, serious impairment of brain circulation is probably taking place, and immediate intervention is required
Which of the following cranial nerves is responsible for muscles that move the eye and lid? a) Oculomotor b) Facial c) Trigeminal d) Vestibulocochlear
Oculomotor Correct Explanation: The oculomotor (III) cranial nerve is also responsible for pupillary constriction and lens accommodation. The trigeminal (V) cranial nerve is responsible for facial sensation, corneal reflex, and mastication. The vestibulocochlear (VII) cranial nerve is responsible for hearing and equilibrium. The facial (VII) nerve is responsible for salivation, tearing, taste, and sensation in the ear.
The nurse is caring for a patient with dysphagia. Which of the following interventions would be contraindicated while caring for this patient? a) Allowing ample time to eat b) Testing the gag reflex prior to offering food or fluids c) Assisting the patient with meals d) Placing food on the affected side of mouth
Placing food on the affected side of mouth Explanation: Interventions for dysphagia include placing food on the unaffected side of the mouth, allowing ample time to eat, assisting the patient with meals, and testing the patient's gag reflex prior to offering food or fluids.
The nurse is performing a neurologic assessment and requests that the patient stand with eyes open and then closed for 20 seconds to assess balance. What type of test is the nurse performing? a) Watch-tick test b) Rinne test c) Romberg test d) Weber test
Romberg test Explanation: The Romberg test is a neurologic assessment of the patient's balance in which the patient is instructed to stand with eyes open and then closed for 20 seconds. The Weber (including the watch-tick) and Rinne tests assess hearing
The nurse is caring for a client who is to have a lumbar puncture. What are the lowest vertebrae that contain the spinal cord? a) Eleventh thoracic vertebrae b) Fifth lumbar vertebrae c) Second lumbar vertebrae d) Coccyx
Second lumbar vertebrae Explanation: The spinal cord ends between the first and second lumbar vertebrae.
The nurse is caring for a patient immediately following a spinal cord injury (SCI). Which of the following is an acute complication of spinal cord injury? a) Spinal shock b) Tetraplegia c) Paraplegia d) Cardiogenic shock
Spinal shock Correct Explanation: Acute complications of SCI include spinal and neurogenic shock and deep-vein thrombosis (DVT). The spinal shock associated with SCI reflects a sudden depression of reflex activity in the spinal cord (areflexia) below the level of injury. Cardiogenic shock is not associated with SCI. Tetraplegia is paralysis of all extremities after a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of spinal cord injury.
After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an: a) assessment of the client's gait. b) evaluation of the corneal reflex response. c) evaluation of bowel and bladder functions. d) examination of the fundus of the eye.
evaluation of the corneal reflex response. Correct Explanation: During an acute crisis, the nurse should check the corneal reflex response to rapidly assess brain stem function. Other components of the brief initial neurologic assessment usually include level of consciousness, pupillary response, and motor response in the arms and legs. If appropriate and if time permits, the nurse also may assess sensory responses of the arms and legs. Emergency assessment doesn't include fundus examination unless the client has sustained direct eye trauma. The client shouldn't be moved unnecessarily until the extent of injuries is known, making gait evaluation impossible. Bowel and bladder functions aren't vital, so the nurse should delay their assessment.
Choice Multiple question - Select all answer choices that apply. The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply. a) Unequal pupils b) Pupil reacts to light c) Pinpoint pupils d) Absence of pupillary response e) Pupil reaction quick
• Unequal pupils • Pinpoint pupils • Absence of pupillary response Explanation: Normal assessment findings includes that the pupils are equal and reactive to light. Pupils that are unequal, pinpoint in nature, or fail to respond indicate a neurologic impairment. (l
A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician? a) A small amount of yellow drainage at the left pin insertion site b) Pain at the insertion site c) Crust around the pin insertion site d) A slight reddening of the skin surrounding the insertion site
A small amount of yellow drainage at the left pin insertion site Correct Explanation: The nurse should report the presence of yellow drainage, which indicates the presence of infection, at the left pin insertion site. Crust formation around the pin site is a natural response to the trauma caused by the pin insertion. Redness at the insertion site may be an early sign of infection; the nurse should continue to monitor the area, but this finding doesn't need to be reported to the physician. The client may experience pain at the pin insertion sites; therefore, the nurse should administer pain medications as ordered. It's necessary to notify the physician only if the pain medication is ineffective.
The client with hemiplegia is at risk for impaired walking. Which nursing intervention would best assist this client in preventing complications associated with lower extremity impairment? a) Use of walker for ambulation b) Use of high-top tennis shoes throughout the day c) Occupational therapy daily d) Whirlpool tub baths and massage therapy
Correct response: Use of high-top tennis shoes throughout the day Explanation: Hemiplegic clients are at risk for the development of plantar flexion, which would impede ambulation. High-top tennis shoes act as splints, providing support to the ankle/foot, and prevent plantar flexion contractures by maintaining the extremity in proper anatomic position. Occupational therapy is an important factor in rehabilitation after a stroke but not significant in preventing complications with walking. Whirlpool tub baths and massage therapy are soothing and assist in reducing muscle tension but not significant in prevention of walking impairment. The client must have strength in both upper extremities to be able to use a walker safely
Which of the following are sympathetic effects of the nervous system? a) Dilated pupils b) Decreased blood pressure c) Decreased respiratory rate d) Increased peristalsis
Dilated pupils Correct Explanation: Dilated pupils are a sympathetic effect of the nervous system. Constricted pupils are a parasympathetic effect. Decreased blood pressure is a parasympathetic effect. Increased blood pressure is a sympathetic effect. Increased peristalsis is a parasympathetic effect. Decreased peristalsis is a sympathetic effect. Decreased respiratory rate is a parasympathetic effect. Increased respiratory rate is a sympathetic effect
The nursing instructor is teaching the senior nursing class about neuromuscular disorders. When talking about Multiple Sclerosis (MS) what diagnostic finding would the instructor list as being confirmatory of a diagnosis of MS? a) Episodes of muscle fasciculations b) Oligoclonal bands c) IV administration of edrophonium d) An elevated acetylcholine receptor antibody titer
Oligoclonal bands Explanation: Electrophoresis of the CSF, a technique for electrically separating and identifying proteins, demonstrates abnormal immunoglobulin G bands, described as oligoclonal bands. An elevated acetylcholine receptor antibody titer and IV administration of edrophonium are diagnostic of Mysthenia Gravis. Episodes of muscle fasciculations are characteristic of ALS.
A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following? a) "The blood provides moisture at the site, which encourages healing." b) "The blood will replace the cerebral spinal fluid that has leaked out." c) "The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid." d) "The blood can repair damage to the spinal cord that occurred with the procedure."
The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid." Explanation: Loss of CSF causes the headache. Occasionally, if the headache persists, the epidural blood patch technique may be used. Blood is withdrawn from the antecubital vein and injected into the site of the previous puncture. The rationale is that the blood will act as a plug to seal the hole in the dura and preven further loss of CSF. The blood is not put into the subarachnoid space. The needle is inserted below the level of the spinal cord, which prevents damage to the cord. It is not a lack of moisture that prevents healing; it is more related to the size of the needle used for the puncture