UWorld Adult Health: Neurological

The emergency department nurse assesses a client involved in a motor vehicle accident who sustained a coup-contrecoup head injury. Which assessment finding is consistent with injury to the occipital lobe?

Deficits in visual perception

The nurse is assessing a client with advanced amyotrophic lateral sclerosis. Which of the following assessment findings does the nurse expect?

Amyotrophic lateral sclerosis causes motor neuron degeneration that leads to progressive muscle weakness, twitching and muscle spasms, difficulty swallowing, difficulty speaking, and respiratory failure. - There is no cure. Treatment focuses on symptom management.

A client is diagnosed with right-sided Bell's palsy. What instructions should the nurse give this client for care at home?

Apply a patch to the right eye at night. (cannot close eyelids r/t palsy) Chew on the left side. Maintain meticulous oral hygiene. - They do not have to avoid driving.

An 86-year-old client with diabetes and gastroparesis has had repeated hospitalizations for aspiration pneumonia following a stroke and is now hospitalized with altered level of consciousness. Which nursing action is most appropriate to decrease the client's risk for developing aspiration pneumonia?

Position patient on left side

What is Oculocephalic reflex (doll's eyes)?

an expected finding indicating an intact brainstem. It is tested by rotating the head and watching for the eyes to move simultaneously in the opposite direction. The test is not performed if spinal trauma is suspected.

The nurse is caring for a client following a transsphenoidal hypophysectomy. Which clinical findings would the nurse recognize as signs that the client may be developing diabetes insipidus?

1) Excess water intake 2) High urine output 3) Increased serum osmolarity 4) decreased urine specific gravity

What is the Babinski reflex?

(ie, toes point downward with stimulus to the sole). The presence of Babinski reflex (ie, toes fan outward and upward with stimuli) is expected in infants up to age 1, but in an adult may indicate a brain or spinal cord lesion.

The nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which of the following as expected neurological changes for the client with a concussion?

- Headache - brief loss of consciousness - retrograde amnesia

The nurse assesses a newly admitted adult client on a neurological inpatient unit. Which assessment findings require immediate follow-up by the nurse?

1) Cannot flex the chin towards the chest 2) New onset of right arm drift 3) Pupils 8mm in diameter bilaterally

The nurse is caring for a client with Bell palsy. Which of the following assessment findings does the nurse expect?

1) Change in lacrimation of the affected side 2) Flattening of nasolabial fold 3) Inability to smile symmetrically - due to inflammation of the facial nerve that is characterized by inability to close the affected eye completely, changes in tear production, facial droop, and asymmetrical smile or frown.

A client with a T4 spinal cord injury has a severe throbbing headache and appears flushed and diaphoretic. Which priority interventions should the nurse perform?

1) Determine if there is bladder distention 2) Measure the client's BP 3) Remove constrictive clothing

What does a neurological assessment consist of?

A neurologic assessment consists of GCS, PERRLA, movement and strength of the extremities, and vital signs.

What are abnormal neuro assessment findings?

Abnormal neurological assessments include nuchal rigidity; new-onset unilateral drift of a limb; pupils <3 mm or >5 mm in diameter; absent oculocephalic reflex; and presence of Babinski reflex in an adult client.

The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring?

Auscultate breathing for crackles - Normal kidney function and adequate urine output are crucial while administering this medication as mannitol accumulation can result in significant volume expansion, dilutional hyponatremia, and pulmonary edema.

A nurse cares for a client with impairment of cranial nerve VIII. What instructions will the nurse provide the unlicensed assistive personnel prior to delegating interventions related to the client's activities of daily living?

Keep items within reach - This impairment puts patient at risk for falls. (vestibularchoclear)

An adult client with altered mental status and fever has suspected bacterial meningitis with sepsis. Blood pressure is 80/60 mm Hg. Which prescribed intervention should the nurse implement first?

NS bolus

What is Cushing's triad?

hypertension bradycardia irregular respirations

What is Bell's Palsy?

peripheral, unilateral facial paralysis characterized by inflammation of the facial nerve (cranial nerve VII) in the absence of a stroke or other causative agent/disease. Paralysis of the motor fibers innervating the facial muscles results in flaccidity on the affected side.

A client is being admitted for a potential cerebellar pathology. Which tasks should the nurse ask the client to perform to assess if cerebellar function is within the defined limits?

1) Touch each finger of one hand to the hand's thumb 2) Walk heel to toe - The cerebellum is involved in coordination of voluntary movements and maintenance of balance and posture. Balance is assessed with heel-to-toe gait testing. Coordination is assessed with finger tapping, rapid alternating movements, finger-to-nose testing, and heel-to-shin testing.

A client with blunt head injury is admitted for observation, including hourly neurologic checks. At 01:00 AM, the client reports a headache; the nurse obtains a normal neurologic assessment and administers the PRN acetaminophen. At 02:00 AM, the client appears to be sleeping. Which action should the nurse take?

Arouse patient and ask what the current month is

The nurse is caring for a female client newly diagnosed with epilepsy who has been prescribed phenytoin. Which of the following should the nurse include in client teaching?

Clients prescribed phenytoin should receive education about the potential need for nonhormonal birth control as well as the importance of good oral hygiene and not abruptly stopping anticonvulsants. Other teaching for epilepsy includes avoiding seizure triggers and wearing a medical identification bracelet.

A speeding driver sustained a closed-head injury in an acceleration/deceleration accident from striking a tree front end first. Based on the coup-contrecoup phenomenon, which assessments are most likely to be affected related to the involved areas of the brain?

Expressive speech, vision - Coup-contrecoup injuries usually affect the frontal and occipital lobes. The frontal lobe controls executive function, memory, speech, and motor skills. The occipital lobe processes vision.

A highly intoxicated client was brought to the emergency department after found lying on the sidewalk. On admission, the client is awake with a pulse of 70/min and blood pressure of 160/80 mm Hg. An hour later, the client is lethargic, pulse is 48/min, and blood pressure is 200/80 mm Hg. Which action does the nurse anticipate taking next?

Have a CT scan performed to rule out an inter-cranial bleed -

The nurse is caring for a client diagnosed with Guillain-Barré syndrome (GBS) after a recent gastrointestinal (GI) illness. Monitoring for which of the following is a nursing care priority for this client?

Inability to cough or lift the head

The nurse is caring for a client with an acute ischemic stroke who has a blood pressure of 178/95 mm Hg. The health care provider prescribes as-needed antihypertensives to be given if the systolic pressure is >200 mm Hg. Which action by the nurse is most appropriate?

Monitor the BP - Elevated blood pressure in the presence of an acute ischemic stroke is an expected finding and may be a protective measure to maintain tissue perfusion.

A client with a C3 spinal cord injury has a headache and nausea. The client's blood pressure is 170/100 mm Hg. How should the nurse respond initially? (autonomic dysreflexia)

Palpate the clients bladder - Assess for autonomic dysreflexia - Often in clients with injuries above T6 - Signs and symptoms include hypertension, bradycardia, a pounding headache, diaphoresis, and nausea.

The nurse assesses several clients using the Glasgow Coma Scale. Which scenario best demonstrates a correct application of this scale?

The nurse applies pressure to the nail bed, and the client tries to push the nurses hand away. The nurse scores motor response as "localization of pain." - It is used to assess LOC. - The nurse follows a standardized assessment to determine the score of the client's eye opening response, verbal response, and ability to obey commands through a motor response.

What are the phases of seizures? ***

The prodromal phase is the period with warning signs that precede the seizure (before the aural phase). The aural phase is the period before the seizure when the client may experience visual or other sensory changes. Not all clients experience or can recognize a prodromal or aural phase before the seizure. The ictal phase is the period of active seizure activity. During the postictal phase, the client may experience confusion while recovering from the seizure. The client may also experience a headache. Postictal confusion can help identify clients by differentiating seizures from syncope. In syncope, there will be only a brief loss of consciousness without prolonged post-event confusion.

What are the primary and secondary steps taken in trauma assessment?

primary survey to determine status of airway, breathing, circulation, disability (eg, Glasgow Coma Scale to assess neurological impairment), and exposure. Health history, head-to-toe assessment, and level of pain are part of the secondary survey.