Neuro Questions

The nurse is planning care for a patient with a T3 spinal cord injury. The nurse includes which intervention in the plan to prevent autonomic hyperreflexia? Administer dexamethasone as per the provider's order Assess vital signs and observe for hypotension, tachycardia, and tachypnea Teach the patient that this condition is relatively minor with few symptoms Assist the patient to develop a daily bowel routine to prevent constipation

Assist the patient to develop a daily bowel routine to prevent constipation Autonomic hyperreflexia is a potentially life-threatening condition that may be triggered by bladder or bowel distention, visceral distention, or stimulation of pain receptors on the skin. A daily bowel regimen program eliminates this trigger. A patient with autonomic hyperreflexia would be hypertensive and bradycardic. Removal of stimuli results in prompt resolution of signs and symptoms. Dexamethasone is unrelated to this specific condition.

A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take? Keep the television on while the nurse speaks. Talk in a louder than normal voice. Use one long sentence to say everything that needs to be said. Face the client and establish eye contact.

Face the client and establish eye contact.

A nurse is providing education to a community group about ischemic strokes. One group member asks if there are ways to reduce the risk for stroke. Which of the following is a risk factor that can be modified? Gender Hypertension Advanced age Ethnicity

Hypertension

A client diagnosed with migraine headaches asks the nurse what he can do to help control the headaches and minimize the number of attacks he is having. What instructions should the nurse give this client? Identify and avoid factors that precipitate or intensify an attack. When an attack occurs, stay in a brightly lit area. Start client on 12L/min O2 for 15-20 minutes Write down any adverse drug effects.

Identify and avoid factors that precipitate or intensify an attack. Important with to be aware of triggers that may cause a migraine-especially those that can be modified/avoided like Alcohol, Wine, Caffeine, Reducing Stress and Anxiety, Sensory Stimulation etc.

Mannitol is administered intravenously to a patient admitted to the hospital with loss of consciousness and a closed head injury. The nurse determines that the medication has achieved its priority effect if which of the following outcomes is noted? Weight loss of 1kg and serum creatinine of 0.8 mg/dL Serum creatinine of 1.2 mg/dL and normal intracranial pressure Improved level of consciousness and normal intracranial pressure Diuresis of 500mL in 2 hours and a BUN of 15 mg/dL

Improved level of consciousness and normal intracranial pressure Mannitol is an osmotic diuretic that can administered parenterally to treat cerebral edema. Lowering of intracranial pressure occurs within 15 minutes of administration and diuresis occurs within 1 to 3 hours. Expected effects of the medication include rapid diuresis and fluid loss. For the patient with cerebral edema, effectiveness is measured by assessing level of consciousness/neurological status and intracranial pressure readings.

Which medication is the most effective agent in the treatment of Parkinson disease? Amantadine Benztropine Bromocriptine mesylate Levodopa

Levodopa Levodopa is a dopaminergic that converts to dopamine in the brain. Dopamine levels are depleted in PD.

A nurse is assessing a patient's extraocular eye movements as part of evaluating neurological functioning. Which cranial nerve status is documented? Select all that apply. Optic (II) Oculomotor (III) Trochlear (IV) Trigeminal (V) Abducens (VI) Acoustic (VIII)

Oculomotor (III) Trochlear (IV) Abducens (VI)

A client the nurse is caring for experiences a seizure. What would be a priority nursing action? Restrain the client during the seizure. Suction the mouth during the convulsion. Protect the client from injury. Insert a tongue blade between the teeth.

Protect the client from injury.

A patient is being brought to the emergency department after suffering a head injury. The first action by the nurse is to determine the patient's: Level of consciousness Pulse and blood pressure Respiratory rate and depth Ability to move extremities

Respiratory rate and depth The first action of the nurse is to ensure that the patient has an adequate airway and respiratory status. In rapid sequence, the patient's circulatory status is evaluated, followed by neurological status.

A nurse is comparing the neurological status of a patient who suffered a head injury with the status on the previous shift. Using the Glasgow Coma Scale, the nurse determines that the patient's score has changed from 11 to 15. Which of the following responses did the nurse assess in the patient? Select all that apply. Spontaneous eye opening Tachypnea, bradycardia, and hypotension Unequal pupil size Orientation to person, place, and time Pain localization Incomprehensible sounds

Spontaneous eye opening Orientation to person, place, and time The Glasgow Coma Scale (GCS) is a tool to assess a patient's response to stimuli. To achieve a perfect score of 15, the patient would have to open his eyes spontaneously (4 points), obey verbal commands (6 points), and be oriented to person, place, and time (5 points). Vital signs and pupil size are not assessed with the GCS. The ability to localize pain earns a motor response score of 5, not the top score of 6. Making incomprehensible sounds earns a verbal response score of 2, not a 5.

A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse? Monitor vital signs. Turn client to side-lying position. Insert an airway or bite block. Manually restrain the extremities.

Turn client to side-lying position. Priority is safety and turning on side moves the tongue from the back of the throat if left supine. Also prevents aspiration of secretions in the side lying position.

A patient with trigeminal neuralgia asks the nurse for a snack and something to drink. Which of the following selections should the nurse provide for the patient? Hot cocoa with honey and toast Vanilla wafers and lukewarm milk Hot herbal tea with graham crackers Iced coffee and peanut butter crackers

Vanilla wafers and lukewarm milk Because mild tactile simulation of the face can trigger pain, the patient needs to eat or drink lukewarm, nutritious foods that are soft and easy to chew. Extremes of temperature will cause trigeminal pain.

The nurse is caring for a patient admitted to the hospital after sustaining a head injury. In which position should the nurse place the patient to prevent increasing intracranial pressure (ICP)? Left Sim's position Reverse Trendelenburg With the head elevated on a pillow With the head of the bed elevated at least 30 degrees

With the head of the bed elevated at least 30 degrees The patient with a head injury is positioned to avoid extreme flexion or extension of the neck and to maintain the head in the midline, neutral position. Elevation of the HOB at least 30 degrees will enhance venous drainage, which helps prevent increased ICP.

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by: Brudzinski's sign. a positive sweat chloride test. Kernig's sign. a positive edrophonium (Tensilon) test.

a positive edrophonium (Tensilon) test.