P+P Exam #5 Neuro

A client who has been immobilized for an extended period of time questions why the tilt table is being used. What is the nurse's best explanation of the tilt table's function?

Calcium leaves the long bones during periods of prolonged bed rest. The tilt table places the client in an upright position, which provides for weight bearing. The tilt table is used to prevent orthostatic hypotension by gradually allowing an individual who has been immobilized to adjust to an upright position.

A client with a spinal cord injury exhibits signs of autonomic hyperreflexia. What is the most common cause of this response?

Distended large intestine (or bladder) Bowel or bladder distention causes autonomic nerve impulses to ascend via the cord to the point of injury; here the reflex is completed, and autonomic outflow causes piloerection (goose bumps), sweating, and splanchnic vasoconstriction. Splanchnic vasoconstriction causes hypertension and a pounding headache.

The nurse is caring for a client with a spinal cord injury who has paraplegia. The nurse can expect which major problem early in the recovery period?

bladder control

A client with a traumatic brain injury is demonstrating signs of increasing intracranial pressure, which may exert pressure on the medulla. What should the nurse assess to determine involvement of the medulla?

breathing and HR The medulla, part of the brainstem just above the foramen magnum, is concerned with vital functions such as breathing. The medulla is concerned with vital functions [1] [2] such as heart rate. The opercular-insular area of the parietal cerebral lobe is concerned with taste sensations. The medulla is not concerned with fluid balance. Osmoreceptors of the hypothalamus cause increased or decreased antidiuretic hormone (ADH) secretion depending on serum osmolarity. Voluntary movements are mediated through the somatomotor area of the cerebral cortex.

A client is admitted to the hospital with a suspected brain tumor. Based on the history of loss of equilibrium and coordination, where does the nurse suspect the tumor is located?

cerebellum The cerebellum is involved in synergistic control of the skeletal muscles and the coordination of voluntary movement.

A client with a herniated nucleus pulposus reports pain, what is the cause?

compression of spinal cord due to "slipped disk"

While assessing a client recovering from a head injury, the nurse notices a loss of movement in the client's tongue while attempting to talk. Which could be the possible reason for the client's condition? (damage to which CN)

hypoglossal nerve Damage to the nerve that supplies the skeletal muscles of the tongue may lead to the loss of its ability to move. These muscles are supplied by the hypoglossal nerve (cranial nerve XII), which assists with motor functions of the tongue such as talking.

how should a nurse explain glaucoma to a client?

increase in pressure within the eyeball An increase in intraocular pressure (IOP) results from a resistance of aqueous humor outflow. Open-angle glaucoma, the most common type of glaucoma, results from increased resistance to aqueous humor outflow

aspirin moa: use: ae:

moa: cox-inhibitor (prevents formation of thromboxane A2 generation which leads to platelet activation/aggregation) use: prevent MI, stroke, angina ae: GI bleeding, hemorrhagic stroke

heparin moa: use: monitor: ae: CI:

moa: injection, rapid-acting (enhances antithrombin) use: PE, stroke, DVT, open heart surgery, renal dialysis, DIC monitor: aPTT ae: hemorrhage, thrombocytopenia CI: after brain, eye, spinal cord surgery

what is the most powerful indicator of a patient's recovery after a stroke?

motor response (deceberate/decorticate posturing)

The nurse is caring for a 60-year-old client who is at an increased risk of corneal damage. Which instructions should the nurse share with the client? "Use saline drops." "Improve lighting at home." "Increase humidity at home." "Wear prescribed lens for best vision." "Have corrective lenses solely for reading."

use saline drops increase humidity wear prescribed lens A client who has reduced tear production may have an increased risk for corneal damage and eye infection. Using saline eye drops and increasing the humidity may reduce dryness and decrease corneal damage. Flattening of the cornea causes blurred vision. Therefore the client should be instructed to have regular eye examinations and to wear the prescribed lens to prevent corneal damage. All the rest of the instructions are associated with the pupil or lens rather than the cornea. A client whose pupils have a decreased ability to dilate has a poor capacity for acclimating to the darkness. These clients are mainly instructed to maintain good lighting in order to prevent an accident. A client with an inelastic lens is mainly instructed to wear corrective lenses while reading.

how do we monitor a patient after a brain injury

ICP PROBE temp, bp CGS

What nursing intervention is anticipated for a client with Guillain-Barré syndrome?

Guillain-Barré syndrome is a progressive paralysis beginning with the lower extremities and moving upward; mechanical ventilation may be required when respiratory muscles are affected.

respirations with high ICP

"cushing reflex" shallow/slow/irregular vagus nerve compressed, turns on PNS

GCS ratings

8 or less = severe 13 or more = mild so 9-12 = moderate

common manifestations of stroke

CONTRALATERAL motor and sensory loss contralateral visual field loss APHASIA

where is CSF made

choroid plexus

hydrocephalus

excess production of CSF, increases ICP

condition found with a milky, white-gray ring encircling the periphery of the cornea why does this happen?

arcus senilis occurs due to cholesterol deposits in the peripheral cornea

what are the common causes of thrombic, embolic and hemorrhagic stroke?

atherosclerosis a. fib chronic HTN

diagnostic test for brain injury

CT scan

common manifestations of TBI and hemorrhage?

decrease LOC increase ICP + headache, N/V CN dysfunction, muscle weakness

In caring for the client with burr holes for a subdural hematoma postoperatively on day 2, the nurse notes the client has an increased temperature to 101.3 F° (38.5° C). What does the nurse understand about this reaction?

sign of an infection -> notify health care provider Any client with a temperature day 2 postoperatively could be exhibiting signs and symptoms of an infection. The nurse should notify the healthcare provider and continue assessment of the client for signs and symptoms of infection. An increased temperature 2 days postoperatively is not normal for any client. The burr holes have nothing to do with whether or not the temperature is okay.

what is a common cause of epidural hematoma, and what is typically the source of the bleed?

skull fracture often middle meningeal artery

A client with expressive aphasia will have trouble with...

speaking and writing Damage to the Broca area, located in the posterior frontal region of the dominant hemisphere, causes problems in the motor aspect of speech, like speaking and writing. Impairments such as following specific instructions, understanding speech or writing, and recognizing words for familiar objects are associated with receptive aphasia, not expressive aphasia; receptive aphasia is associated with disease of the Wernicke area of the brain.

A man walks into the emergency room (ER) with sunglasses on and tells the nurse that he fell off a ladder and hit his head and was unconscious for a few minutes. Why should the nurse ask him to remove his sunglasses?

The nurse needs to quickly assess the client for raccoon eyes. Raccoon eyes is periorbital ecchymosis around the eyes. If bilateral, it is highly suggestive of basilar skull fracture. It is caused by rupture of the meninges causing the venous sinuses to bleed into the arachnoid villi and cranial sinuses, resulting in pooling of blood around the eyes. It most often is associated with fractures of the anterior cranial fossa and requires immediate attention.

A client is experiencing visual disturbances like hallucinations, where would you expect a brain tumor to be located?

The occipital lobe is concerned with special sensory perception; tumors here cause visual disturbances, visual agnosia, or hallucinations.

A client with suspected brain tumor is experiencing seizures and sensory function loss, where do you suspect the tumor is located?

The parietal lobe is concerned with localization and two-point discrimination; tumors here cause motor seizures and sensory function loss.

A client is having trouble chewing, which CN might be damaged?

The trigeminal nerve (cranial nerve V) assists in the sensory perception from the skin of the face and scalp and the mucous membranes of the mouth and nose. It also assists with the motor functions of the mouth such as mastication (chewing).

left homonymous hemianopia

due to R optic tract pressure from hemorrhagic stroke you left visual field is gone in both eyes

Which information should be included in the teaching plan for the client diagnosed with epilepsy and prescribed phenytoin (dilantin)?

floss regularly to prevent gingival hyperplasia

after left cataract extraction, a client reports severe discomfort in operated eye. this problem may be caused by _____?

hemorrhage into the eye Acute postoperative pain is a sign of increased intraocular pressure and is caused by hemorrhaging; this is a medical emergency.

which anticoagulant has the risk of thrombocytopenia?

heparin HIT

pt has headache, projectile vomiting and altered LOC

high ICP (brain injury)

decorticate posturing

indicates damage between brain and spine -> can progress to deceberate

which types of herniation are usually the cause of decerebate posturing?

uncal (supratentorial) or tonsillar (infratentorial) both push brain tissue DOWN

which anticoagulant is preferred during pregnancy? which is teratogenic?

warfarin - teratogenic heparin - preferred

antidote for warfarin? heparin?

warfarin - vitamin K heparin - protamine sulfate

warfarin moa: use: monitor: ae:

moa: oral, delayed onset (decreases formation of fibrin) use: long-term prophylaxis of thrombosis (& w prosthetic heart valves) monitor: PT, INR ae: hemorrhage *fetal* NOT FOR PREGNANCY

cataract

opacity of crystalline lens or its capsule

manifestations of brain injury/high ICP

projectile vomiting headache altered mentation and sensorium

detached retina

separation of neural retina from pigmented retina

astigmatism

curvature of cornea that becomes unequal

a client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. within 1 hr of admission, the clients legs are numb all the way up to the hips. the nurse should do which of the following next? SATA 1. call the family to come in to visit 2. notify the health care provider of the change 3. place resuscitation equipment in the clients room 4. check for advancing levels of paresthesia 5. have the client perform ankle pumps

2, 3, 4 client has clinical manifestation of GUILLIAN BARRE SYNDROME (an autoimmune disease). family does not need to visit until client is stable

After sustaining a head trauma, a client reports hearing ringing noises. Which area should the nurse assess further?

8th CN (vestibulocochlear) sensation of hearing conducted by cochlear nerve

A client with a suspected brain tumor experiences involuntary movements and paralysis, where would we expect the tumor to be located?

Basal ganglia are concerned with large subconscious movements and muscle tone; damage here may cause paralysis, as in a brain attack, or involuntary movements and uncontrollable shaking, as in Parkinson disease.

A client with myastenia gravis should plan to _______ if they plan to be more active

Contract their doctor Increased activity without an increase in medication can precipitate a myasthenic crisis [1] [2]. Self-medication may result in drug interactions; a change in medical therapy can have serious consequences. A dose should not be skipped because doing so may result in severe respiratory distress.

how do we assess the neurologic status of brain-injured patients?

GCS and CN fxn tests

Initially after a brain attack (stroke, cerebrovascular accident), a client's pupils are equal and reactive to light. Four hours later the nurse identifies that one pupil reacts more slowly than the other. The client's systolic blood pressure is beginning to increase. On which condition should the nurse be prepared to focus care?

Increased ICP Increased intracranial pressure is manifested by a sluggish pupillary reaction and elevation of the systolic blood pressure. Spinal shock is manifested by a decreased systolic blood pressure with no pupillary changes. Brain herniation is manifested by dilated pupils and severe posturing. Hypovolemic shock is indicated by a decrease in systolic pressure and tachycardia, with no changes in pupillary reaction.

After surgery to repair a retinal detachment, an older adult client is transferred to the postanesthesia care unit with the affected eye patched. During the first four hours after surgery, the nurse should plan to notify the primary healthcare provider if the client reports which information?

Reports of sharp pain in the eye indicate that hemorrhage may be occurring in the eye.

A client complains they cannot taste their food, which CN might be damaged?

The facial nerve (cranial nerve VII) assists with sensory functions such as taste perception of the anterior two-thirds of the tongue.

Why should a patient with myastenia gravis avoid crowds and people with colds?

They are more prone to respiratory infections because of an ineffective cough and a potential for aspiration.

what is the Crede maneuver and how is it used for clients with MS?

To help with urinary retention Credé maneuver is the use of manual pressure over the suprapubic area to compress the bladder and promote emptying. Urinary retention is a risk factor for urinary tract infection. Physical stressors, such as infections, can trigger exacerbations in clients with multiple sclerosis.

A client who had a cerebrovascular accident (also known as a "brain attack") becomes incontinent of feces. What is the most important nursing action to support the success of a bowel training program?

adhering to definite time for attempted evacuations Bowel training is a program for the development of a conditioned reflex that controls regular emptying of the bowel. The key to success is adherence to a strict time for evacuation based on the client's individual schedule. The indiscriminate use of laxatives can result in dependency. Although previous habits should be considered, the brain attack affects the responses of the client by altering motility, peristalsis, and sphincter control despite adherence to previous habits. The passage of food into the stomach does stimulate peristalsis, but it is only one factor that should be considered when planning a specific time for evacuation.