Adult health test 2
brain stem stroke
- "Life-support area" - Respirations, BP, heart rate, Eye movements, hearing, speech & swallowing
Causes of seizures
-Cerebrovascular disease -Hypoxemia -Fever (childhood) -Head injury -Hypertension -Central nervous system infections -Metabolic and toxic conditions -Brain tumor -Drug and alcohol withdrawal -Allergies
Collaborative Problems and Potential Complications of stroke
-Decreased cerebral blood flow -Inadequate oxygen delivery to brain -Pneumonia
tonic-clonic seizure( most common)
-Stiffening of muscles/jerking motions of extremities -Incontinence -Confusion or sleepiness afterwards -Unusual sensations or movements -'Aura' alerts prior to seizure
Altered LOC Nursing Interventions
-maintaining body temperature -preventing urinary retention -Promoting bowel function -Meeting patient family needs - Preventing further complications
t-PA time frame
4.5 HOURS
how long does brain death take after disruption of blood flow to the brain
5 minutes
partial seizure
A seizure affecting a limited portion of the brain. pt retains conciousness
The nurse is ordered to administer Lorazepam to a patient experiencing seizure activity. As a precautionary measure, the nurse will also have what reversal agent on standby? A. Narcan B. Flumazenil C. Calcium Chloride D. Idarucizumab
B. Flumazenil
A nurse is preparing a client for a computed tomography (CT) scan that requires infusion of radiopaque dye. Which question is the most important for the nurse to ask? A. "When did you last take any medication?" B. "When did you last have something to eat or drink?" C. "Are you allergic to seafood or iodine?" D. "How much do you weigh?"
C. "Are you allergic to seafood or iodine?"
A nurse conducts the Romberg test on a client by asking the client to stand with the feet close together and the eyes closed. As a result of this posture, the client suddenly sways to one side and is about to fall when the nurse intervenes and saves the client from being injured. How should the nurse interpret the client's result? A. Positive Romberg test, indicating a problem with level of consciousness B. Negative Romberg test, indicating a problem with body mass C. Negative Romberg test, indicating a problem with vision D. Positive Romberg test, indicating a problem with equilibrium
D. Positive Romberg test, indicating a problem with equilibrium
How are seizures diagnosed?
EEG, MRI, CT scan
Modifiable risk factors for stroke
Hypertension Cardiac Disease Atrial Fibrillation Diabetes Mellitus Smoking Alcohol abuse Hyperlipidemia sickle cell
Treatment for stroke
If within 4.5 hours: TPA If later than 4.5 hours intra-arterial (IA) is used
Transient Ischemic Attack (TIA)
Minor stroke; where neurological function is regained quickly with time ( usually 3 hours), can be a warning sign of a progressive cerebrovascular disease.
ischemic stroke
Most common type of stroke, occurs in 87 percent of strokes. PATHO: when the flow of blood to the brain is blocked by the narrowing or blockage of a carotid artery.
t-PA IV
Patients treated with IV t-PA within 3 hours of symptom onset had at least a 33% greater likelihood of good outcome
Glascow Coma Scale
Severe impairment <8 Moderate impairment 9-12 Minor impairment >13
Your patient has a history of epilepsy. While helping the patient to the restroom, the patient reports having this feeling of déjà vu and seeing spots in their visual field. Your next nursing action is to? A. Continue assisting the patient to the restroom and let them sit down. B. Initiate the emergency response system. C. Lay the patient down on their side with a pillow underneath the head. D. Assess the patient's medication history.
The answer is C.
You're assessing your patient load for the patients who are at MOST risk for seizures. Select all the patients below that are at risk:* A. A 32-year-old with a blood glucose of 20 mg/dL. B. A 63-year-old whose CT scan shows an ischemic stroke. C. A 72-year-old who is post opt day 5 from open heart surgery. D. A 16-year-old with bacterial meningitis. E. A 58-year-old experiencing ETOH withdrawal.
The answers are A, B, D, and E.
autonomic nervous system
The part of the PNS that controls the glands and the muscles of the internal organs.
hemmorhagic stroke
Type of CVA that occurs when a weakened blood vessel, such as an aneurysm, ruptures and bleeds into the surrounding tissue of the brain.
complex partial seizure
a partial seizure, starting from a focus and remaining localized, that produces loss of consciousness
Nonmodifiable risk factors for stroke
age, gender, ethnicity, race, family history, heredity
hemianopsia
blindness in half the visual field
vasospasm
involuntary contraction of a blood vessel
ataxia
lack of muscle coordination
hemiplegia
paralysis of one side of the body
Generalized seizures
seizures that involve the entire brain
SIGNS of decreased LOC
sluggish or pinpoint pupils inability to open eyes inability to move extremities when told to do so
Dysarthria
slurred speech
Agnosia
the inability to recognize familiar objects.
Romberg test
used to evaluate cerebellar function and balance
hemiparesis
weakness on one side of the body
right hemisphere stroke
•Controls movement of left side of body •Controls analytical and perceptual tasks (judging, distance, size, speed) •Patients may have difficulties with judgement and short-term memory
left hemisphere stroke
•Controls movement of right side of body •Controls speech and language abilities •Patients may become aphasic and a slow cautious style of behavior •Patients may also experience memory problems and limited attention spans