neurologic and sensory eaq Flashcards
the following flashcards are going to be about neurologic and sensory case study
which clinical manifestation would the nurse expect to identify in a client experiencing spinal shock immediately after sustaining a functional transection of the spinal cord at T7-T8? select all that apply. One, some, or all responses may be correct. (2)
- severe throbbing headache
- blurred vision
- spasticity
- incontinence
- flaccid paralysis
- respiratory failure
- sudden increase in blood pressure
- lack of reflexes below the injury
tell me why we selected the 2 that we did ?
tell me why we did not select the rest?
what is spinal shock syndrome ?
- flaccid paralysis
- lack of reflexes below the injury
spinal shock syndrome is immediate after a transection of the spinal cord ; it results in flaccid paralysis of skeletal muscles that usually lasts for 48 hours but may persist for several weeks.
Transection of the spaniel cord causes spaniel shock and will result in a loss of reflex activity below the level of the injury
autonomic dysreflexia is a potential life threatening condition that can occur in those with high level spinal cord injury - it presents as severe headache, and blurred vision
spasititiy occurs after spaniel shock has subsided
during the acute phase, retention of urine and feces occurs because of the decreased tone of the bladder and bowel; thus, incontinence is unusual.
respirations are labored but spontaneous breathing continues, indicating the level of injury may be located below c4.
a sudden increase in blood pressure is associated with autonomic dysreflexia
which clinical manifestation would the nurse expect to find when assessing a client with Parkinson disease? select all that apply. one, some, or all responses may be correct. (6)
- resting tremors
- pill-rolling
- unblinking eyes
- flattened affect
- muscle flaccidity
- tonic-clonic seizures
- slow voluntary movements
- loss of balance
what is Parkinson disease?
why did we select these 6?
why did we not select the rest?
- resting tremors
- pill-rolling
- unblinking eyes
- flattened affect
- slow voluntary movements
- loss of balance
Parkinson disease is often associated with the lack of dopamine in your brain - causing a neuro response to degenerate a part of your brain.
resting tremores, often accompanied by pill-rolling movements of the thumb abasing the fingers are associated with the destruction of the neurons of the basal ganglia and substantial nigra - usually this destruction causes decrease muscle tone
a masklike apterande, unblinking eyes, and monotonous speech patterns can be interpretated as flat affect
slow voluntary movements ( bradykinesia ) and loss of balance are associated with this disorder
muscle flaccidity is not
rigidity is caused by a sustained muscle contractions. Movement is jerky in quality ( cog-wheel rigidity )
tonic-clonic seizures are not associated
which clinical manifestation would the nurse expect to assess in the client diagnosed with Alzheimer disease? select all that apply. one,some, or all responses may be correct.(5)
- loss of recent memory
- focused attention span
- perceptual disturbances
- agnosia
- willingness to accept change
- enhanced sense of smell
- difficulty learning something new
- visuospatial deficits
what is Alzheimer diseases?
why did we select those 5 ?
why did we not select the rest?
- loss of recent memory
- perceptual disturbances
- agonsia
- difficulty learning something new
- visuospatial deficits
Alzheimer disease is associated with a global intellectual impariment that affects learning, thinking and language. Progressive deterioration of the regions of the brain results in
- cognitive deficits, decreased attention span, confusion, disoriented
patients with Alzheimers require a sense of security, so they are not likely to accept change or new.
patients will also have a sensory-perceptual alterations that can cause hallucinations
agnosia, is the inability to interpret sensation and recognize objects is common for patients with Alzheimer
patients with Alzheimer will have decreased sense of smell.
which test would the nurse use to assess a clients cortical sensory function? select all that apply. one, some, or all responses may be correct.(4)
- stereognosis
- Romberg test
- graphesthesia
- finger to nose test
- glasgow coma scale
- pseudoathetosis
- two point discrimination
- extinction
what is a cortical sensory function?
why did we select these 4?
why did we not select the rest?
- sterognosis
- graphesthesia
- two-point discrimination
- extinction
cortical sensory functions help interpretate sensory functions that require analysis of individual sensory modalities by the parietal lobes
stereognosis measures the ability to perceive the form and nature of objects
graphestheisa is the ability to feel writing on the skin
two point discrimination is the ability to perceive a separation between fingers and toes
extinction is the inability to identify a sensation on one side of the body when both sides are tested at the same time, however when only one side is tested at the time the sensation can be felt.
now the no’s
Romberg test measures proprioception
the finger to nose measure coordination and cerebellar function
glasgow coma scale is a standardized tool for rapid neurologcal assessment
pseduoathetosis is the involuntary movement of limbs which results from a loss of position sense but indicated intact motor pathways
which physical assessment would the nurse document on a client who is experiencing Cushing triad? select all that apply. one, some, or all responses may be correct (4)
- bradycardia
- decreased level of consciousness
- tachycardia
- irregular respiration
- systolic hypertension
- diastolic hypertension
- asymmetric pupils
- widening pulse pressure
what is Cushing triad?
why did we select these 4?
why did we not select the rest?
-bradycardia
- irregular respirations
- systolic hypertension
- widening pulse pressure
Cushing triad is a set of vital signs and assessments we do on patients that can indicate a increasing intracranial pressure
Cushing triad presents itself as bradycardia with a full bounding pulse, irregular respiration, systolic hypertension and widening pulse pressure.
asymmertrical pupils are associated with brain stem injury
choose the most likely options for the information missing from the statement by selecting from the list of options provided.
the client is at risk for developing
(3)
- hypertension
- diabets
- atelectasis
- aspiration pneumonia
- cholecystitis
- constipation
to provide some context the patient was Brought into the emergency department by his wife who was informing us of his past medication history. Ischemic stroke, diabetes, hypertension. He was found on the bathroom floor and was unable to take his morning medications due to gagging and inability to swallow properly.
- atelectasis
- aspiration pneumonia
- conspitation
the reason why the patient is at risk for developing atelectasis is because his increased respiratory rate, decreased lung sounds and hypoxemia.
aspiration pneumonia can occur due to the dysphagia as evidenced by the coughing and choking on water. the client would need to have a swallow test done prior to introducing liquids or foods - so that why he is npo
consitpation is another risk for the client due to the immobility - hypoactive bowel sounds is a manifestation of constipation
the client has hypernteison, so he is not at risk for developing hypertension he is already has 2 medications to help with it
same for diabetes it takes metformin
cholecystitis is an inflammation of the gallbladder, which is not an evident in clinical assessment findings
select the 3 findings that require immediate follow-up
- right sided weakness
- troponin level
- co2 level
- a1c level
- word-finding difficulty
- pain in left hip
- oxygen saturation
why those 3
why not the rest?
- right sided weakness
- a1c level
- word finding difficulty
the right sided weakness is a typical sign of a stroke
A1C is elevated and the client has no history of diabetes so that must be investigated
word-finding difficulty is common in left sided stroke - causing concern that the patient may be having a stroke
troponin levels are within range
co2 was elevated however the client has a long history of smoking, so the potential of his co2 being more than his oxygen could indicate possible COPD?
pain in the left hip, however still has full motion to walk around
oxygen above 90 does not require immediate flow up
which client findings indicate a risk factor for stroke? select all that apply. (5)
- smoking
- obesity
- hypertension
- hyperlipidemia
- glucose level
- potassium level
- tachycardia
- confusion
why did we select these 5
why did we not select the rest
- smoking
- obesity
- hypertension
- hyperlipidemia
- glucose level
potassium level is within normal limits
tachycardia is not a risk factor
confusion can be a sign of stroke not a risk factor
choose the most likely options for the information missing from the statements by selecting from the lists of options provided.
the nurse on the neurology unit determines the client most likely had an _____(1)stroke. the nurse would ask the priority initial question of when ____(2).the nurse would further assess the client for ___(3) and ___(4).
- right sided stroke
- ischemic
- hemorrhagic
- symptoms began
- ate last
- received flu shot
- poor impulse control
- analytic thinking deficits
- photophobia
- sensory perception
- proprioception alternations
- personality changes
- ischemic
- symptoms began
- analytic thinking deficits
- sensory perception
its important to note that a client history of hypertension and atherosclerosis and ischemic stroke isomer than likely to develop another one.
to determine the form of treatment it would be good to ask when the symptoms began because certain medications like TPA can only be given within 3 hours of symptom onset, but remember we dont give this thrmobolyci agent to hemorrhagic stroke cause of massive bleeding.
left sided stroke can cause right sided weakness, speech and language issues, which is why the patient has these symptoms
hemorrhagic stroke can cause headache, lethargy which he didn’t have
flu shot and last food are not priority
poor impulse is right sided
photophobia is hemorrhagic or right sided
and proprioception and personality changes in right sided stroke
the priority outcome is to ___. to achieve this outcome, the nurse should ___
- improve cerebral perfusion
- enhance cardiac output
- reduce pain
- lower head of the bed
- check gag reflex
- manually push alteplae
- improve cerebral perfusion
- lower head of the bed
the reason why we want to improve cerebral perfusion is because of the patient having ischemic stroke- meaning the lack of blood flow to the brain is very little. but by lowering the head of the bed, it doesn’t require the body to push so hard when trying to give blood to the head when sitting up.
yes we want to enhance cardiac output, but we can’t do that while laying down and It isn’t a priority
checking gag reflex is a priority for aspiration
alteplase is recommended for ischemic stroke but you never push it manually its placed on a programmable pump
neurologic (3)
- encourage smoking cessation
- monitor for icp
- maintain head in neutral,midline position
- cluster nursing care
elimination/nutrition (2)
- adminiter stool softener as prescribed
- apply condom urinary catheter
- suggest intake of simple sugars rather than saturated fats
- monitor intake and output
cardiopulmonary (2)
- encourage coughing every hour
- notified rapid response team for bp over 185
- hyper oxygenate before and after suctioning
- place client on npo status to prevent aspiration
neuro
- encourage smoking cessation
- monitor for icp
- maintain head in neutral,midline position
smoking cessation is needed because smoking is a risk factor for stroke - risk for icp is huge after a stroke
maintaining head neutral helps venous drainage from the brain
cluster care as this increases the risk for icp
elimination/nutrition
- adminiter stool softener as prescribed
- monitor intake and output
stool softener help prevent valsalva maneuver which cause increase icp
fluid balance is important
- he doesn’t have urine problems
- and no need to give simple sugars since that would make his a1c worse
cardiopulmonary
- notified rapid response team for bp over 185
- hyper oxygenate before and after suctioning
185 systolic is hypertension crisis
hyperpxygeninag hopes prevent hypoxemia
coughing is bad and can put pressure on the brain
for each assessment finding, click to specify if the finding indicates that the clients condition has improved, has not changed, or has declined.
is slightly confused to time and place
states is taking prescribed metformin for blood sugar
develops ataxia
displays decerebrate posturing
is feeding self with assistive devices
has decreasing score on the national institutes of health stroke scale
no change
improved
declined
declined
improved
improved
