Patho Exam 3
3. Schedule for A STAT computer tomography (CT) scan of the head.
A 78 year old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for A STAT computer tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult.
Fasciculations
A brief, spontaneous contraction affecting a small number of muscle fibers, often causing a flicker of movement under the skin
2. increased intracranial pressure.
A fall during a rock climbing expedition this morning has caused a 28-year-old woman to develop an epidural hematoma. Immediate treatment is being organized by the emergency department team because this woman faces a risk of serious neurological damage as a result of: 1. decreased intravascular volume. 2. increased intracranial pressure. 3. ischemic cerebrovascular accident. 4. brain tissue synthesis.
2. Cloudy CSF, elevated protein, and decreased glucose
A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis? 1. Cloudy CSF, decreased protein, and decreased glucose 2. Cloudy CSF, elevated protein, and decreased glucose 3. Clear CSF, elevated protein, and decreased glucose 4. Clear CSF, decreased pressure, and elevated protein
2. Rigid extension and pronation of the arms and legs
A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present? 1. Abnormal flexion of the upper extremities and extension of the lower extremities 2. Rigid extension and pronation of the arms and legs 3. Rigid pronation of all extremities 4. Flaccid paralysis of all extremities
3. Abnormal flexion of the upper extremities and extension of the lower extremities
A nurse is reviewing the record of a client with increased ICP and notes that the client has exhibited signs of decorticate posturing. On assessment of the client, the nurse would expect to note which of the following if this type of posturing was present? 1. Flaccid paralysis of all extremities 2. Rigid pronation of all extremities 3. Abnormal flexion of the upper extremities and extension of the lower extremities 4. Rigid extension and pronation of the arms and legs
1. Flaccid paralysis and lack of sensation below the level of the injury.
A patient with a neck fracture at the C5 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding: 1. Flaccid paralysis and lack of sensation below the level of the injury. 2. Hypertension, bradycardia, and warm extremities. 3. Involuntary, spastic movements of the arms and legs. 4. The presence of hyperactive reflex activity below the level of the injury.
Vertigo
A sensation of whirling and loss of balance
Paresthesias
An abnormal sensation, typically tingling or pricking ("pins and needles")
MG
An antibody attack on the acteylcholine receptors in the muscle end plate membranes. As a result, nerve impulses are not transmitted to the skeletal muscle at the neuromuscular junction.
Photophobia
An experience of discomfort or pain to the eyes due to light exposure
Lupus
An inflammatory disease caused when the immune system attacks its own tissues and organs
MS
An inflammatory response causes damage to the myelin sheath and its thickness is reduced
Stroke
Brain cells die when they no longer receive oxygen and nutrients from the blood or when sudden bleeding into or around the brain damages them
Ocular palsies
Damage to the third cranial nerve results in:
Hypalgesia
Decreased sensitivity to painful stimuli
Dysphagia
Difficulty swallowing
Diplopia
Double vision
Ptosis
Eyelid drooping
Hyperglycemia
High blood sugar
CT scan
How can you determine if a stroke is ischemic or hemorrhagic?
Autopsy
How is PD definitively diagnosed?
The right side
If a patient is experiencing a left brain stroke what side of the body will be affected?
Nuchal rigidity
Inability to flex the neck forward
Agnosia
Inability to use an object correctly
Paralysis of respiratory muscles and all four extremities
Injuries above C4 =
Dysmetria
Lack of coordination of movement typified by the undershoot or overshoot of intended position with the hand, arm, leg, or eye
Lethargy
Lack of energy and enthusiasm
Ataxia
Loss of full control of body movements
Homonymous hemianopsia
Loss of visual field on right or left side of midline in eye
Hyperreflexia
Overactive or over responsive reflexes
Paralytic ileus
Paralysis of the intestinal muscles
Nystagmus
Repetitive uncontrolled eye movements
Tinnitus
Ringing or buzzing in the ears
Flaccidity
Soft, limp; not firm
Higher
The ______________ the injury the more severe it is.
Proprioception
The body's ability to sense itself
3. Respiratory or gastrointestinal infection during the previous month
The client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse inquires during the nursing admission interview if the client has a history of 1. Back injury or trauma to the spinal cord 2. Seizures or trauma to the brain 3. Respiratory or gastrointestinal infection during the previous month 4. Meningitis during the past 5 years
3. Assist the client to prepare an advance directive.
The client is diagnosed with ALS. As the disease progresses, which priority intervention should the nurse implement? 1. Discuss the need to be placed in a long-term care facility. 2. Explain how to care for a sigmoid colostomy. 3. Assist the client to prepare an advance directive. 4. Teach the client how to use a motorized wheelchair.
1. Giving the client thin liquids
The client with a CVA has dysphagia. When a diet order is initiated, the nurse avoids doing which of the following 1. Giving the client thin liquids 2. Thickening liquids 3. Placing food on the unaffected side of the mouth 4. Allowing plenty of time for chewing and swallowing
4. 21 mmHg
The nurse is caring for a client with an ICP monitoring device. The nurse becomes most concerned if the ICP reading drifted to and stayed in the vicinity of 1. 5 mmHg 2. 8 mmHg 3. 14mmHg 4. 21 mmHg
2. Increasing temperature, decreasing pulse, decreasing respiration, increasing BP
The nurse is caring for the client with an increased intracranial pressure. The nurse assesses which of the following trends in vital signs if the intracranial pressure is rising? 1. Increasing temp, increasing pulse, increasing respiration, decreasing BP 2. Increasing temperature, decreasing pulse, decreasing respiration, increasing BP 3. Decreasing temperature, decreasing pulse, increasing respirations, increasing BP 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing BP
1. A positive Brudzinski's sign
The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: 1. A positive Brudzinski's sign 2. A negative Kernig's sign 3. Absence of nuchal rigidity 4. A negative Brudzinski's sign
2. Within the client's reach on the left side
The nurse is planning care for the client with hemiparesis of the right arm and leg. The nurse incorporates in the care plan to place objects 1. Within the client's reach, on the right side 2. Within the client's reach on the left side 3. Just out of the client's reach, on the right side 4. Just out of the client's reach, on the left side
3. Clustering nursing activities to be done all at one time
The nurse is providing care to the client with ICP. Which of the following approaches may not be beneficial in controlling the client's ICP from an environmental viewpoint 1. Maintaining a calm atmosphere 2. Reducing environmental noise 3. Clustering nursing activities to be done all at one time 4. Allowing the client uninterrupted time for sleep
1. Difficulty sequencing, 4. Impaired communication, 5. Right homonymous hemianopsia
The nurse is taking care of a client with a new diagnosis of left-sided cerebral vascular accident. What clinical manifestations would you expect to see on assessment? (Select all that apply). 1. Difficulty sequencing 2. Impulsive behavior 3. Left-sided weakness 4. Impaired communication 5. Right homonymous hemianopsia
1. Impulsiveness, 2. Left homonymous hemianopsia, 4. Short attention span
The nurse is told in report that an assigned client suffered a right cerebral hemisphere brain attack (stroke). The nurse expects to note which manifestations on assessment of the client? (Select all that apply.) 1. Impulsiveness 2. Left homonymous hemianopsia 3. Right-sided weakness 4. Short attention span 5. Impaired ability to think analytically
2. Completing the sentences that the client cannot finish
The nurse is trying to communicate with a CVA client with aphasia. Which of the following actions by the nurse is least helpful to the client? 1. Speaking to the client at a slower rate 2. Completing the sentences that the client cannot finish 3. Looking directly at the client during attempts at speech 4. Allowing plenty of time for the client to respond.
2. Restlessness, 4. Pupillary changes, 5. Abnormal posturing
The nurse monitors a client who experienced a head injury. Which of the following manifestations indicates to the nurse an increase in intracranial pressure (ICP)? (Select all that apply.) 1. Hypotension 2. Restlessness 3. Tachycardia 4. Pupillary changes 5. Abnormal posturing
3. HR 38 beats per minute; BP 198/107 mm Hg; RR 7 breaths per minute
The victim of a motor vehicle accident has been admitted with massive trauma, including traumatic brain injury. Emergency treatment of increased intracranial pressure (ICP) has failed to resolve the problem, and monitoring reveals the ominous presence of Cushing's triad. What assessment findings would be consistent with this clinical phenomenon? 1. BP 101/77 mmHg; RR 12 breaths per minute; HR 116 beats per minute 2. Temperature 104 degrees F; RR 33 breaths per minute; HR 111 beats per minute 3. HR 38 beats per minute; BP 198/107 mm Hg; RR 7 breaths per minute 4. Temperature 96.9 degrees F; RR 9 breaths per minute; HR 49 beats per minute
Apraxia
Unable to carry out a purposeful movement
Ascending GBS
Weakness and paresthesia begin in the lower extremities and progress upward toward the trunk, arms, and cranial nerves
Descending GBS
Weakness of the face or muscles of the jaw, the head rotators and the tongue, larynx and pharynx. Progresses down toward the limbs. This type quickly affects respiratory function. Often causes paralysis or weakness of the eye muscles causing double vision.
Hemiparesis or Hemiplegia
Weakness on entire right or left side of the body
Aneurysm, Arteriovenous malformation and Hypertension
What 3 things cause a hemorrhagic stroke?
Frequent vital sings, Cardiac monitor, Fever control, Positioning (head of bed elevated at least 30 degrees), Management of oxygen and carbon dioxide levels
What are 5 basic nursing treatments for clients with increased ICP?
Plavix
What are TIA's treated with?
Genetic factors, environmental factors, antiemetic and neuroleptic medications
What are risk factors of PD?
Thrombotic and embolic
What are the two types of Ischemic strokes?
An infection, emotional upset, pregnancy, anesthesia, overgrowth of the thymus gland, 20-30 years old and women get it 3x more often than men
What causes MG?
Guillain-Barre
What disorder is characterized by: immune system starts to destroy the myelin sheath surrounding the axons. Segmental destruction of myelin between the Nodes of Ranvier. This destruction slows or stops the conduction from node to node resulting in muscle weakness and pain that have an abrupt onset
A high stroke risk
What do multiple TIA's indicate?
Diaphragm, chest wall muscles, arms and shoulders
What do the cervical spinal nerves control?
Lower body, bowel and bladder
What do the lumbar spinal nerves control?
Upper body and gastrointestinal function
What do the thoracic spinal nerves control?
Touch, position and vibration
What function is kept with anterior cord syndrome?
Motor function in lower extremities (legs)
What function is kept with central-cord syndrome?
Motor function, pain and temperature sensation
What function is lost with Anterior cord syndrome?
Paralysis, proprioception on same side of injury and pain and temperature sensation on the opposite side of injury
What function is lost with Brown-Sequard syndrome?
Lumbar and sacral motor or sensory loss, neurogenic bowel and bladder
What function is lost with cauda equina and what does it result in?
Motor function in the upper extremities (arms)
What function is lost with central-cord syndrome?
They decrease
What happens to blood pressure and pulse in neurogenic and spinal shock?
Increased blood pressure (hypertension) Low pulse (bradycardia) Low respirations (bradypnea)
What is Cushing's triad?
A brief interruption in cerebral blood flow - 30 to 60 min
What is a Transient Ischemic Attack (TIA)?
5 - 15 mmHg
What is a normal ICP measurement?
5th leading cause of death
What is significant about strokes?
Face, Arms, Speech, Time
What is the FAST acronym for recognition of a stroke?
Unknown
What is the cause of Guillain-Barre?
There is no known cause
What is the cause of MS?
The cause of PD is unknown
What is the cause of PD?
Mono
What is the common name of the Epstein-Barr virus?
Complete: Elimination of all innervation below the level of the injury. Incomplete: Allows some function of movement below the level of the injury.
What is the difference between complete and incomplete SCI's?
Spinal shock occurs immediately after injury where as neurogenic shock can take 24+ hours to occur
What is the difference between spinal shock and neurogenic shock?
Results from the loss of sufficient production of dopamine, the neurons begin to degenerate and die.
What is the pathophysiology of PD?
Patients should recover between 4 - 6 months and up to one year
What is the prognosis for GB?
Death by respiratory complications within 3 - 5 years
What is the prognosis for an ALS patient?
3 - 6 hours
What is the time period between initial symptoms and muscle death in a stroke?
Flaccid paralysis and loss of reflex activity below the level of the lesion
What two things characterize spinal shock?
Neurogenic shock
What type of shock is defined as: Insufficient blood flow due to loss of signals to the sympathetic nerves that maintain muscle tone in blood vessels. Relaxation and dilation occur resulting in pooling in the venous system resulting in decreased blood pressure and pulse
Spinal shock
What type of shock is defined as: Occurs immediately after injury as a result of disruption in the communication pathways between upper and lower motor neurons. May last a few days to several months. Return of reflex activity indicates resolution.
Ischemic stroke
What type of stroke is characterized by: Occlusion of a cerebral artery by a thrombus or embolus?
Hemorrhagic
What type of stroke is characterized by: Vessel integrity is interrupted and bleeding into the brain tissue occurs
A patient whose had symptoms for greater than 6 hours or who has a bleeding risk
What type of stroke patient should not be given clot busters?
In an embolic stroke the clot travels and a thrombotic clot is stationary
Whats the difference between a thrombotic and embolic stroke?
1. A 75-year-old African American male.
Which client would the nurse identify as being most at risk for experiencing a CVA? 1. A 75-year-old African American male. 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female.
3. Muscle weakness spreads downward until a flaccid quadriplegia develops.
Which of the following is expected in clients with the diagnosis of amyotrophic lateral sclerosis (ALS)? 1. Many clients live long lives with minimal complications. 2. Many clients pass away from complications of a stroke. 3. Muscle weakness spreads downward until a flaccid quadriplegia develops. 4. Clients will experience a very low creatine kinase (CK).
3. Restlessness and confusion
Which of the following signs and symptoms of increased ICP after head trauma would appear first? 1. Bradycardia 2. Large amounts of very dilute urine 3. Restlessness and confusion 4. Widened pulse pressure
Injuries above T6
Which spinal cord injuries have the highest risk for cardiovascular changes?
Hemorrhagic shock
Which type of shock is least common but most deadly?
