ECCO Neuro part 2
What is the chief symptom of diffuse axonal injury in a patient with traumatic brain injury?
Abnormal posturing
A patient who sustained a traumatic spinal cord injury in a motor vehicle crash is admitted. The patient reports loss of movement and sensation below the waist. What is the initial priority?
Administer IV fluids to prevent shock
What interventions should a nurse perform for a patient in status epilepticus?
Administer fluid... Protect airway... Ensure a safe environment...
A patient has had four episodes of generalized tonic-clonic movements with lethargy lasting 10-12 minutes each without recovery from the postictal period. What treatment is indicated?
Administer of lorazepam
A patient has an aSAH and is responsive to verbal commands. Vital signs are BP 162/80 (107), HR 96, RR 24, Temp 37.4 (99.3). What intervention should the nurse anticipate?
Administration of antihypertensive medications
Which of the following initial interventions should the nurse anticipate when caring for a patient who developed sudden unilateral weakness and expressive asphasia two hours ago?
Administration of rtPA
A patient with a history of seizure has new-onset nausea, confusion, and Temp 38.3 (100.9). He becomes unconscious, with 15 seconds of greater muscle one and rhythmic jerks. What intervention was indicated in the patient's initial state?
Allow the patient to lie down
A patient with skull fracture has WBC 14,000 (was 11,000), is more lethargic, and wants the room dark. In flexing he patient's neck, you note involuntary flexion of knees and hips. What is indicated?
Antimicrobial therapy
Brain abscess is suspected in a patient reporting persistent headache, left hand tremor, and numbness. BP has increased. What other symptoms should the nurse observe for?
Chills Fever
A patient is recovering from an ischemic stroke. Which of the following interventions should the nurse anticipate?
Collaborate with physical therapy to decrease falls risk.
The application of blunt force to the head can result in which primary injuries to brain tissue?
Compression... Stretching... Impact and rebound impact...
A patient with aSAH has BP 150/80 (103), HR 68, RR 18, Temp 39 (102.2), and a GCS score of 9. What is the initial treatment priority for this patient?
Control fever
A patient who fell and sustained a traumatic brain injury is admitted. The patient is unconscious and has a GCS score of 6. Which of these is the main priority?
Endotracheal intubation
A patient with a history of hypertension reports nausea, "a terrible headache," and numbness and weakness of the right arm and leg. What neurologic event should the nurse suspect?
Hemorrhagic stroke
A patient with ischemic stroke received IV rtPA 18 hours ago. BP is 173/105 (128), ten minutes later BP is 186/110 (135), and five minutes after that is 198/115 (143). What should he nurse anticipate?
IV labetalol
A nurse assesses a patient with hemorrhagic stroke and finds a GCS score of 6. What order should the nurse anticipate?
Intubation
A patient with hypertension reports partial loss of vision in her left eye and numbness in her left arm. She does not have a headache. What process should the nurse suspect?
Ischemic stroke
What is the initial drug of choice for a patient with ischemic stroke who is not eligible for fibrinolysis with rtPA with a BP greater than 220/120?
Labetalol
What characteristic of generalized onset seizures distinguishes them from focal onset seizures?
Loss of consciousness
Which assessment findings in a trauma patient indicate a traumatic spinal cord injury?
Loss of temperature-regulating...
In early status epilepticus, a patient experiences hyperglycemia. After 30 minutes of status epilepticus, what sequence of processes occur?
Lower BP, hypoxemia; greater demand, hypoglycemia
A patient with a history of hypertension develops sudden severe headache and numbness on the right side. The patient is awake but confused. What actions should the nurse anticipate?
Lower the SBP to less than 160
For a patient suspected of undergoing ischemic stroke, which diagnostic imaging tests should the nurse anticipate?
MRI DWI Non-contrast CT
A patient with blunt traumatic brain injury has bruising behind the ears and persistent CSF leakage. Which of the following are goals of treatment?
Maintain ICP... Maintain SBP greater than 90
A patient is admitted with traumatic spinal cord injury from a fall. What immediate interventions should the nurse prioritize?
Maintain oxygenation... Maintain immobilization Assess circulation
For a patient with aSAH, which steps should the nurse take to prevent complications?
Manage airway Manage BP Control fever
A patient with ischemic stroke in the middle cerebral artery has an NIHSS score of 8, meets guideline timeframes for treatment, and is to receive combination therapy. What treatment should the patient receive?
Mechanical extraction... Intravenous fibrinolysis
A patient with an ischemic stroke has undergone endovascular therapy. Which of the following should be included in the patient's plan of care?
Monitor for presence of groin, flank, or back pain
IV rtPA was initiated seven hours ago in a patient with ischemic stroke. Assessment shows a decline in NIHSS score, and the patient indicates head pain. What are the nurse's immediate priorities?
Obtain a non-contrast... Draw blood... Monitor BP
A patient with an ischemic stroke is to receive rtPA. Which of the following should the nurse include in the process?
Perform neurologic checks every 15 minutes for two hours
A patient developed sudden severe headache, trouble seeing out of the right eye, and unilateral weakness of the right leg five hours ago. Which of these should the nurse initially anticipate?
Performing a non-contrast CT
The WBC of a patient admitted for seizures and increasing confusion has increased. She placed a towel over her eyes against the light. What other sign should the nurse observe for?
Positive Brudzinski's sign
A patient has a subarachnoid hemorrhage. For which of the following electrolyte abnormalities should the nurse observe?
Sodium 130
A patient with an ischemic stroke is receiving rtPA. For which of the following should the nurse observe?
Sudden severe headache
A patient with a history of atherosclerosis and hypertension reports sudden unilateral weakness. For which symptoms should the nurse observe?
Sudden trouble walking and unilateral facial numbness
A patient with a 30-year history of cigarette smoking, alcohol abuse, and hypertension develops sudden confusion and weakness on one side. For which symptoms should the nurse observe?
Unilateral numbness
Which of the following patients with an ischemic stroke may be considered to receive rtPA? A patient:
Who had spinal surgery within the last year
Which of the following patients is at greatest risk for development of an aSAH? A patient:
Who uses methamphetamine
A patient with a history of smoking and recent cocaine use, reports a stiff neck and severe headache. He hides his eyes from light and evidences decreasing LOC. What should the nurse suspect?
aSAH
Which of the following can cause traumatic spinal cord injury?
hyperflexion hyperextension
