Neurological Exam
the nurse is caring for a patient with myasthenia gravis. the patient asks the nurse about the causes of the disease. which response by the nurse is correct?
" antibodies attacking the acetylcholine receptors, damaging then, and reducing their number is the most likely cause of myasthenia gravis"
when teaching a patient with Parkinson's disease which response would indicate the need for further education?
" if I miss an occasional does of the medication, it doesn't matter much"
the client has just undergone computed tomography (CT) scanning with a contrast medium. Which statement by the client demonstrates an understanding pf post procedure care?
"I should drink extra for the remainder of the day"
Phenytoin, 100 mg orally three times daily, has been prescribed for a client for seizure control. The nurse reinforces instructions regarding the medication to the client. Which statement by the client indicates an understanding of the instructions?
"I will use a soft toothbrush to brush my teeth"
a patient is admitted to the hospital with a diagnosis of transient ischemic attack. the patient asks the nurse to explain to him what a TIA is. which statement by the nurse is most accurate?
"a TIA is often a precursor to a stroke"
a patient experiencing TIAs is scheduled for a carotid endarterectomy. the patient asks the nurse what this procedure is. the nurse correctly responds with which response?
"this procedure provides a circulatory bypass around thrombotic plaques obstructing cranial circulation"
a 70 year old with back pain is scheduled to have a myelogram on the morning to rule out a pathologic condition of the spine. in preparing him for the procedure, what statement by the nurse is accurate?
"we will ask you if you have any numbness or tingling in your legs after the procedure"
a 76 year old who has had parkinson's disease for the past 6 years has now been admitted to a long term care facility. the nurse doing the admission interview and assessment notices which characteristics sign the disease? select all that apply
1. bradykinesia 4. tremor 5. rigidity
a 35-year old patient is being seen for complaints of headache, which she has experienced for the past month. her health provider wants to rule out a brain tumor. what diagnostic tests will be most helpful in formulating this diagnosis? select all that apply
1. brain scan 2. PET scan 3. lumbar puncture 4. electroencephalogram 5. MRI
a patient was involved in a snowmobile accident. on admission to the emergency department, he is receiving oxygen and is intubated. his Glasgow coma scale score is 6. about 10 minutes after arrival, he is noted to have a widened pulse pressure, increased systolic blood pressure, and bradycardia. which finding indicates to the nurse that late stage increased ICP is present? select all that apply
1. deepening respirations 3. Cushing's response
a nurse in the emergency department of her community hospital is teaching a group of high school students how to prevent head and spine injuries. what should the nurse include in the presentation? select all that apply
1. helmets for bicycles, motorcycles, and skateboarding 2. use helmets when participating in contact sports. 3. never drive or ride with someone under the influence of alcohol or drugs 4. wear seatbelts and shoulder harness when driving or riding in a car
which s/s of late stage increased intracranial pressure would the LVN be aware of? select all that apply
1. increase in systolic blood pressure 2. widening of pulse pressure 3. bradycardia
The client is taking phenytoin for seizure control, and a blood sample for a serum drug level is drawn. which laboratory finding indicates a therapeutic serum drug result?
15 mcg/ml
The client is receiving meperidine hydrochloride for pain. which s/s are side and adverse effects of this medication? select all that apply
2. tremors 3. drowsiness 4. hypotension
a patient who has been experiencing recent seizure activity is preparing to have diagnostic testing performed. the health care provider a graphic recording of the electrical conduction activities of the brain. the patient understands that which test will be performed?
EEG
when caring for a patient who has undergone a craniotomy, what is the primary nursing intervention?
Preventing increased intracranial pressure
The client with spinal cord injury is prone to experiencing autonomic dysreflexia, The least appropriate measure to minimize the risk of autonomic dysreflexia is which action?
limiting bladder catheterization to once every 12 hours
The client is admitted to the hospital for observation with a probable minor head injury after automobile crash. The nurse expects the cervical collar will remain in place until which time?
the primary health care provider reviews the x ray results
which plan of care is considered beneficial for select patients who have experienced an ischemic stroke?
thrombolytic such as tPA in the first 3 hours
The client with myasthenia graves becomes increasingly weak. the primary health care provider prepares to identify whether the client is reacting to an overdose of the medication or increasing severity of the disease. an injection of edrophonium is administered. which change in condition indicates that the client is in cholinergic crisis?
a temporary worsening of the condition
The client with myasthenia graves is receiving pyridostigmine. the nurse monitors for s/s of cholinergic crisis caused by overdose of the medication. the nurse check the medication supply to ensure that which medication is available for administration if a cholinergic crisis occurs?
atropine sulfate
the nurse is caring for a patient with a spinal cord injury who displays symptoms of autonomic dysreflexia. what intervention should the nurse implement first?
check for bladder distention
The client with cervical spine injury has crutch field tongs applied in the emergency department. The nurse should perform which essential action when caring for this client?
comparing the amount of prescribed weights with the amount in use
a Patient has been diagnosed with bell's palsy. this condition affects which cranial nerve?
cranial nerve VII
The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understand measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?
exhaling during repositioning
The nurse is caring for a client who has undergone craniotomy with a supratentorial incision. The nurse should plan to place the client in the position postoperatively?
head of bed elevated 30 to 45 degrees, head and neck midline
The nurse observes the unlicensed assistive personnel positioning the client with increased intracranial pressure. Which position would require intervention by the nurse?
head turned to the side
The client with myasthenia graves is suspected of having cholingeric crisis. which s/s indicates this crisis is taking place?
hypertension
Carbidopa/Levodopa is prescribed for a client with Parkinson's disease, and the nurse monitors the client for adverse effects of the medication. which s/s indicates the client is experiencing an adverse effect?
impaired voluntary movements
The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising?
increasing temperature, decreasing pulse, decreasing respirations, increasing BP
a 12 year old has a history of generalized tonic-clonic seizures. the nurse educates the patient and his family by including which teaching points?
it is not uncommon to lose consciousness during this type of seizure
a 13 year old student is admitted to the pediatric unit with possible meningitis. the nurse finds that the patient cannot extends her legs completely without experiencing extreme pain. the nurse correctly documents this as which sign?
kernig' sign
a right handed patient has right sided hemiplegia and aphasia from a stroke. what is the most likely location of the lesion?
left frontal lobe
the nursing care plan for a patient with increased intracranial pressure will include what as the most therapeutic position for the patient?
maintain the head of the bed at 30 degrees
The client was seen and treated in the emergency department for a concussion. Before discharge, the nurse explains the s/s of a worsening condition. The nurse determines that the family needs further teaching if they will return to the ED if the client experiences which s/s?
minor headache
During admission of a patient with a severe head injury to the emergency department the nurse places the highest priority on assessment for
patent of airway
when reviewing the medical plan of treatment for a patient with Guillian-Barre syndrome, which therapies are considered to be most therapeutic?
plasmapheresis and intravenous immune globulin
The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, which immediate action should the nurse take?
raise the head of the bed and remove the noxious stimulus
The nurse is caring for a client who is taking phenytoin for control of seizures. during data collection, the nurse notes that the client is taking birth control pills. which information should the nurse provide to the client?
the potential for decreased effectiveness of the birth control pills exists while taking phenytoin
The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that this is cerebrospinal fluid if the fluid meets which criteria?
separates into concentric rings and tests positive for glucose
The nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspect's this complication if which s/s is noted?
severe, throbbing headache
The client is having a lumbar puncture performed. The nurse should place the client in which position for the procedure?
side-lying with legs pulled up and chin to the chest
Ibuprofen is prescribed for a client. Which instruction should the nurse give the client about taking this medication?
take with 8 oz of milk
the nurse is caring for a patient who suffered cervical spinal cord injury. what injury can most likely be anticipated?
tetraplegia
a patient is diagnosed with bell's palsy as indicated by a feeling of stiffness and a drawing sensation of the face. what is important to teach her about the disease?
the eye is susceptible to injury if the eyelid does not close
the nursing assessment of an 80 year old who has a had stroke four that she had difficulty swallowing. a video fluoroscopy with barium was performed to rule out aspiration. the rehabilitation team in the skilled nursing facility determined that she can eat a soft diet with one to one supervision. which action is important to prevent aspiration?
tipping the head toward the unaffected side while swallowing
The client with trigeminal neuralgia is being treated with carbamazepine. which laboratory result indicates that the client is experiencing an adverse effect of the medication?
white blood cell count 3000 mm3
The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made?
"I will drive only during the daytime"
A client with a seizure disorder is being admitted to the hospital. Which should the noire plan implement for this client? Select all that apply
1. pad the bed's side rails 2. place an airway at the bedside 3. place oxygen equipment at the bedside 4. place suction equipment at the bedside
what nursing interventions should the nurse include in the plan of care for a patient who has had a stroke with high sided hemiplegia and expressive aphasia? select all that apply
2. encourage self help behaviors as much as possible, such as feeding 4. perform ROM to affected extremities every shift 5. implement the use of a communication board for the patient to use as needed