Neuro Flashcards
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
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.
the ongoing process of awareness of self and the environment
Consciousness
Levels of LOC
conscious aware disorientation semiconscious (obtunded) stupor semicomatose unconscious (coma) deep coma
Semiconscious
obtunded is a state similar to lethargy in which the patient has a lessened interest in the environment
Unconscious
coma
Painful stimuli to see if patient is responsive
sternal rub
supraorbital pressure
nail-bed pressure
Cushing’s Triad
systolic HTN with widening pulse pressire
bradycardia with bounding pulse
changes in respirations
Cheyne stokes breathing
increase then decrease in rate and depth of respirations and then apneic phase
Ataxic
random, irregular, some deep breaths and some shallow
normal pupils size is
2-5
sluggish or slow reaction to light means
increased ICP
nonreactive pupils can mean
Brain damage or pt is blind
if one pupil is Dilated it means
there is a compressed CN III
Bilaterally dilated pupils (ominous sign) mean
Increased ICP
pinpointed pupils can mean
pt is on opioids or durg OD
The Babinski relax is when the toes
fan out
adults should have a _____ Babinski sign
negiative
What is the pronator drift test
when the pt closes their eyes and sees if their hand drifts down and they lose balance
Sign of ICP when the pt has flexed extremities coming inward
Decorticate
sign of ICP when the patient’s extremities are facing outwards
Dececerbate
clinical signs of ICP
worst headache of their life
vomiting
Glasgow coma scale is 13-14 indicates
mildly impaired consciousness
Glasgow coma scale is 9-12 indicates
moderate impariement
Glasgow coma scale is 3-8 indicates
severe impariement
What Cn do motor function for the eyes
III (3)
IV (4)
VI (6)
Oculocephalic reflex (doll eyes)
abnormal = eyes remain stationary when moved
Can not do a lumbar puncture if there is
ICP suspected
normal ICP
0-15
MAP normal
70-150
Ischemia results when CPP falls below
50 mmHg, less than 30 is death
What is CPP
Cerebral perfusion pressure
what is normal Cerebral perfussion pressure?
70-100
patients w increased ICP must avoid
Valsalva manuve
Traumatic Brain injury
Secondary to MVAs, falls, struck by objects, and assaults
Higher in males
Prevention
Primary and secondary injury
Scalp injuries: abrasions, contusion, lacerations, or hematoma
Rhinorrhea
CSF from the nose
Otorrhea
CSF from the ear
Halo sign
test for CSF (blood in center ring)
Battle’s sign
bruising behind the ear
raccoon eyes
swelling around the eyes
battle sign and raccoon eyes indicate
skull fuctures
Contusion
Contusion: loss of consciousness, stupor, confusion
Coup
injury at point of impact
Coup-contracoup
acceleration to decelation
2 points of injury
Intracranial hemorrhage: hematoma symptoms
are delayed
Epidural hematoma:
bleeding between skull and dura d/t laceration of vein or artery, occurs with skull fx
what is the ventriculostomy system used for?
The monitoring system helps show whether blood flow to the brain is adequate.
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
. 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.
c
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
c
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.
c
CLUSTERING CARE CAN CAUSE INCREASE ICP
- 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.
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
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
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.
d
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
Meningococcal meningitis is spread by
respiratory secretions–AIRBONE
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
d
ccp calculation=
MAP-ICP
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.
B
CPP is
56 mm Hg, which is below the normal of 60 to 100 mm Hg
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.
B
