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Medical-Surgical Nursing > Neuro, CVA, Spinal Injury > Flashcards

Neuro, CVA, Spinal Injury Flashcards

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1
Q

what is the neural synapse?

A

the space between the axons of one neuron and the dendrites of the next neuron

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2
Q

What is an abnormal neurological finding in an 88 year old?

A

dizziness and problems with balance

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3
Q

What is the most reliable indicator of neurological status?

A

level of consciousness

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4
Q

How would you classify a patient who is stuperous, but reacts by withdrawing from painful stimuli?

A

semi comatose

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5
Q

what is a normal Babinski response?

A

toes curl down

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6
Q

what should a nurse assess on a patient scheduled for an angiogram?

A

allergy to shellfish

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7
Q

if a severe head injured patient assumes a posture of flexed upper extremities, with plantar flexed lower extremities, what would that indicate?

A

increasing ICP with decorticate posture

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8
Q

when caring for a 90 year old patient with a closed head injury, know what a nurse would immediately report, related to increased intracranial pressure.

A

BP elevations, increase in systolic with little or no associated increase in diastolic. widening pulse pressure

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9
Q

if a patient with a generalized convulsive disorder has the following nursing diagnosis: “deficient knowledge, related to lack of information about side effects of Dilantin”, what goal and outcome criteria would be most appropriate for the patient?

A

take meds with food to decrease nausea and vomiting.

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10
Q

what is a positive Brudinski sign, what will show in a patient with meningitis?

A

flexion of both hips when the neck is flexed by the nurse

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11
Q

When assessing a patient with ICP/cerebral edema, how would the nurse know that the drug “Mannitol” was effective for ICP?

A

increased urine output

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12
Q

what would a nurse implement for a patient to prevent a headache after a lumbar puncture?

A

lay them flat after the procedure

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13
Q

3 classic signs of Cushing’s triad

A

hypertension, bradycardia, and a widening pulse pressure

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14
Q

in a patient with MS who has a nursing diagnosis of: knowledge deficit, related to conservation of energy, how would the nurse evaluate a positive outcome to the goal of teaching with what the patient tells the nurse?

A

I will rest in between my periods of activity.

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15
Q

if a patient fell and hit their head and blacked out for a while, and the nurse suspects an epidural hematoma what would the nurse be diligent in assessing?

A

drowsiness

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16
Q

An intervention related to eating, that should be added to a nursing care plan, to support nutritional intake, in a patient with Parkinson’s disease?

A

thicken liquids to make it easier to swallow

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17
Q

if a patient with Parkinson’s disease states that his current drug regimen of L-dopa and Sinemet are no longer controlling the symptoms, what would the nurses best response be?

A

other drugs can be combined to increase the effectiveness

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18
Q

If a Parkinson’s patient is considering taking St. John’s Wort, in addition to Sinemet and L-dopa, what is the best response for the nurse to give the patient?

A

it can interfere with the effectiveness of their medication

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19
Q

In a patient with Guillain-Barre syndrome, who is experiencing impaired breathing patterns, because of neuromuscular failure, what would indicate to the nurse that the patient needs to be suctioned?

A

increase pulse and adventitious breath sounds

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20
Q

a family member asks the nurse what an appropriate gift for a patient with Parkinson’s disease would be, what is the most useful reply?

A

Satin sheets or a wheelchair

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21
Q

when a patient falls to the floor with generalized seizure, what should the nurse do?

A

the head can be cradled or turn to one side to maintain a patent airway.

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22
Q

What can the nurse do when caring for a patient post craniotomy, to help reduce ICP?

A

elevate the head of the bed

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23
Q

in caring for an unconscious patient, who had a head injury 10 days ago, how should the nurse position the patient’s limbs ( to prevent what?)

A

prevent flexation, lay them flat

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24
Q

what should a nurse do before giving an enteral feeding to a patient?

A

elevate the head of the bed

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25
Q

If a patient has weakness of the right side and impaired reasoning after having a CVA, what area did the CVA occur in?

A

left

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26
Q

what patient is at greatest risk for a CVA

A

African American male 55-65

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27
Q

if a patient experiences a TIA and was prescribed warfarin (coumadin) what would be the effective therapeutic lab values for the PT and INR?

A

PT is 1.5 to 2.0 times normal and the INR is 2.0 - 3.0

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28
Q

what would the nursing teaching plan for a patient with a TIA include regarding OTC medications?

A

daily aspirin dose prevents blood clots

29
Q

a patient recovering from a CVA asks the nurse the purpose of coumadin, what does the nurse tell the patient?

A

prevents blood clots

30
Q

what is the nursing priority immediately after a CVA?

A

airway maintenance

31
Q

how does a nurse recognize when the acute phase of a CVA has ended?

A

vital signs return to normal 24 - 48 hours

32
Q

in a patient with CVA, several days ago, know how many hours the drug “plasminogen activator” (tPA) should be used after the onset of symptoms?

A

3 hours

33
Q

why is a lumbar puncture a most helpful diagnostic tool for a new patient who has had a CVA?

A

it will tell you if the stroke is hemorrhagic or embolic

34
Q

in a patient who has suffered a hemorrhagic stroke, is placed on a protocol of 60 mg of Nimodipine (calcium channel blocker) every 4 hours, if the patient’s pulse is 82 beats/minute before administration of the medication, what should the nurse do?

A

give the medication

35
Q

During the acute phase of CVA, a risk for falls related to paralysis is present, what nursing intervention will best protect the patient from injury?

A

side rails up

36
Q

since pneumonia is the most frequent cause of death after a stroke, what intervention would be contraindicated in the acute care of a patient with a hemorrhagic CVA?

A

forceful cough discouraged

37
Q

what nursing intervention will help preserve joint mobility in the acute phase of a CVA?

A

ROM and support affected joints, splint

38
Q

A patient in the acute phase of an embolic CVA had the following order: 400 unites of heparin per hour IV. the heparin is in a solution of 5000 units/100ml normal saline. what should the nurse set the electronic IV monitor at? how many milliliters per hour?

A

8 ml

39
Q

how does a nurse on assessment know that a patient with a CVA is in transition to the rehabilitation phase?

A

no neurologic deficits

40
Q

What is Homonymous Hemianopia and how should the nurse arrange the patients environment if the patient had a CVA?

A

half of the field of vision is lost, put things on the unaffected side.

41
Q

if a nurse is using the nursing diagnosis: imbalanced nutrition, related to dysphagia, with the goal of adequate nutrition, what appropriate outcome criterion would the nurse use?

A

maintain body weight

42
Q

if a patient is in the rehab phase after a CVA and accidentally knocks an adapted plate from the table and burst into tears, what would be the nurses best response?

A

how can we fix it

43
Q

what is the most helpful family teaching for a patient who is in the rehab phase after a CVA, regarding altered sensation

A

make frequent assessments of the area for signs of pressure and to protect it from injury

44
Q

what post hospital option would provide the most comprehensive assistance to a patient who is recovering from a CVA?

A

rehab

45
Q

why can Hyperglycemia occur in a patient after a stroke, what is this in response to?

A

stress

46
Q

what level does the spinal cord extend to from the brainstem?

A

2nd lumbar

47
Q

if a patient sustains a C5 compression fracture and can move only his head and has flaccid paralysis of all extremities, is the paralysis permanent?

A

you can’t tell until the spinal shock is gone

48
Q

what nursing assessment would indicate resolution of spinal shock

A

appearance of spastic involuntary movement of extremities

49
Q

what nursing assessment in the ER would show that a patient’s spinal cord injury is below C4?

A

unlabored respirations

50
Q

inability of a patient to dorsiflex his/her foot against the resistance of a nurses hand confirms cord damage at what level?

A

L5

51
Q

how does a nurse move the impaired leg of a patient with an SCI to avoid stimulating muscle spasms

A

support the knee and ankle when moving

52
Q

when recording findings of muscle strength, the nurse records a 2 for the right arm. what does that show for the muscles of the arm?

A

muscles move when supported against gravity

53
Q

what technique would a nurse use when opening the airway in a newly admitted patient with an SCI?

A

jaw thrust

54
Q

which neurological deficit the Brown sequard syndrome results in

A

ipsilateral loss of motor function with contralateral loss of pain and temperature perception

55
Q

level of independence for a patient with c8 transection?

A

upper extremities, manage use of normal wheelchair

56
Q

if a paraplegic excitedly reports seeing his foot move when he was being turned, how would the nurse explain

A

reflexive movement

57
Q

after spinal shock resolves and the patients indwelling catheter is removed, what does the nurse tell the patient about how to expect the bladder to empty?

A

bladder will be spastic and spontaneously empty

58
Q

purpose of Gardner Wells tongs

A

keep cervical vertebrae aligned

59
Q

what is the major advantage of the halo device over the Gardner Wells tongs

A

patient can be taken out of bed

60
Q

why a patient with a spinal cord injury would receive the medication methylprednisone

A

reduce the damage to the cellular membrane

61
Q

what are the signs and symptoms of autonomic dysreflexia?

A

nasal congestion, facial flushing and a pounding headache, diaphoresis

62
Q

when a nurse recognizes autonomic dysreflexia in a patient with SCI, what is the immediate nursing intervention?

A

inspect indwelling catheters, relieve distended bladder, fecal impaction removed if necessary. topically relieve pain or itching

63
Q

if no urinary output has occurred in a patient who underwent a laminectomy 2 hours earlier, what should the nurse do?

A

intermittent catheterization

64
Q

how should a nurse respond to a sci patient with a nursing diagnosis of sexual dysfunction related to altered body function

A

with thoughtful discussion and counseling

65
Q

what does rehab do for a patient with an sci

A

help them achieve the highest level of independence

66
Q

what nursing interventions would be for prevention of contractures in a patient with an sci

A

splinting

67
Q

if a patients family is concerned with lack of bowel function two days after a sci, what is the best response

A

bowel function usually returns after 3 days

68
Q

if a sci has a cat scan with contrast medium, what should the nurse have the patient do after the scan

A

drink plenty of fluids

69
Q

if a patient sustains a sci at level c4 will the patient ever be free of the ventilator

A

no, c1-c4 need mechanical ventilation

Medical-Surgical Nursing (11 decks)

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