Neuro/Cranial/Sensory Flashcards
The nurse is educating a student nurse about collaborative care methods used with clients with increased intracranial pressure (IICP). Which method is appropriate treatment for clients with IICP?
- “Anti-hypertensives are considered first line therapy in client’s with ICP.”
- “Intravenous calcium antagonists increase perfusion.”
- “Glycerin has been clinically proven to increase ICP and should not be used.”
- “Clients given mannitol should be monitored for electrolyte imbalances.”
4
Mannitol lowers intracranial pressure by reducing fluid in the client’s brain cells. After administering mannitol, the nurse should closely monitor the patient to be sure excessive dehydration does not occur.
Which action should the nurse take when caring for a client with a spinal injury who suddenly begins showing signs of autonomic dysreflexia?
- Turn the client every 4-6 hours.
- Monitor blood pressure every 2-3 hours.
- Elevate the head of the bed.
- Encourage the client to ambulate.
3
Clients with spinal injuries are at risk for developing autonomic dysreflexia (AD) due to lack of parasympathetic or sympathetic nervous system activity. When the client exhibits symptoms of AD, the nurse should elevate the head of the bed or place the client in a seated position to promote a decrease in blood pressure and look for signs of possible cause such as an overextended bladder or impacted rectum that is eliciting the AD response.
The nurse is assessing a client who is 12 hours post spinal cord injury at C-6. The client is flushed in appearance with hot and dry skin. The client’s heart rate has dropped to 58 beats per minute and blood pressure dropped to 86/52 mmHg. The client’s signs and symptoms are indicative of which complication?
- Spinal shock.
- Neurogenic shock.
- Cardiogenic shock.
- Hemorrhagic shock.
2
Neurogenic shock is a type of distributive shock, resulting in the loss of vasomotor tone and system innervation causing the client to experience peripheral vasodilation and venous pooling, characterized by hypotension and bradycardia. Initially the skin temperature may be warm due to the peripheral dilation. This is seen with spinal cord injuries at or above T6.
The nurse is providing care for a client with hydrocephalus. Which would alert the nurse that the client’s intracranial pressure has increased?
- Narrowing pulse pressure.
- Regular breathing pattern.
- Worsening headache.
- Tachycardia.
3
Hydrocephalus is caused by an accumulation of cerebrospinal fluid in the brain. A worsening headache should alert the nurse to increased intracranial pressure.
A client with hydrocephalus has been admitted to the critical care unit. Which assessment finding should the nurse report to the physician?
- Oxygen level of 95%.
- Temperature of 98.9.
- Pulse of 42.
- Blood pressure of 126/82.
3
Hydrocephalus is an abnormal accumulation of cerebrospinal fluid within the brain, a condition which can lead to increased intracranial pressure (ICP). A heart rate below 60 (bradycardia) is an indication of ICP and should be reported to the physician immediately.
A client arrives to the emergency department (ED) via ambulance for a suspected stroke. According to the client’s spouse, the stroke-like symptoms occurred approximately 1.5 hours ago. An IV of 0.9% Normal Saline is infusing at 75ml/hr. The client has no airway compromise and no arrhythmias have been detected. Admission blood work has been drawn and sent to lab. What should the nurse anticipate as the next action in the client’s care?
- A bilateral carotid ultrasound and endarterectomy.
- The client transported to radiology for CT scan without contrast.
- The administration of recombinant tissue plasminogen activator (rtPA).
- Loading dose of ½ the dose of IV administration of digoxin 8-12 mcg/kg.
2
Standard of care for clients suspected of a stroke includes a CT scan without contrast within 30 minutes upon arrival to the ED to determine whether they are eligible to receive fibrinolytic therapy. Clients diagnosed with an acute ischemic stroke are eligible. Clients with a hemorrhagic stroke are not. Clients may receive the recombinant tissue plasminogen activator (rtPA) if given within 3-4.5 hours after the onset of the stroke symptoms.
The nurse is caring for a client who takes carbidopa/levodopa for treatment of Parkinson’s symptoms. What side effect of this medication should the nurse be aware of when helping the client ambulate?
- Shortness of breath.
- Incontinence.
- Syncope.
- Uncontrolled bleeding.
3
Carbidopa/levodopa (Sinemet) is a baseline medication used to treat clients with Parkinson’s disease. Clients who take Sinemet may experience syncope, so the nurse should be aware of an increased risk of falling.
Which condition should the nurse identify as a contributing factor for the development of peripheral neuropathy?
- Diabetes insipidis.
- Diabetes mellitus.
- Congestive heart failure.
- Hypertension.
2
Chronically elevated blood sugar can result in damage to peripheral nerves. Clients with diabetes mellitus are at risk for developing peripheral neuropathy, a condition marked by numbness, tingling, and pain in areas such as the hands, feet, legs, and face.
The nurse is assigned to provide care to a client with traumatic brain injury following a motor vehicle accident. Treatment has included intravenous fluid of hypertonic saline, a mannitol IV bolus, and a hypothermia blanket. The client hs been placed in a barbiturate coma and has been placed on a mechanical ventilator. What is the goal of these medical interventions?
- Decrease the risk of seizure activity.
- Prevent increased intracranial pressure.
- Increase the client’s Glasgow Coma Scale score.
- Promote perfusion and oxygenation to the brain tissue.
2
The medical interventions of administering hypertonic saline and osmotic diuretic mannitol are to pull fluid out of the intracranial space and into the vascular system for excretion. Placing the client into a hypothermic state with a hypothermic blanket is to slow down the brain’s metabolism. Placing the client into a barbiturate coma and using mechanical ventilation causes vasoconstriction of the cerebral vessels and decreases the oxygen demands of the brain. All these interventions are implemented to help decrease the risk of increased intracranial pressure.
The nurse plans to assess function of a client’s Cranial Nerve XI, the Spinal Accessory nerve. The nurse instructs the client to shrug both shoulders. What action should the nurse take while the client shrugs the shoulders?
- Apply pressure on both shoulders.
- Observe accessory muscle movement.
- Visually compare shoulder movement.
- Listen for crepitation in the joint.
1
The nurse assesses Spinal Accessory nerve function by applying pressure while the client shrugs the shoulders. The nurse should check for symmetrical strength as the client shrugs the shoulders against the resistance applied.
When doing an assessment of sensory nerve function, which test should the nurse omit if the pain sensation is normal?
- Temperature.
- Light touch.
- Vibration.
- Position.
1
The temperature assessment is conducted to determine if an individual can demonstrate a distinction between a “hot” and “cold” and is only appropriate to use for further evaluation if the pain test indicates any areas of numbness or increase sensitivity.
An alert child has been treated for a submersion injury (near drowning). Which complication should the nurse anticipate?
- Hypertension.
- Edema.
- Oliguria.
- Hypothermia.
4
Almost half of all children who experience near drowning, whether they are asymptomatic or minimally symptomatic, will experience complications during the first 24 hours after the incident. Hypothermia is common in children due to their large surface area relative to body mass, decreased subcutaneous fat, and limited thermoregulation.
The nurse is conducting a health promotion presentation about stroke prevention for a group of residents in a retirement community. Which should the nurse identify as a modifiable risk factor for stroke?
- Gender.
- Race.
- Age.
- Diet.
4
Diet is a modifiable risk factor. Choosing foods that are high in fiber and low in saturated fats, trans fats, and cholesterol can help prevent stroke.
Which client abilities are evaluated in an assessment of cranial nerve function?
- A Babinski response.
- Symmetrically smiling and frowning.
- Sticking out and moving the tongue.
- Tactile discrimination and fine touch.
- Distinguishing salty and sweet tastes.
2, 3, 5
Cranial nerve III, IV and VI assess the client’s ability to move the eyes in different positions. Cranial nerve VII assesses for symmetrical movement of facial expression. Cranial VII and IX assess the ability of taste. Testing cranial IX nerve assesses the different movements of the tongue.
A client is diagnosed with lesions in the right occipital lobe. Which clinical manifestation should the nurse expect to find?
- Loss of vision on the left side.
- Lack of coordination of movement on the right side.
- Inability to recognize bodily defects or diseases.
- Diminished response to verbal cues or pain on the left side.
1
A client with lesions in the right occipital lobe may present with loss of vision on the left side.
