Neuro Part One Session 2 Flashcards
Select the main structures below that play a role with altering intracranial pressure:
A. Brain
B. Neurons
C. Cerebrospinal Fluid
D. Blood
E. Vertebra
Answer: A, C, D
Which patient below is at MOST risk for increased intracranial pressure?
A. A patient who is experiencing severe hypotension.
B. A patient who is admitted with a traumatic brain injury.
C. A patient who recently experienced a myocardial infarction.
D. A patient post-op from eye surgery.
Answer: B
Rationale: Head trauma, cerebral hemorrhage, hematoma, hydrocephalus, tumor, encephalitis etc. can all increase ICP.
A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication?
A. Bradycardia
B. Decerebrate posturing
C. Restlessness
D. Unequal pupil size
Answer: C
Rationale: Mental status changes are the earliest indicator a patient is experiencing increased ICP. All the other signs and symptoms listed happen later.
A resident in a long term care facility fell during the previous shift and has a head laceration that was cleaned and bandaged. Which signs or symptoms would warrant transferring the resident to the emergency department?
A. 4 centimeters area of bright red drainage on the dressing.
B. A weak pulse, shallow respirations, and cool pale skin.
C. pupils that are equal, react to light, and accommodate.
D. Complaints of a headache that’s resolved with medication.
Answer: B
Rationale: These signs and symptoms indicate increased intracranial pressure from cerebral edema secondary to the fall, and they require immediate attention.
The mother of a patient diagnosed with bacterial meningitis asks the nurse, “I am so scared. What is this?” Which statement would be the most appropriate
response by the nurse?
A. “There is bleeding into his brain causing irritation of the meninges.”
B. “Your child is experiencing inflammation of the brain due to a blockage of CSF drainage.”
C. “This is a bacterial infection of the tissues that cover the brain and spinal cord.”
D. “This is an inflammation of the brain parenchyma caused by a mosquito bite.”
Answer: C
The public health nurse is giving a lecture on potential outbreaks of bacterial meningitis. Which population is most at risk for an outbreak?
A. Clients recently discharged from the hospital.
B. Residents of a college dormitory.
C. Individuals who visit a third world country.
D. Employees in a high-rise office building.
Answer: B
Rationale: Outbreaks of infectious meningitis are most likely to occur in dense community groups such as college campuses, jails, and military installations.)
The nurse is assessing a patient diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect them to demonstrate? SATA
A. Elevated temperature
B. Seizures
C. Visual Disturbances
D. Electrolyte imbalances
E. Personality changes
Answer: B, C, E
The nurse is alerted to a possible acute subdural hematoma in the patient who
A. Has periorbital ecchymosis and otorrhea
b. Has focal symptoms of brain damage with no recollection of a head injury
c. Develops decreased LOC and a headache within 48 hours of a head injury
d. Has an immediate loss of consciousness with a brief lucid interval followed by a decreasing LOC
Answer: C
T/F: A patient who is experiencing a tonic-clonic seizure is experiencing a focal (partial) seizure.
False
Rationale: A patient who is experiencing a tonic-clonic seizure is experiencing a GENERALIZED seizure. This type of seizure affects both sides of the brain
A child is being evaluated for seizures. While in the child’s room talking with the parents, you notice that the child appears to be daydreaming. You time this event to be 10 seconds and then the child appropriately responds and doesn’t recall the event.
This is known as what type of seizure?
A. Status Epilepticus
B. Atonic
C. Tonic-clonic
D. Absence
Answer: D
Your patient is experiencing a tonic clonic seizure. The environment is safe and you have started a timer. It began at 1402 and it is now 1410 and the patient is still seizing.
As the nurse you know
A. This will require intervention
B. The patient is likely brain dead
C. This patient now meets the criteria for a diagnosis of epilepsy
D. This is an appropriate length of time for this type of seizure
Answer: A
Rationale: If the seizure lasts MORE than 5 minutes, the patient needs medical treatment FAST to stop the seizure. This patient is experiencing status epilepticus.
The ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture?
A) Epistaxis
B) Periorbital edema
C) Bruising over the mastoid
D) Unilateral facial numbness
Answer: C
Rationale: An area of bruising may be seen over the mastoid (Battles sign) in a basilar skull fracture.
A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?
A) Respiratory distress and projectile vomiting
B) Bradycardia and hypertension
C) Tachycardia and agitation
D) Third-spacing and hyperthermia
Answer: B
A patient with a spinal cord injury (SCI) has complete paralysis of the upper extremities and complete paralysis of the lower part of the body. The nurse should use which medical term to adequately describe this in documentation?
A. hemiplegia
B. paresthesia
C. paraplegia
D. quadriplegia
Answer: D
What respiratory manifestations would you expect to see in a patient with a SCI between C6-C8?
A. Complete respiratory arrest
B. Loss of diaphragmatic innervation
C. Weakened accessory muscles and a weak cough
D. No respiratory involvement whatsoever
Answer: C
