Neuro part 1 Test 7 SG- DONE Flashcards
1.How would you assess the motor response of an unconscious client? (pg.458)
-administering a painful stimulus to determine the client’s response.
2.What is Decorticate Posturing (pg.458):
the arms are flexed, fists are clenched, and the legs are extended
3.Decerebrate Posturing (pg. 458, ATI pg.17):
Extension of elbows & wrists, abduction of arms
Decerebrate rigidity = extremities are stiff rigid
- What is Flaccid (pg.458):
no motor response to stimuli
5.What is a Glasgow Coma Scale? (pg.459, ATI pg.17)
Glasgow Coma Scale: is an objective assessment tool for evaluating LOC of a client. The GCS # allows providers to immediately determine if neurologic changes have occurred.
6.What does the GCS scale consist of? (pp slide 3)
Eye- Opening response: 4 spontaneous, 3 to voice, 2 to pain, 1 none
Verbal response: 5 oriented x time, person, place ;4 confused, 3 inappropriate words, 2 incomprehensive sounds, 1 none
Motor response: 6 obeys commands, 5 moves to localized pain, 4 flex to withdraw from pain, 3 abnormal flexion, 2 abnormal extension, 1 none
7.At what level is the client considered to be in a coma? (pg.459, ATI pg.17)
Score of 8 or less.
8.How do you check for neck rigidity? (pg.460)
Move the head and chin towards the chest.
9.Nuchal rigidity:
pain & stiffness, resistance when you move the neck towards the chest or inability to place the chin on the chest
- Brudzinski? (pg.469)
Flexion of the neck towards the chin if the knees and hips flex up its positive.
- Kernig? (pg.469)
Inability to extend the leg when the thigh is flexed on the abdomen (severe stiffness in hamstring)
12.Manifestations of increased intracranial pressure? (PP slide 5)
-decreasing LOC (early manifestation) *LOC is the earliest indicator of neurologic status
-changes in pupils
-headache (more severe in the morning
-vomiting, papilledema, decorticate or decerebrate posturing
-stuporous, semi-comatose: confusion, restlessness periodic disorientation
-Cushing’s triad: pulse rate that increases initially but then decreases & respiratory rate that is irregular, Pulse pressure (difference between systolic & diastolic) 40-60 difference is normal.
-Cheyenne-Stokes respirations
13.Nursing considerations for intracranial pressure (pp slide 6)
-maintain head in midline,30-degree elevation
-maintain BP & ensure cerebral perfusion/fluids as ordered (AVOID hypotonic solutions)
-maintain airway (monitor o2 levels)
-monitor neurologic status (change in LOC)
-seizure precautions
-decrease stimuli (may need pt to be sedated)
-indwelling catheter may be placed to monitor I & O’s
-stool softener (important to avoid straining)
-avoid hypothermia
14.What is Cushing’s Triad? (PP slide 5)
pulse rate that increases initially but then decreases(bradycardia) & respiratory rate that is irregular, Pulse pressure (difference between systolic & diastolic) 40-60 difference is normal.
15.What is meningitis and what is it caused by? (PP slide 7)
Infection of the meninges which surround & protect the brain & spinal cord caused by a virus, bacteria/fungi, or parasite.
16.Meningitis manifestations (pp slide 8)
-high fever
-positive Brudzinski’s sign
-excruciating headache
-nuchal rigidity
17.Phenytoin need to knows (pp slide 28, pg.485)
(seizures)
-do not abruptly stop medication
-can cause gingival hyperplasia (overgrowth of the gums, puffy & red), good dental hygiene is important
-can be toxic to the liver, monitor LFT
-check phenytoin levels (narrow therapeutic range 10-20)
-monitor calcium (can cause low calcium)
-can cause thrombocytopenia (bruising, nose bleeds, flu like symptoms) >notify PCP
-skin rash > Steven Johnson syndrome REPORT
-no oral contraceptives
-hypotension (low & slow vitals)
-suicidal thoughts
18.Levodopa need to know(pp slide 23, flashcard, pg.480)
(parkinsons)
**-decrease protein (can interfere w/med) **
-do not stop abruptly
-monitor LFTS
-don’t take w/MAOI’s (risk for hypertensive crisis)
-can cause dark color in saliva, urine or sweat
-change positions slowly
-monitor for behavioral & mood changes
19.Seizure nursing actions (PP slide 28)
-keep safe from injury (pillow under head)
-position client on their side, loosen restrictive clothing, keep airway patent, suction client, administer oxygen
-document of the situation that proceeded the seizure, to assist in identifying precipitating factors like an aura, duration of the seizure, parts of the body involved.
20.Seizure classifications (PP slide 27)
Absence seizure: stares blankly, eyelids flutter, lack of prominent movements
Myoclonic seizure: sudden brief jerking
Tonic-Clonic seizure: muscle alternate between contraction & relaxation, jerking movements
21.Post seizure nursing actions (slide 29, ATI pg.34)
Ask the patient if they know what happened?
-Ask what type of body movements? Automatisms (repetitive non purposeful actions/movements)
-did they lose consciousness?
-how long was the seizure?
-was there an aura?
-monitor postictal phase (period after the seizure, very often will be very sleepy)
-check vitals, check for injuries, perform neurological check, reorient client
22.Parkinson’s manifestations (PP slide 22)
assess for progression of disease
(For progressive diseases we try to keep client as independent as possible.)
*Parkinson medications can decrease symptoms drastically at first, but overtime effects will decrease.
*Metoclopramide given for Gerd can give extrapyramidal effects
-muscle rigidity
-tremors: pill rolling
-bradykinesia (slow movements including slow speech, masklike expression & decreased blinking)
-stooped posture
-hypophonia (low volume of speech) & slow speech
-shuffling gait: difficulty redirecting forward motion
-dysphagia
23.Guillan-Barre syndrome nursing considerations (pp slide 12)
-assess signs of respiratory distress
-monitor airway
-spirometer
-have emergency suction near bedside
-skin care
-change position every 2 hrs
-ROM exercises to prevent muscle atrophy
24.Guillan-Barre syndrome manifestations (pp slide 11)
**disease is ascending **
-difficulty chewing, talking, swallowing
-tingling in the arms & legs
-incontinence
-weakness that progresses
-paralysis
25.ALS manifestations (PP slide 18)
-wasting of the arms, legs, and trunk
-develop atrophy (experiences episodes of muscle fasciculations -twitching)
-progressive muscle weakness
-if ALS affects the brainstem > difficulty speaking & swallowing, periods of inappropriate laughter & crying, respiratory failure & total paralysis
26.Encephalitis manifestations and diagnosis (pp slide 10, Pg.470)
ASK IF THEYVE HAD ANY RECENT BUG BITES
- Sudden fever
- Severe headache
- Stiff neck
- Seizures
- Spastic or flaccid paralysis
- Tremors
- Muscle weakness
- Incontinence
- Lethargy
- Irritability
- Delirium
- Visual disturbances
- Vomiting
- Drowsiness
- Coma
Dx: lumbar puncture, EEG.
27.Baclofen need to knows(pp slide 17, pharm pg.360)
(MS)
-decrease & minimize the muscles spasticity & rigidity (for M.S)
-causes drowsiness, dizziness, nausea, weakness
-hypotension
28.Brain tumor manifestations, focal (PP slide 30)
-headache (most common in the AM, becoming increasingly severe & occurs more frequenltly as the tumor grows)
-vomiting occurs w/out nausea or warning
-papilledema
-double vision and other sensory loss
-speech difficulty
-seizures
-muscle weakness.
-paralysis
(Focal= focused on certain part of the brain)
(Generalized= over general area> vomiting)
29.Brain tumor priority (PP slide 31)
-prevent increased ICP
30.Huntington’s Disease manifestations (PP slide 24)
-choreiform (jerking, riving -exaggerated movements) movements
-intellectual decline
-difficulty chewing & swallowing
-grimacing
-speech difficulty
-severe depression (can lead to suicide)
-mental apathy & emotional disturbances
-loss of bowel & bladder control
31.Valproic acid need to knows (pp slide 24, pg.484)
(seizures)
-can cause thrombocytopenia (watch 4 bruising, nose bleeds, flu like symptoms) >notify PCP
-monitor LFT’s
-do not abruptly stop medication
-monitor calcium levels
- avoid alcohol use
-monitor platelets & bleeding time, ammonia levels
32.Amantadine need to knows (pp slide 23, ATI pg.40, pg.480)
(Parkinson’s)
-can cause insomnia & lightheadedness
-monitor for discoloration of the skin that subsides when amantadine is discontinued
-may cause anxiety, confusion, anticholinergic effects (dry mouth, constipation).
-can cause hypotension (slow position changes)
-do not stop abruptly
-do not mix w/MOI’S
- Selegiline need to knows (pp slide 23)
(Parkinson’s)
- avoid foods high in tyramine
-massive HTN crisis risk (massive headache)
-major risk for stroke
-begin diet at least 2 weeks before beginning treatment & 2 weeks after treatment.
-avoid OTC drugs (calcium, antacids, Tylenol, NSAIDS naproxen/ibuprofen)
-increase suicide risk
-2 wk wash out period (no other antidepressants)
