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NCLEX > Neuro > Flashcards

Neuro Flashcards

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1
Q

What does the GCS measure

A

measures LOC in a client who has altered LOC or potential of altered LOC

  • Eye opening
  • Motor response
  • verbal response
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2
Q

What is the normal pupil size

A

2-6mm

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3
Q

What is the normal score for the GCS

A

13-15

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4
Q

What does PERRLA stand for

A 
Pupil
Equal
Reactive
Round
Light
Accomodation
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5
Q

Assessment of reflexes name one

A

Babinski Reflex

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6
Q

Is it normal for a babinski reflex in an infant one year or less

A

Yes

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7
Q

Is it normal for a babinski reflex in an adult or infant over 1 year

A

NO

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8
Q

What reflex is normal for an adult or infant over 1

A

Plantar Reflex

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9
Q

Someone who has a tumor or lesion on spinal cord, MS or Lou Gehrig’s disease what type of reflex do you expect to see

A

Babinkski (severe problem in the CNS)

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10
Q

In a CT test, what do you need and what should you tell client

A

A signed consent because of dye
Keep Head still
No Talking

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11
Q

In a MRI do we use a dye or ratiation, magnet

A

Not usually, doesn’t have to use dye
No radiation
Yes to magnet

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12
Q

Which is better MRI or CT

A

MRI, Picks up on problems earlier

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13
Q

Someone with a pacemaker can they use a MRI

A

No

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14
Q

Is fillings ok in teeth ok

A

YEs it is fine

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15
Q

What type of client can’t tolerate this

A

Clostraphobic clients

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16
Q

In an MRI can they talk

A

Yes

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17
Q

What is a cerebral angiography

A

X ray of cerebral circulation from femoral artery using dye

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18
Q

Do we need a consent for an angiography

A

Yes

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19
Q

What do we make sure as a nurse pre cerebral angiography

A

Tell patient to be well hydrated, void
Check peripheral pulses,make sure groin is prepped

Check for BUN and Creatinine because dye will be excreted through kidneys
Hold metformin, monitor output
Check for allergies to iodine/shellfish
Explain that they will have a warmth in face and a metallic taste

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20
Q

What do we make sure as a nurse post-cerebral angiography

A

Tell client to bed rest 4-6 hours
Watch femoral site for bleeding
Watch for embolus (arm, heart, lung, kidneys

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21
Q

With a cerebral angiography what are we concerned about in terms of embolus

A

If the embolus goes to brain, we will see a change in LOC, one-sided weakness, paralysis, motor/sensory deficits

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22
Q

What does an Electroencephalopgraphy (EEG)do?

A
  • diagnose seizure disorders
  • evaluates types of seizures occuring
  • evaluates LOC and dementia
  • electric activity in the brain,
  • diagnose sleep disorders narcolepsy, cerebral infarct, brain tumors, or abscess
  • Screening for COMA
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23
Q

What nursing considerations should occur pre-EEG

A
  • Hold sedatives, because we are measuring electric activity and it would give us a false reading
  • No caffeine
  • Not NPO (drops BS)
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24
Q

What could the client be asked to be positioned during an EEG

A
  • first lying down quiety
  • then hyperventilate to assess brain circulation
  • for an unconscious, pain stimuli to see what happends to brain activity
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25
Q

What is the site used for a lumbar puncture

A

Lumbar Subarachnoid space

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26
Q

What is the purpose of a lumbar puncture

A
  1. To obtain and analyze spinal fluid
  2. To measure pressure using a manometer
  3. To administer drugs intrathecally (brain, spinal cord)
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27
Q

What position should the client be for a lumbar puncture

A

Propped to bedside table, head toward chest

Lyying fetal position chin to chest

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28
Q

What position should the client be post-lumbar puncture

A

Flat for 2-3 hours
Increase fluids to replace lost spinal fluid
Watch for headache- inceases when sitting up and decreases when lying down

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29
Q

How is the headache post lumbar treated

A

Bed rest
Fluids
Pain meds
Blood patch

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30
Q

What are some complications/ lifethreatening complications from lumbar puncture

A
  • Headache
  • Brain Herniation contraindicated with ICP
  • Meningitis
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31
Q 
If someone has a change in LOC
Slurred/slowed speech
delay in verbal response
increased drowsiness
Restless
confusion
What are these signs
A

Early signs of Increased ICP

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32
Q

If someone has a change in LOC and is progressing to stupor then coma
They have a change in vital signs; cushings triad and are posturing what are these signs of?

A

Late signs of Increased ICP

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33
Q

What are cushings triad

A
  1. systolic htn with a widening pulse pressure
  2. Slow full bounding pulse
  3. Irregular Resps
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34
Q

What is posturing

A

It’s a response to painful or noxious stimuli and indicates a compromise to motor response in brain

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35
Q

If a patient’s arms are flexed inwards and bent toward the body and the legs are extended what does this indicate

A

Decorticate posturing

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36
Q

If a patient has all four extremities are rigid extension

A

Decerebrate posturing

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37
Q

Which client is more serious, decorticate or decerebrate

A

Decerebrate

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38
Q

Can a client have both decorticate and decerebrate

A

Yes

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39
Q

What should we be concerned about if a client is rigid and tight

A

Burning more calories

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40
Q

What are the signs to watch out for with Increased ICP

A
  • Headaches
  • changes in pupils and pupil response (fixed and dilated)
  • Projectile vomitting (vomitting centers in brain are being stimulated)
41
Q

What are some complications of Increased ICP

A
  1. Brain Herniation

2. DI and SIADH

42
Q

What is brain herniation

A

Something in the brain putting pressure, that obstructs the blood flow to the brain and causes anoxia and then brain death

43
Q

What are the treatments for Increased ICP

A
  1. oxygenation
  2. Maintain cerebral perfusion- isotonic saline and inotropic agents: dobutamine and norepinephrine
  3. Keep temp below 100.4/ 38
  4. Elevate HOB
  5. Keep head in midline so jugular veins can drain
  6. Watch for ICP monitor turning
  7. Avoid restraints, valsalva, isometric exercise, sneezing, nose blowing, hip flexion, bladder distention
44
Q

Should you be suctioning a patient with increased ICP

A

Limit suctioning

45
Q

What should you be monitoring for in a client with increased ICP

A
  • monitor GCS

- Monitor vitals for cushings triad

46
Q

If a client’s GCS is below 8 what should you be thinking

A

Intubation

47
Q

Why is phenobarbital given to a patient with increased ICP

A

cause it causes a decrease in cerebral metabolism treat increased ICP that can’t be treated with other measures

48
Q

Why is mannitol given with increased ICP

A

It pulls fluid from brain cells and filters through kidneys

49
Q

Why is dexamethasone given with increased ICP

A

decreases cerebral edema

50
Q

What is a risk for using ICP monitoring device

A

Infection

51
Q

How do we prevent infection with ICP monitoring devices

A

Keep dressings dry

No loose connections

52
Q

What is meningitis

A

It’s an inflammation of spinal cord or brain

53
Q

What causes meningitis

A

Viral/Bacterial

Bacterial transmitted through resp system

54
Q 
If someone has 
chills/fever
severe headache
n/v
nuchal rigidity (rigid neck)
photophobia (light sensitivity)
A

Meningitis

55
Q

What are some treatment options for someone with meningitis

A

Steroids
Abx - if infection is bacterial
analgesics

56
Q

What type of precaution should we put the client in if it is a bacterial meningitis

A

Droplet precautions

57
Q

What type of precaution should we put the client in if it is a viral meningitis

A

contact

58
Q

How is bacterial meningitis transmitted

A

Respiratory tract

59
Q

How is viral meningitis transmitted

A

Feces

60
Q

What are the 2 types of seizures

A

Partial

Generalized

61
Q

If a person has partial seizure what is affected

A

a specific local area of brain

62
Q

If a person has a generalized seizure what is affected

A

involves the entire brain

63
Q

which seizure is a focal seizure and which is a non-focal

A

Focal seizure is partial seizure

Nonfocal is generalized

64
Q

Which seizure can an aura be it’s only manifestation

A

Partial

65
Q

In a partial seizure you can have symptoms from simple to complex, what does this mean

A
  • Simple means without loosing conscious, will see numbness, tingling, prickling or pain
  • complex is that they have an impaired conscious and may be confused and unable to respond
66
Q

What is the initial manifestation in a generalized seizure

A

Loss of Conscious

67
Q

What is a tonic/clonic seizure

A

Grand mal

68
Q

What is a myoclonic seizure

A

sudden, brief contractures of a muscle or group of muscles

69
Q

What is an absence seizure

A

petit mal, brief loss of conscious

70
Q

What are some complications of seizure

A
  1. Status epilepticus

2. Trauma

71
Q

What is a status epilepticus

A

it’s when a patient has continous seizures and does not return to conscious between seizures

72
Q

What are some treatment options for a person with seizures

A
  1. Neuro exam including lab and xrays, EEG’s
  2. Anticonvulsants
  3. Airway/ safety during seizures
73
Q

What are phenytoin, phenobarbital

A

Long acting anticonvulsants

74
Q

What are lorazepam and diazepam

A

Rapid acting anticonvulsants

75
Q

With a skull injury could you damage the brain

A

may or may not

76
Q

With a skull injury could you have an open fracture, if so what is torn

A

Yes Dura is torn

77
Q

With a skull injury could you have a closed fracture

A

Yes, Dura is not torn

78
Q

With a skull injury and with a basal skull fracture where do you see bleeding

A

Ears
Eyes
Nose
Throat

79
Q

What is a battle’s sign

A

It’s bruising over mastoid, bone behind ear

80
Q

What are peri-orbital bruising

A

It’s Raccoon eyes

81
Q

What is cerebrospinal rhinorrhea

A

It’s having spinal fluid leak from nose

82
Q

What is it that differentiates CSF from other fluids

A

Glucose in CSF and halo test

83
Q

What type of skull fractures require surgery, Depressed or non-depressed

A

Depressed

84
Q

What are some brain injuries

A

Concussion

Hematomas

85
Q

What happens in a concussion

A

There is temporary loss of neurological function with complete recovery
Will have a short period where they are unconscious or may just be dizzy or see spots

86
Q

What should we teach caregivers about s/s to bring the client back to the ED if a concussion occurs

A
  1. if they are having a difficult time awakening/speaking
  2. if the patient is confused
  3. Severe headache/ vomitting
  4. Has Pulse changes
  5. Has unequal pupils
  6. One sided weakenss
    ALl of these indicate increase in ICP
87
Q

Which one is more fatal of a hematoma:
a) Small hematoma developing rapidly
b) massive hematoma developing slowly
and why

A

Small hematoma, because a massive one that develops slowly gives the client a chance to adapt

88
Q

Two types of hematoma to worry about

A

Epidural

Subdural

89
Q

What is an epidural hematoma

A

It’s when you have an injury, rupture to the middle meningeal artery
injury, loss of consc, recovery period, can’t compensate any longer, neuro changes

90
Q

What is a subdural hematoma

A

It’s when you have a venous bleed

91
Q

What are the treatments for a epidural hematoma

A

Burr Holes and remove clot control ICP

Ask questions to ID the type of injury, eg. how long was the patient out

92
Q

Which hematoma is an emergency

A

Epidural

93
Q

What are the treatment options for subdural hematoma

A

Chronic imitates other conditions, such as acting drunk
Bleeding and compensating
Neuro changes
Immediate crainotomy and remove clot; control ICP

94
Q

What is a major complication with an upper spinal cord injury

A

An upper spinal cord injury (above T6), Autonomic Dysreflexia
Hyperflexia

95
Q

What are some S/s of autonomic reflexia

A 
Severe HTN and headache
Bradycardia
Nasal stuffiness
Flushing
Sweating
Blurred vision
Anxiety
96
Q

Does autonomic reflexia occur suddenly or after a while

A

Suddenly and it is an emergecy

97
Q

If autonomic reflexia is not treated promptly what can this cause

A

Hypertensive stroke

98
Q

What can cause autonomic reflexia

A

Distended bladder, constipation, painful stimuli

99
Q

What are some treatment options for autonomic reflexia

A

Treat BP, have client sit up
Treat cause; put catheter and remove impaction, look for skin pressure or painful stimuli, cold draft or breeze in room
Teach preventions

NCLEX (21 decks)

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