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Med Surg 3 > Neuro > Flashcards

Neuro Flashcards

1
Q

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having
a tonic-clonic seizure. Which action should the nurse take?

a. Insert an oral airway during the seizure to maintain a patent airway.
b. Restrain the patients arms and legs to prevent injury during the seizure.
c. Time and observe and record the details of the seizure and postictal state.
d. Avoid touching the patient to prevent further nervous system stimulation

A

C. Because the diagnosis and treatment of seizures frequently are based on the description of the seizure,
recording the length and details of the seizure is important. Insertion of an oral airway and restraining the
patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of
injury during the seizure.

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2
Q

the ongoing process of awareness of self and the environment

A

Consciousness

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3
Q

Levels of LOC

A 
conscious
aware
disorientation
semiconscious (obtunded)
stupor
semicomatose 
unconscious (coma)
deep coma
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4
Q

Semiconscious

A

obtunded is a state similar to lethargy in which the patient has a lessened interest in the environment

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5
Q

Unconscious

A

coma

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6
Q

Painful stimuli to see if patient is responsive

A

sternal rub
supraorbital pressure
nail-bed pressure

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7
Q

Cushing’s Triad

A

systolic HTN with widening pulse pressire
bradycardia with bounding pulse
changes in respirations

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8
Q

Cheyne stokes breathing

A

increase then decrease in rate and depth of respirations and then apneic phase

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9
Q

Ataxic

A

random, irregular, some deep breaths and some shallow

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10
Q

normal pupils size is

A

2-5

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11
Q

sluggish or slow reaction to light means

A

increased ICP

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12
Q

nonreactive pupils can mean

A

Brain damage or pt is blind

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13
Q

if one pupil is Dilated it means

A

there is a compressed CN III

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14
Q

Bilaterally dilated pupils (ominous sign) mean

A

Increased ICP

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15
Q

pinpointed pupils can mean

A

pt is on opioids or durg OD

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16
Q

The Babinski relax is when the toes

A

fan out

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17
Q

adults should have a _____ Babinski sign

A

negiative

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18
Q

What is the pronator drift test

A

when the pt closes their eyes and sees if their hand drifts down and they lose balance

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19
Q

Sign of ICP when the pt has flexed extremities coming inward

A

Decorticate

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20
Q

sign of ICP when the patient’s extremities are facing outwards

A

Dececerbate

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21
Q

clinical signs of ICP

A

worst headache of their life

vomiting

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22
Q

Glasgow coma scale is 13-14 indicates

A

mildly impaired consciousness

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23
Q

Glasgow coma scale is 9-12 indicates

A

moderate impariement

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24
Q

Glasgow coma scale is 3-8 indicates

A

severe impariement

25
Q

What Cn do motor function for the eyes

A

III (3)
IV (4)
VI (6)

26
Q

Oculocephalic reflex (doll eyes)

A

abnormal = eyes remain stationary when moved

27
Q

Can not do a lumbar puncture if there is

A

ICP suspected

28
Q

normal ICP

A

0-15

29
Q

MAP normal

A

70-150

30
Q

Ischemia results when CPP falls below

A

50 mmHg, less than 30 is death

31
Q

What is CPP

A

Cerebral perfusion pressure

32
Q

what is normal Cerebral perfussion pressure?

A

70-100

33
Q

patients w increased ICP must avoid

A

Valsalva manuve

34
Q

Traumatic Brain injury

A

Secondary to MVAs, falls, struck by objects, and assaults
Higher in males
Prevention
Primary and secondary injury
Scalp injuries: abrasions, contusion, lacerations, or hematoma

35
Q

Rhinorrhea

A

CSF from the nose

36
Q

Otorrhea

A

CSF from the ear

37
Q

Halo sign

A

test for CSF (blood in center ring)

38
Q

Battle’s sign

A

bruising behind the ear

39
Q

raccoon eyes

A

swelling around the eyes

40
Q

battle sign and raccoon eyes indicate

A

skull fuctures

41
Q

Contusion

A

Contusion: loss of consciousness, stupor, confusion

42
Q

Coup

A

injury at point of impact

43
Q

Coup-contracoup

A

acceleration to decelation

2 points of injury

44
Q

Intracranial hemorrhage: hematoma symptoms

A

are delayed

45
Q

Epidural hematoma:

A

bleeding between skull and dura d/t laceration of vein or artery, occurs with skull fx

46
Q

what is the ventriculostomy system used for?

A

The monitoring system helps show whether blood flow to the brain is adequate.

47
Q

Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse?

a. Blood pressure 154/68, pulse 56, respirations 12
b. Blood pressure 134/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30

A

A

48
Q

. When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of
the arms, the nurse reports the response as
Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 724
a. flexion withdrawal.
b. localization of pain.
c. decorticate posturing.
d. decerebrate posturing.

A

c

49
Q

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter
should the nurse monitor to determine the medications effectiveness?
a. Blood pressure
b. Oxygen saturation
c. Intracranial pressure
d. Hemoglobin and hematocrit

A

c

50
Q

A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion
related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care?
a. Encourage coughing and deep breathing.
b. Position the patient with knees and hips flexed.
c. Keep the head of the bed elevated to 30 degrees.
d. Cluster nursing interventions to provide rest periods.

A

c

CLUSTERING CARE CAN CAUSE INCREASE ICP

51
Q
  1. A 23-year-old patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take?
    a. Administer IV furosemide (Lasix).
    b. Prepare the patient for craniotomy.
    Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 727
    c. Initiate high-dose barbiturate therapy.
    d. Type and crossmatch for blood transfusion.
A

ANS: B
The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent
herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate therapy
may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs
with head injuries, and transfusion is usually not necessary

52
Q

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the
nurse collect to determine whether a patient is developing postconcussion syndrome?
a. Short-term memory
b. Muscle coordination
c. Glasgow Coma Scale
d. Pupil reaction to light

A

A

53
Q

After having a craniectomy and left anterior fossae incision, a 64-year-old patient has a nursing diagnosis
of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate
nursing intervention is to
a. cluster nursing activities to allow longer rest periods.
Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 729
b. turn and reposition the patient side to side every 2 hours.
c. position the bed flat and log roll to reposition the patient.
d. perform range-of-motion (ROM) exercises every 4 hours.

A

d

54
Q

A 42-year-old patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be
included in the plan of care?
a. Encourage family members to remain at the bedside.
b. Apply soft restraints to protect the patient from injury.
c. Keep the room well-lighted to improve patient orientation.
d. Minimize contact with the patient to decrease sensory input.

A

a

55
Q

Meningococcal meningitis is spread by

A

respiratory secretions–AIRBONE

56
Q

When assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the following data. Which
finding should be reported immediately to the health care provider?
a. The patient exhibits nuchal rigidity.
b. The patient has a positive Kernigs sign.
c. The patients temperature is 101 F (38.3 C).
d. The patients blood pressure is 88/42 mm Hg

A

d

57
Q

ccp calculation=

A

MAP-ICP

58
Q

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and
an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?
a. Document the BP and ICP in the patients record.
b. Report the BP and ICP to the health care provider.
c. Elevate the head of the patients bed to 60 degrees.
d. Continue to monitor the patients vital signs and ICP.

A

B

CPP is
56 mm Hg, which is below the normal of 60 to 100 mm Hg

59
Q

After endotracheal suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic
head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first?
a. Document the increase in intracranial pressure.
b. Ensure that the patients neck is in neutral position.
c. Notify the health care provider about the change in pressure.
d. Increase the rate of the prescribed propofol (Diprivan) infusion.

A

B

Med Surg 3 (7 decks)

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