BN Ch.78 Nervous System Disorders

Question 1

__________ epilepsy is a form of focal
seizure in which rhythmic jerking movements start in one muscle group and
spread to another.

Answer 1

Jacksonian

Question 2

A __________ hematoma is caused by the
accumulation of blood on the brain’s surface as the result of a torn vein.

Answer 2

subdural

Question 3

_________ is a sensation of rotation of self or one’s surroundings without true dizziness.

Answer 3

Vertigo

Question 4

An acute spasm in which the body is bowed forward with the head and heels bent backward, seen in meningitis, is known as _________.

Answer 4

opisthotonos

Question 5

Difficulty in maintaining balance and
coordination, seen commonly in individuals
with Parkinson disease, is referred to as __________.

Answer 5

Ataxia

Question 6

Medications for migraine headache

Answer 6

Administer at the first sign to be most effective.

Question 7

Medications for status epilepticus

Answer 7

Observe for CNS signs and monitor kidney function

Question 8

Medications for Parkinson disease

Answer 8

Avoid high-protein foods and foods high in Vitamin B6

Question 9

Write the correct sequence to assist the
healthcare provider in obtaining a sample of cerebrospinal fluid (CSF).

1. Note the beginning CF pressure, color, and clarity, as measured by the healthcare provider.
2. Position the client on the side with the lower part of the back at the edge of the bed.
3. Place equipment within the healthcare
   provider’s reach, and provide extra lighting as necessary.
4. Keep the client’s head flat (supine) for at least 6 hr or as otherwise ordered.

Answer 9

3. Place equipment within the healthcare
   provider’s reach, and provide extra lighting as necessary.
4. Position the client on the side with the lower part of the back at the edge of the bed.
5. Note the beginning CF pressure, color, and clarity, as measured by the healthcare provider.
6. Keep the client’s head flat (supine) for at least 6 hr or as otherwise ordered.

Question 10

What are the common signs and symptoms of a brain tumor?

Answer 10

• The characteristic signs and symptoms of brain tumor include headache, sudden projectile vomiting, and visual abnormalities, all caused by an increase in intracranial pressure (ICP).
• Many other signs and symptoms may develop, depending on the area of the brain that is affected.

Question 11

What are the characteristic features of a depressed skull fracture?

Answer 11

• A severe blow to the head may cause a depressed skull fracture.
• The fracture breaks the bone and forces the broken edges to press against the brain, causing a significant risk for increased ICP and meningitis.
• The effects of the fracture vary with the injury’s severity and location.
  
  • For example, if the bone fragment presses on the brain’s speech center, the client’s speech may be impaired until the pressure is relieved.

Question 12

What are the vaccines available to prevent
poliomyelitis?

Answer 12

• Two types of vaccines are available to prevent polio:
  
  • The inactivated poliovirus vaccine (IPV) also referred to as the Salk vaccine
  • The trivalent oral poliovirus vaccine (OPV), also referred to as the Sabin vaccine.
• Oral vaccine prevents polio in most cases.

Question 13

What are the important nursing considerations involved in the treatment of
encephalitis?

Answer 13

• Nursing care for clients with encephalitis focuses on reducing fever and maintaining a quiet environment.
• Warm, moist packs may be applied to relieve muscle spasms.
• Unresponsive clients may require tube feedings or total parenteral nutrition (TPN).
• If there is acute respiratory distress, a tracheostomy and mechanical ventilation may be required.

Question 14

What is meant by myasthenic crisis?

Answer 14

• A myasthenic crisis is an emergency situation that occurs rapidly in clients with myasthenia gravis.
• The usual manifestations of myasthenic crisis include:
  
  • Dysphagia (difficulty in swallowing)
  • Dysphasia (difficulty in speaking)
  • Ptosis (drooping eyelids)
  • Diplopia (double vision)
  • Respiratory distress
• Emotional upsets, infections, and extremes of temperature can precipitate a myasthenic crisis

Question 15

The medical specialty dealing with the nervous system is referred to as neurology. Neuroscience nurses are registered nurses who specialize in the care of people with nervous system disorders.

1. A client is brought into the emergency
   department with a head injury after a motor vehicle accident. The client is conscious and well oriented to place and time at the time of admission. The neurosurgeon admits the client to the intensive care unit to monitor their ICP.

a. What ICP value would be considered an
increased ICP?

Answer 15

• The normal value of ICP is 4 to 13 mm Hg.
• Sustained ICP greater than 15 to 20 mm Hg is considered to be increased ICP.

Question 16

Which signs of increased ICP would the nurse look for in the client?

Answer 16

• The nurse should observe the client for the following signs of increased ICP and chart all observations:
  
  • Any change in level of consciousness, such as loss of consciousness, lethargy, confusion, or seizures
  • Any change in sensory–motor function, such as slowed reflexes, slowed response time, restlessness, ataxia, aphasia, or slowed speech
  • Headache that becomes progressively worse or is aggravated by movement
  • Change in eye signs or vision, such as change in pupil size, unequal pupils, slowed or no response to light, inability to follow examiner’s finger, or difficulty in seeing
  • Change in vital signs, such as pulse <60 or >100 beats/min, increased blood pressure, widening of pulse pressure, or increased or lowered body temperature
  • Evidence of respiratory distress
  • Nausea and vomiting or urinary incontinence
  • Leakage of CSF (clear yellow or pinkish) from nose or ear

Question 17

What should the nurse consider during
IC monitoring?

Answer 17

• The nurse should take the following precautions during ICP monitoring:
  
  • Report any break in an ICP monitoring system to the healthcare provider immediately
  • Keep the ICP monitoring system sterile throughout the procedure
  • Never move the client’s head up or down without specific orders from the healthcare provider

Question 18

A 32-year-old female client with paralysis
from the neck down is admitted to the
neurology department of the healthcare
facility. A nurse is advised to provide care
and monitor this client.

a. Which measures would the nurse employ when caring for a client with paralysis?

Answer 18

• The nursing steps involved in caring for a client with paralysis include the following:
  
  • Use measures that aid in maintaining normal anatomic alignment of the joints, to prevent footdrop.
  • Change the client’s position frequently and provide passive and active range of motion exercise, to prevent immobility/disuse disorders.
  • Give respiratory care as needed, to prevent respiratory complications.
  • Encourage the client to sit up as much as possible with adequate support.
  • Use special devices such as beds, chairs, and other mechanical devices in the early phases of treatment.
  • Trochanter rolls and sandbags may also be used.
  • These devices help to maintain proper body alignment and positioning.
  • If cervical traction, tongs, or a halo device is in place, give pin site care as ordered by the healthcare provider to prevent infection.
  • Teach the client and family the warning signs of genitourinary infection, which is a common complication of immobility.
  • Encourage fluid intake, and institute bladder retraining and rehabilitation.
  • If a catheter is used, make sure it is draining properly and is handled in as clean a manner as possible.
  • Take care to avoid pressure on the client, and keep sharp objects from touching the client, because the client may have decreased sensation.
  • Maintain nutritional status, to promote healing and maintain health.
  • Establish some sort of communication system if the client cannot speak.

Question 19

Which client teaching would the nurse
provide for female clients with paralysis?

Answer 19

• The nurse should provide the following client teaching for female clients with paralysis:
  
  • Reassure the clients that menses usually resume within 3 months after the injury.
  • Instruct the clients not to use tampons, because they may forget that a tampon is in place as a result of decreased sensation.
  • Ask the clients to avoid using birth control pills, because they can lead to thrombus formation.
  • Do not recommend use of intrauterine devices, because they can promote thrombus formation and infections.
  • Instruct the clients that labor and childbirth may be dangerous.

Question 20

Which special skin care would the nurse
provide the client?

Answer 20

• The nurse should provide the following special skin care to clients with paralysis:
  
  • Use lotions and emollients, because the skin of clients with paralysis is subject to pressure areas and skin breakdown.
  • Make sure the bedsheets are smooth and the bed is clean.