neuro

Which Glasgow Coma Scale score is indicative of a severe head injury?

7 A score between 3 and 8 is generally accepted as indicating a severe head injury.

The nurse reviews the physician's emergency department progress notes for the client who sustained a head injury and sees that the physician observed the Battle sign. The nurse knows that the physician observed which clinical manifestation?

An area of bruising over the mastoid bone Explanation: Battle sign may indicate a skull fracture. A bloodstain surrounded by a yellowish stain on the head dressing is referred to as a halo sign and is highly suggestive of a cerebrospinal fluid (CSF) leak. Escape of CSF from the client's ear is termed otorrhea. Escape of CSF from the client's nose is termed rhinorrhea.

Which nursing intervention is appropriate for a client with double vision in the right eye due to MS?

Apply an eye patch to the right eye. Explanation: An eye patch to the affected eye would help the client with double vision see more clearly, thus promoting safety. Exercises for the eye would not benefit the client. Eye drops may be needed for dryness to prevent corneal abrasion but would not have any benefit for a client with double vision. Needed items should be placed on the unaffected (left) side

he nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes which measure to assist the client in reducing the pain associated with the headache?

Apply warm or cool cloths to the forehead or back of the neck

The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop?

Damage to the optic nerve Explanation: Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing. Sequelae to meningitis do not include damage to the vagal nerve, the olfactory nerve or the facial nerve.

While performing an initial nursing assessment on a client admitted with suspected tic douloureux (trigeminal neuralgia), for which of the following would the nurse expect to observe?

Facial pain in the areas of the fifth cranial nerve

A male client who has undergone a cervical discectomy is being discharged with a cervical collar. Which of the following would be most appropriate to include the client's discharge plan?

Keeping the head in a neutral position Explanation: After a cervical discectomy, the client typically wears a cervical collar. The client should be instructed to keep his head in a neutral position and wear the collar at all times unless the physician has instructed otherwise. The front part of the collar is removed for shaving and the neck should be kept still while the collar is open or off.

The nurse is performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome. On which of the following areas will the nurse focus most heavily?

Respiratory Explanation: Because of its possible rapid progression and neuromuscular respiratory failure, Guillain-Barre syndrome is a medical emergency. After baseline values are identified, assessment of changes in muscle strength and respiratory function alert the team to the physical and respiratory needs of the client. The other three choices may become problem areas later, but respiratory issues are always a priority.

What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?

Tinnitus and sensorineural hearing loss

A client has just returned from surgery after undergoing a lumbar laminectomy. Which of the following would be most important to do when positioning the client in bed?

Using a logrolling motion to change positions Explanation: After a laminectomy, logrolling is used to change the client's position. When in bed, a pillow is placed under the client's head and the knee rest is elevated slightly to relax the back muscles. When lying on his or her side, extreme knee flexion is avoided. Sitting is discouraged except for defecation.

High doses of which medication can produce bilateral tinnitus?

aspirin

halo sign

blood stain surrounded by a yellowish stain; highly suggestive of a cerebrospinal fluid leak

Which type of hematoma is evidenced by a momentary loss of consciousness at the time of injury, followed by an interval of apparent recovery (lucid interval)?

epidural

The nurse is providing discharge teaching to a client with a spinal cord tumor and instructs the client to avoid hot water bottles and heating blankets for what reason?

impaired sensory perception

A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following?

monro-kellie

When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women?

osteoporosis

A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements?

"A secondary headache is associated with an organic cause, such as a brain tumor." Explanation: A secondary headache is a symptom associated with an organic cause, such as a brain tumor or an aneurysm. A primary headache is one for which no organic cause can be identified. These types include migraine, tension, and cluster headaches. Secondary headaches can be located in all areas of the head.

A client has undergone surgery for a spinal cord tumor that was located in the cervical area. The nurse would be especially alert for which of the following?

respiratory dysfunction

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?

shivering Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption. A capillary refill of 2 seconds, urine output of 100mL/hr, and cool, dry skin are expected findings.

A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient?

uggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Explanation: After the sensitivity of the nerve to touch decreases and the patient can tolerate touching the face, the nurse can suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Facial exercises, such as wrinkling the forehead, blowing out the cheeks, and whistling, may be performed with the aid of a mirror to prevent muscle atrophy. Exposure of the face to cold and drafts is avoided

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client

vomits Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in a client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty in waking the client should be reported or treated immediately.