Neuro, CVA, Spinal Injury Flashcards
what is the neural synapse?
the space between the axons of one neuron and the dendrites of the next neuron
What is an abnormal neurological finding in an 88 year old?
dizziness and problems with balance
What is the most reliable indicator of neurological status?
level of consciousness
How would you classify a patient who is stuperous, but reacts by withdrawing from painful stimuli?
semi comatose
what is a normal Babinski response?
toes curl down
what should a nurse assess on a patient scheduled for an angiogram?
allergy to shellfish
if a severe head injured patient assumes a posture of flexed upper extremities, with plantar flexed lower extremities, what would that indicate?
increasing ICP with decorticate posture
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.
BP elevations, increase in systolic with little or no associated increase in diastolic. widening pulse pressure
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?
take meds with food to decrease nausea and vomiting.
what is a positive Brudinski sign, what will show in a patient with meningitis?
flexion of both hips when the neck is flexed by the nurse
When assessing a patient with ICP/cerebral edema, how would the nurse know that the drug “Mannitol” was effective for ICP?
increased urine output
what would a nurse implement for a patient to prevent a headache after a lumbar puncture?
lay them flat after the procedure
3 classic signs of Cushing’s triad
hypertension, bradycardia, and a widening pulse pressure
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?
I will rest in between my periods of activity.
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?
drowsiness
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?
thicken liquids to make it easier to swallow
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?
other drugs can be combined to increase the effectiveness
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?
it can interfere with the effectiveness of their medication
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?
increase pulse and adventitious breath sounds
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?
Satin sheets or a wheelchair
when a patient falls to the floor with generalized seizure, what should the nurse do?
the head can be cradled or turn to one side to maintain a patent airway.
What can the nurse do when caring for a patient post craniotomy, to help reduce ICP?
elevate the head of the bed
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?)
prevent flexation, lay them flat
what should a nurse do before giving an enteral feeding to a patient?
elevate the head of the bed
If a patient has weakness of the right side and impaired reasoning after having a CVA, what area did the CVA occur in?
left
what patient is at greatest risk for a CVA
African American male 55-65
if a patient experiences a TIA and was prescribed warfarin (coumadin) what would be the effective therapeutic lab values for the PT and INR?
PT is 1.5 to 2.0 times normal and the INR is 2.0 - 3.0
what would the nursing teaching plan for a patient with a TIA include regarding OTC medications?
daily aspirin dose prevents blood clots
a patient recovering from a CVA asks the nurse the purpose of coumadin, what does the nurse tell the patient?
prevents blood clots
what is the nursing priority immediately after a CVA?
airway maintenance
how does a nurse recognize when the acute phase of a CVA has ended?
vital signs return to normal 24 - 48 hours
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?
3 hours
why is a lumbar puncture a most helpful diagnostic tool for a new patient who has had a CVA?
it will tell you if the stroke is hemorrhagic or embolic
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?
give the medication
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?
side rails up
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?
forceful cough discouraged
what nursing intervention will help preserve joint mobility in the acute phase of a CVA?
ROM and support affected joints, splint
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?
8 ml
how does a nurse on assessment know that a patient with a CVA is in transition to the rehabilitation phase?
no neurologic deficits
What is Homonymous Hemianopia and how should the nurse arrange the patients environment if the patient had a CVA?
half of the field of vision is lost, put things on the unaffected side.
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?
maintain body weight
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?
how can we fix it
what is the most helpful family teaching for a patient who is in the rehab phase after a CVA, regarding altered sensation
make frequent assessments of the area for signs of pressure and to protect it from injury
what post hospital option would provide the most comprehensive assistance to a patient who is recovering from a CVA?
rehab
why can Hyperglycemia occur in a patient after a stroke, what is this in response to?
stress
what level does the spinal cord extend to from the brainstem?
2nd lumbar
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?
you can’t tell until the spinal shock is gone
what nursing assessment would indicate resolution of spinal shock
appearance of spastic involuntary movement of extremities
what nursing assessment in the ER would show that a patient’s spinal cord injury is below C4?
unlabored respirations
inability of a patient to dorsiflex his/her foot against the resistance of a nurses hand confirms cord damage at what level?
L5
how does a nurse move the impaired leg of a patient with an SCI to avoid stimulating muscle spasms
support the knee and ankle when moving
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?
muscles move when supported against gravity
what technique would a nurse use when opening the airway in a newly admitted patient with an SCI?
jaw thrust
which neurological deficit the Brown sequard syndrome results in
ipsilateral loss of motor function with contralateral loss of pain and temperature perception
level of independence for a patient with c8 transection?
upper extremities, manage use of normal wheelchair
if a paraplegic excitedly reports seeing his foot move when he was being turned, how would the nurse explain
reflexive movement
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?
bladder will be spastic and spontaneously empty
purpose of Gardner Wells tongs
keep cervical vertebrae aligned
what is the major advantage of the halo device over the Gardner Wells tongs
patient can be taken out of bed
why a patient with a spinal cord injury would receive the medication methylprednisone
reduce the damage to the cellular membrane
what are the signs and symptoms of autonomic dysreflexia?
nasal congestion, facial flushing and a pounding headache, diaphoresis
when a nurse recognizes autonomic dysreflexia in a patient with SCI, what is the immediate nursing intervention?
inspect indwelling catheters, relieve distended bladder, fecal impaction removed if necessary. topically relieve pain or itching
if no urinary output has occurred in a patient who underwent a laminectomy 2 hours earlier, what should the nurse do?
intermittent catheterization
how should a nurse respond to a sci patient with a nursing diagnosis of sexual dysfunction related to altered body function
with thoughtful discussion and counseling
what does rehab do for a patient with an sci
help them achieve the highest level of independence
what nursing interventions would be for prevention of contractures in a patient with an sci
splinting
if a patients family is concerned with lack of bowel function two days after a sci, what is the best response
bowel function usually returns after 3 days
if a sci has a cat scan with contrast medium, what should the nurse have the patient do after the scan
drink plenty of fluids
if a patient sustains a sci at level c4 will the patient ever be free of the ventilator
no, c1-c4 need mechanical ventilation
