EX 5 A3 Prep u highlights
Severe TBI
- GCS score of 3-8 - Loss of consciousness of more than 24 hours - Posttraumatic amnesia of more than 7 days A score of 3 indicates severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response
Meningitis signs and symptoms
-Fever -headache -Neck stiffness -and vomiting
The nurse reviews the physician's emergency department progress notes for the client who sustained a head injury and sees that the physician observed the Battle sign. The nurse knows that the physician observed which clinical manifestation?
An area of bruising over the mastoid bone
Recovery rate with gullian barre
Approximately 60% to 75% of clients recover completely.
Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?
Apraxia
Which is the earliest sign of increasing intracranial pressure?
Change in level of consciousness
cardinal signs of brain death
Coma Absence of brain stem reflexes Apnea
Which condition is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain?
Creutzfeldt-Jakob disease
Bell palsy is a disorder of which cranial nerve?
Facial (VII)
While performing an initial nursing assessment on a client admitted with suspected tic douloureux (trigeminal neuralgia), for which of the following would the nurse expect to observe
Facial pain in the areas of the fifth cranial nerve
. Which symptom is an early sign of UTI in a client with a spinal cord injury?
Fever and change in urine clarity
What does the nurse recognize is the type of posturing that occurs with the most severe neurologic impairment?
Flaccid
global aphasia.
Form understandable words and comprehend spoken words
A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?
Frontal
What is the most common type of brain neoplasm?
Glioma
Which findings indicate spasm or occlusion of a cerebral vessel by a clot?
Hemiplegia, seizures, and decreased level of consciousness
A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment?
Lack of deep tendon reflexes
with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings?
Left-sided cerebrovascular accident (CVA)
A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment?
Limited attention span and forgetfulness
primary sites as commonly metastasizing to the spinal cord
Lung Breast Gastrointestinal tract
Which statement indicates appropriate nursing intervention for a client with post-polio syndrome?
Provide care aimed at slowing the loss of strength and maintaining overall well-being.
Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?
Spasticity
Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?
Speeds nerve impulse transmission
A score of 8 or less on the Glasgow coma scale is what level of injury after a TBI?
a score of 8 or less typically indicates an unconscious patient;
grade I meningioma
benign "Grade 1 is the most common type of this tumor."
Contusion (bruise)
blow from external object that causes soft tissue damage resulting in pain, ecchymosis, swelling
A neurologic deficit is best defined as a deficit of the:
central and peripheral nervous systems with decreased, impaired, or absent functioning.
scotoma
dark spot in the visual field
dysphonia
difficulty producing speech sounds, usually due to hoarseness
bradykinesia
extreme slowness in movement
Agraphia
inability to write
cerebellar
pertaining to the cerebellum
expressive aphagia
slow staggering speech due to brain injury
papilledema
swelling of the optic disc
Bell's Palsy
temporary paralysis of the seventh cranial nerve that causes paralysis only on the affected side of the face
focal symptoms
◦Dysfunction of particular brain areas ◦Seizures, hallucinations, weakness or palsies in specific areas, sensory deficits
mild TBI
-score of 13-15 -concussion, confusion, disorientation is less than 30 minutes
A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last?
1 to 3 days
moderate TBI
9-12 LOC >30 mins /< 24 hours, alteration of consciousness >24 hrs, posttraumatic amnesia >1/<7 days, GCS 9-12, imaging normal or abnormal
people at high risk for stroke.
A 60-year-old Black man
Parkinson's disease
A disorder of the central nervous system that affects movement, often including tremors.
Huntington's disease
A human genetic disease caused by a dominant allele; characterized by uncontrollable body movements and degeneration of the nervous system; usually fatal 10 to 20 years after the onset of symptoms.
MS education
A stretching routine should be established. Stretching can help prevent contractures and muscle spasticity. Hot baths are discouraged because of the risk of injury.
Which of the following is a reason why a neurosurgeon may choose to create a burr hole in a patient
Aspiration of a brain abscess
What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?
Autonomic dysreflexia
Which positions is used to help reduce intracranial pressure (ICP)?
Avoiding flexion of the neck with use of a cervical collar
the nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture?
Basilar
When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?
Body temperature
Cerebral Perfusion Pressure (CPP)
CPP = MAP - ICP want it to be 70 Changes in ICP are closely linked with cerebral perfusion pressure (CPP).
clinical manifestations of stroke
Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation.
Cerebrospinal fluid (CSF) studies would indicate which of the following in a patient suspected of having meningitis?
Decreased glucose Increased protein Increased white blood cells
symptoms are indicative of a rapidly expanding acute subdural hematoma
Decreased reactivity of the pupils Bradycardia coma Hemiparesis
The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?
Diplopia and ptosis
Impaired balance and uncontrolled tremors of Parkinson's disease is correlated with which neurotransmitter?
Dopamine
The nurse is preparing the client for an acetylcholinesterase inhibitor test to rule out myasthenia gravis. Which is the priority nursing action?
Ensure atropine is readily available. Atropine should be ready before administration of edrophonium chloride so it is available if needed to control the side effects of the medication
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)?
Every 15 minutes
A client with epilepsy is having a seizure. What intervention should the nurse do after the seizure?
Keep the client on one side. The nurse will need to keep the client on one side to prevent aspiration. Make sure the airway is patent
A client with spinal cord compression from a tumor must undergo diagnostic testing. Which of the following is the most likely procedure for this client
Magnetic resonance imaging
The diagnosis of multiple sclerosis is based on which test?
Magnetic resonance imaging
The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?
Maintain cerebral perfusion pressure from 50 to 70 mm Hg
Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord
Multiple sclerosis
client diagnosed with a brain tumor is exhibiting focal symptoms. Which assessment findings are the nurse likely to note
Muscle weakness Sensory loss Aphasia Visual changes
Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere?
Neglect of the left side
What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for?
Noncontrast computed tomogram
Which of the following is the initial diagnostic in suspected stroke?
Noncontrast computed tomography (CT)
Physical examination shows bradykinesia and a shuffling gait. What would the nurse suspect is the causative factor for these symptoms
Parkinson's disease
Which action will the nurse take to prevent adduction of the client's affected shoulder
Place a pillow in the axilla area. Position the wrist higher than the elbow.
Nursing measures in the care of the client with viral encephalitis
Providing comfort measures to reduce headache, including dimmed lights, limited noise, and analgesics,
Bell's Palsy tx
R/O stroke, TIA, mastoid infection, bone fx, lyme's disease and tumors. Corticosteroids high doses X 10 days. Acyclovir if herpes simplex is suspected. Drops to protect cornea from drying. Patch to cover eye while sleeping.
Basilar skull fracture
Raccoon eyes (periorbital ecchymosis) and Battle's sign (mastoid ecchymosis).
A client has undergone surgery for a spinal cord tumor that was located in the cervical area. The nurse would be especially alert for which of the following?
Respiratory dysfunction
clinical signs of increased ICP
Respiratory irregularities Slow bounding pulse Widened pulse pressure
For a patient with a left hemispheric stroke, the nurse would expect to see:
Right-sided paralysis.
A client has a herniated disk in the region of the third and fourth lumbar vertebrae. Which nursing assessment finding most supports this diagnosis?
Severe lower back pain
Which of the following tests confirms the diagnosis of myasthenia gravis (MG)?
Tensilon test
A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?
Transient ischemic attack
global aphasia
When both production and understanding of language is damaged
A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient?
Within 24 hours after exposure
myasthenia gravis
a chronic autoimmune disease that affects the neuromuscular junction and produces serious weakness of voluntary muscles
Trigeminal neuralgia
a painful disorder of one or more branches of cranial nerve V (trigeminal), produces paroxysmal attacks of excruciating facial pain. Attacks are precipitated by stimulation of a trigger zone on the face. Triggering events may include light touch to a hypersensitive area, a draft of air, exposure to heat or cold, eating, smiling, talking, or drinking hot or cold beverages
Glasgow Coma Scale (GCS)
a scale used to assess the consciousness of a patient upon physical examination, typically in patients with neurological concerns or complaints
partial seizure
a seizure that affects only one part or one side of the brain
angioneurotic edema
acute swelling of the face, neck, lips, larynx, hands, feet, genitals, and internal organs
signs and symptoms are consistent with bacterial meningitis.
altered LOC, high fever, and a purpura rash on the lower extremities neck stiffness
Korsakoff's syndrome
an alcohol related disorder marked by extreme confusion, memory impairment, and other neurological symptoms
MS IS A DISORDER OF WHAT
central nervous system (CNS) disorder
Decorticate posturing
characterized by upper extremities flexed at the elbows and held closely to the body and lower extremities that are externally rotated and extended. occurs when the brainstem is not inhibited by the motor function of the cerebral cortex. The client's head and neck arch backward, and the muscles are rigid.
Epilepsy
chronic brain disorder characterized by recurrent seizure activity
Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at
controlling seizures and increased intracranial pressure.
amyotrophic lateral sclerosis (ALS)
degenerative disorder of motor neurons in the spinal cord and brainstem
MS
disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self"
tissue plasminogen activator (tPA)
drug that breaks up blood clots
Confirmation dx tests for ALS
electromyography (EMG).
decerebate posturing
extension and external rotation of the arms and wrists and plantar flexion of the feet the result of lesions at the midbrain and is more ominous than decorticate posturing.
absence seizure
form of seizure consisting of momentary clouding of consciousness and loss of awareness of surroundings
Score of 15
fully alert and oriented patient.
tonic-clonic seizure
generalized seizure in which the patient loses consciousness and has jerking movements of paired muscle groups
Monroe-Kellie Hypothesis
increase in volume of one component must be compensated by a decrease in volume of another The dynamic equilibrium of cranial contents
encephalitis
inflammation of the brain usually caused by a virus
Meningitis
inflammation of the meninges
The nurse must logroll a client following a:
laminectomy. The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight when turning.
When the infarct is on the left side of the brain, the symptoms are l
likely to be on the right, and the speech is more likely to be involved.
complex seizure
loss of consciousness
Bone density testing in clients with post-polio syndrome has demonstrated
low bone mass and osteoporosis.
The primary arthropod vector in North America that transmits encephalitis is the
mosquito
primary headache
one for which no organic cause can be identified. These types include migraine, tension, and cluster headaches.
paralysis that accompanies Guillain-Barré syndrome is
only temporary. Return of motor function begins proximally and extends distally in the legs
hemiplegia
paralysis of one side of the body
Autonomic Dysreflexia
patients with spinal cord injuries are at risk for developing autonomic dyreflexia (T-7 or above)
subdural hematoma
pertaining to below the dura mater, tumor of blood
Post-polio syndrome
progressive muscle deterioration in 25-50% of patients decades after the initial infection
For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to:
promote carbon dioxide elimination.
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:
raccoon's eyes and Battle sign.
Plasmapheresis
removal of plasma from withdrawn blood by centrifuge remove antibodies from the plasma
Which assessment finding would lead the nurse to suspect that the client is experiencing a hemorrhagic stroke
severe exploding headache
secondary headache
symptom associated with an organic cause, such as a brain tumor or an aneurysm can be located in all areas of the head.
Agnosia
the inability to recognize familiar objects.
post-polio syndrome
the recurrence later in life of some polio symptoms in individuals who have had childhood poliomyelitis and have recovered from it
laminectomy
the surgical removal of a lamina, or posterior portion, of a vertebra
Monro-Kellie hypothesis
theory that states that due to limited space for expansion within the skull, an increase in any one of the cranial contents—brain tissue, blood, or cerebrospinal fluid—causes a change in the volume of the others; also referred to as Monro-Kellie doctrine
Cushing's triad
three classic signs—bradycardia, hypertension, and bradypnea—seen with pressure on the medulla as a result of brain stem herniation
A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client
vomits
