NERVOUS SYSTEM Flashcards
cranial nerve _ controls vision
2
cranial nerve_controls the ear and balance
8
cranial nerve that can be affected by toxicity to aminoglycosides such as erythromycin, gentamicin
8
uses 3 subscale: best eye opening, best verbal responses, best motor response with a maximum score of 15
Glascow Coma Scale
Signs of ototoxicity
are tinnitus, dizziness, vertigo, nausea and vomiting
Meniere’s disease
a balance disorder
abnormal increase in intraocular pressure
Glaucoma
A triad of symptoms of vertigo, hearing loss, and tinnitus characterizes
Meniere’s disease.
Is glaucoma a medical emergency
yes
results in gradual loss of peripheral vision (tunnel vision)
Open angle Glaucoma
Glasgow Coma Scale
used to assess levels of consciousness in clients with neurological problems
The cranial nerve #5 affects the
trigeminal nerve which controls the face, eye surface and chewing
A neurologic client who opens eyes to speech has a
higher Glasgow Coma Scale rating
salt restricted diet
A patient with Meniere’s disease can benefit from a
This patient should avoid alcohol, caffeine and tobacco use
Meniere’s disease
Cataract
an eye disease where the normally transparent lens becomes clouded and opaque leading to progressive blurring and gradual loss of vision
After cataract surgery, teach patient to avoid
increasing intraocular pressure – coughing, bending or rapid head movement and to avoid vomiting or constipation
The most significant sign of increased in intercranial pressure
decrease in the level of consciousness
A common complaint of the patient with a retinal detachment is seeing
a veil-like curtain in the visual field as well as flashes of light
photocoagulation
retina detachment surgery
After retina detachment surgery (photocoagulation
keep patch on both eyes and keep both eyes bandaged for 24 hours
What causes gum hyperplasia?
Dilantin
Cataract
an eye disease where the normally transparent lens becomes clouded and opaque leading to progressive blurring and gradual loss of vision
After cataract surgery, teach patient to avoid
increasing intraocular pressure
Glaucoma
abnormal increase in intraocular pressure
coughing, bending or rapid head movement and to avoid vomitinIs flaucoma a medical Is
increasing intraocular pressure
Is Glaucoma a medical emergency?
yes
Open angle Glaucoma results in
gradual loss of peripheral vision (tunnel vision)
Kernig’s sign
present if the lower leg if the lower leg cannot extend due to pain and spasm when a client is lying I supine with one leg bent over the abdomen
Kernig’s sign and Brundzinki’s sign
frequently seen in client suffering from Meningitis
During a seizure episode, the nurse should first move anything in the environment that could
injure a patient but should not move the patient
The client stands erect with feet together. First with eyes open and then closed
Romberg’s Test
Negative Babinski’s reflex
When the sole of the foot is stroked from the heel to the ball of the foot, toes should curl downward
If client is unable to maintain balance with eyes closed
this is Romberg’s sign and indicates cerebellar damage
If toes fan upward this is termed a positive Babinski’s sign and is an abnormal response (after age
That suggests brain stem damage
The characteristic problem in Parkinson’s disease is
rigidity and tremors
Brundzinski’s sign
present if the client’s hips and knees flex when he is lying supine with his head lifted towards the chest
Multiple sclerosis
is a progressive C.N.S. disorder
caused by demyelination in the brain and spinal cord
Multiple sclerosis
Nursing intervention for clients with MS are aimed at
safety and maximizing the client’s independence
Tensilon test
used to diagnose Myasthenia Gravis
Bell’s palsy
Involves paralysis of one side of the face, usually due to inflammation of the 7th cranial nerve
Nursing care for clients with ALS
monitor respiratory function, and monitor ability to swallow
Lou Gehrig’s disease
a progressive, fatal, motor neuron disease causing progressive muscular atrophy
Lou Gehrig’s disease
Amyotropic Lateral Sclerosis
Thoracic and lumbar spinal cord injuries affect the
legs, bladder and bowel movement
muscles used for breathing are paralyzed
A spinal cord injury at C3 or above is usually fatal because
Following a lumbar puncture
the client should be on bed rest for 6 to 8 hours
Deafness and Vertigo indicates
that cranial nerve number 8 is affected
The best position for a lumbar puncture is
the patient lying on her side with her knees curled up towards the chest
A patient with a diagnosis of meningitis should be placed in
isolation with less sources of stimuli
Cerebral spinal fluid would test
positive for glucose
this finding should be reported if a person has drainage testing positive for glucose after a head injury
Cerebral spinal fluid test
The first sign of increased intracranial pressure (ICP)
an alteration in the level of consciousness
Very often with head injury what is observed?
hyperthermia with body temperature of approximately 105 degrees Fahrenheit is observed
Elevating the head of bed approximately 30 degrees
can help reduce intracranial pressure by promoting venous return
Myasthenia Gravis
an autoimmune disorder causing disturbances in the transmission of impulses from muscles resulting in extreme muscle weakness
Weber and Rinne test
are used to evaluate hearing problems
Parkinson’s disease
progressive, degenerative disorder
Cardinal signs of Parkinson’s disease
Tremor at rest, rigidity, slow movement, shuffle gait, mask-like face, emotional labiality, drooling, sweating.
Parkinson’s disease
caused by dopamine depletion and resulting in a generalized decline in muscular functions
Teach client with Bell’s palsy
It usually lasts 2 to 8 weeks
client should prevent corneal drying by using artificial tears or manually closing eyes if necessary
Bell’s Palsy
A nurse’s primary responsibility for the client with Parkinson’s disease is to
maintain a safe environment in deference to the decline in muscular function
With left sided CVA
right side involvement (right side paralysis) would be expected
right sided CVA
left side involvement (right side paralysis) would be expected
