Neurological Disorders Flashcards
The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client’s peripheral response to pain? 1. Sternal rub 2. Nail bed pressure 3. Pressure on the orbital rim 4. Squeezing of the sternocleidomastoid muscle
Nail Bed Pressure
Nail bed pressure tests a basic motor and sensory peripheral response.
Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
The nail beds are the most distal of all options and are therefore the most peripheral. Each of the other options may elicit a generalized response, but not a localized one.
The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising?
1.
Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure
2.
Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
3.
Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
4.
Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
A change in vital signs may be a late sign of increased intracranial pressure.
Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.
A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?
1.
Blowing the nose
2.
Isometric exercises
3.
Coughing vigorously
4.
Exhaling during repositioning
Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure.
Some of these activities include isometric exercises, Valsalva’s maneuver, coughing, sneezing, and blowing the nose.
Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.
How can CSF be distinguished from other body fluids ?
CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.
A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present?
1.
Fluid is clear and tests negative for glucose.
2.
Fluid is grossly bloody in appearance and has a pH of 6.
3.
Fluid clumps together on the dressing and has a pH of 7.
4.
Fluid separates into concentric rings and tests positive for glucose.
Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.
Focus on the subject, the characteristics of CSF. Recall that CSF contains glucose, whereas other secretions, such as mucus, do not. Knowing that CSF separates into rings also will help you to answer this question
The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists?
1.
Hyperreflexia
2.
Positive reflexes
3.
Flaccid paralysis
4.
Reflex emptying of the bladder
Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.
Recall that spinal shock is characterized by the loss of movement of skeletal muscles, loss of bowel or bladder wall function, and depressed reflex action.
Return of any of these indicates that spinal shock is beginning to resolve. Note that options 1, 2, and 4 are comparable or alike, indicating the presence of reflexes.
What is spinal shock characterized by ?
the loss of movement of skeletal muscles, loss of bowel or bladder wall function, and depressed reflex action. Return of any of these indicates that spinal shock is beginning to resolve the loss of movement of skeletal muscles, loss of bowel or bladder wall function, and depressed reflex action. Return of any of these indicates that spinal shock is beginning to resolve
The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply.
1.
Loosening restrictive clothing
2.
Restraining the client’s limbs
3.
Removing the pillow and raising padded side rails
4.
Positioning the client to the side, if possible, with the head flexed forward
5.
Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist
Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage.
The limbs are never restrained because the strong muscle contractions could cause the client harm.
If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head from injury; and moves furniture that may injure the client.
Think about ethical and legal issues to eliminate option 5. Next, evaluate this question from the perspective of causing possible harm. No harm can come to the client from any of the options except for restraining the limbs. Remember to avoid restraints.
Aphasia
A language disorder that affects a person’s ability to communicate.
It can occur suddenly after a stroke or head injury, or develop slowly from a growing brain tumor or disease.
Aphasia affects a person’s ability to express and understand written and spoken language.
Once the underlying cause is treated, the main treatment for aphasia is speech therapy.
a weakness of one side of the body that may occur after a stroke.
hemiparesis
It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters.
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply.
1.
The client is aphasic.
2.
The client has weakness on the right side of the body.
3.
The client has complete bilateral paralysis of the arms and legs.
4.
The client has weakness on the right side of the face and tongue.
5.
The client has lost the ability to move the right arm but is able to walk independently.
6.
The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance
Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.
Homonymous hemianopsia is _____________. What nursing interventions should be done ?
loss of half of the visual field.
The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.
The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully?
1.
Gets angry with family if they interrupt a task
2.
Experiences bouts of depression and irritability
3.
Has difficulty with using modified feeding utensils
4.
Consistently uses adaptive equipment in dressing self
Clients are evaluated as coping successfully with lifestyle changes after a stroke if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions.
Options 1 and 2 are not adaptive behaviors; option 3 indicates a not yet successful attempt to adapt.
Options 1 and 2 are behaviors that may be expected in the client with a stroke, but they are not adaptive responses. Instead, they are a result of the insult to the brain. Options 3 and 4 indicate that the client is trying to adapt, but the correct option has the best outcome.
the common causes of myasthenic and cholinergic crises are __________________ and __________________,
undermedication and overmedication
The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective?
1.
Taking medications as scheduled
2.
Eating large, well-balanced meals
3.
Doing muscle-strengthening exercises
4.
Doing all chores early in the day while less fatigued
Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important.
Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.
defined by slow movement and an impaired ability to move the body swiftly on command
Bradydyskinesia
The client with Parkinson’s disease should be instructed regarding safety measures in the home. The client should use his or her _________as support to get to the bathroom because of bradykinesia. The client should sit down to put on pants and shoes to prevent __________. The client should exercise every day in the ____________when energy levels are highest.
The client should have all loose rugs in the home removed to prevent falling.
walker; falling; morning
the pain of trigeminal neuralgia is triggered by mechanical or thermal stimuli. Very _________foods are likely to trigger the pain, not relieve it.
hot or cold
The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement?
“I will wash my face with cotton pads.”
2.
“I’ll have to start chewing on my unaffected side.”
3.
“I should rinse my mouth if toothbrushing is painful.”
4.
“I’ll try to eat my food either very warm or very cold.”
Facial pain can be minimized by using cotton pads to wash the face and using room temperature water. The client should chew on the unaffected side of the mouth, eat a soft diet, and take in foods and beverages at room temperature. If brushing the teeth triggers pain, an oral rinse after meals may be helpful instead.
Recall that the pain of trigeminal neuralgia is triggered by mechanical or thermal stimuli. Very hot or cold foods are likely to trigger the pain, not relieve it.
The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease?
1.
Meningitis or encephalitis during the last 5 years
2.
Seizures or trauma to the brain within the last year
3.
Back injury or trauma to the spinal cord during the last 2 years
4.
Respiratory or gastrointestinal infection during the previous month
Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves.
Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. On occasion, the syndrome can be triggered by vaccination or surgery.
The client with Guillain-Barré syndrome experiences fear and anxiety from the __________paralysis and ________onset of the disorder. The nurse can alleviate these fears by
ascending; sudden; providing accurate information about the client’s condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.
A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit?
1.
Is disoriented to person, place, and time
2.
Affect is flat, with periods of emotional lability
3.
Cannot recall what was eaten for breakfast today
4.
Demonstrates inability to add and subtract; does not know who is the president of the United States
The limbic system is responsible for feelings (affect) and emotions.
Calculation ability and knowledge of current events relate to function of the frontal lobe.
The cerebral hemispheres, with specific regional functions, control orientation. Recall of recent events is controlled by the hippocampus.
The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client’s safety? Select all that apply.
1.
Padding the side rails of the bed
2.
Placing an airway at the bedside
3.
Placing the bed in the high position
4.
Putting a padded tongue blade at the head of the bed
5.
Placing oxygen and suction equipment at the bedside
6.
Flushing the intravenous catheter to ensure that the site is patent
Evaluate this question from the perspective of causing possible harm. No harm can come to the client from any of the options except for placing the bed in the high position and using a tongue blade.
Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure medications must be administered, and as part of the routine assessment the nurse should be checking patency of the catheter. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client’s teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.
A Glasgow Coma Scale score of 15 is
a perfect score and indicates that the client is awake and alert, with no neurological deficits.
Signs of meningeal irritation compatible with meningitis include ………….
nuchal rigidity, a positive Brudzinski’s sign, and positive Kernig’s sign.
_____________sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip.
Kernig’s
_______________sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest
Brudzinski’s
The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery?
1.
A negative Kernig’s sign
2.
Absence of nuchal rigidity
3.
A positive Brudzinski’s sign
4.
A Glasgow Coma Scale score of 15
Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinski’s sign, and positive Kernig’s sign.
You can eliminate options 1, 2, and 4 because they are comparable or alike and are normal findings.
Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig’s sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski’s sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological deficits.
What is a halo device ?
A halo is a medical device used to stabilize the cervical spine after traumatic injuries to the neck, or after spine surgery. The apparatus consists of a halo vest, stabilization bars, and a metal ring encircling the patient’s head and fixated to the skull with multiple pins.
The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions?
1.
“I will use a straw for drinking.”
2.
“I will drive only during the daytime.”
3.
“I will be careful because the device alters balance.”
4.
“I will wash the skin daily under the lamb’s wool liner of the vest.”
The client cannot drive at all because the device impairs the range of vision. The inability to turn the head without turning the torso would contraindicate driving.
The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the use of powder or lotions. The liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed.
With an ascending paralysis, the client is at risk for involvement of ___________________
respiratory muscles and subsequent respiratory failure.
The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client’s room?
1.
Nebulizer and pulse oximeter
2.
Blood pressure cuff and flashlight
3.
Flashlight and incentive spirometer
4.
Electrocardiographic monitoring electrodes and intubation tray
The client with Guillain-Barré syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray should be available for use
. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the use of electrocardiographic monitoring. Because the client is immobilized, the nurse should assess for deep vein thrombosis and pulmonary embolism routinely. Although items in the incorrect options may be used in care, they are not the most essential items from the options provided.
The correct option is the only one that includes an intubation tray, which would be needed if the client’s status deteriorated to needing intubation and mechanical ventilation. This option most directly addresses the airway
Use of proper positions promotes _____________from the cranium to keep intracranial pressure from elevating.
venous drainage
The head of the client at risk for or with increased intracranial pressure should be positioned so that it is in a neutral, midline position. The head of the bed should be raised to 30 to 45 degrees. The nurse should avoid flexing or extending the client’s neck or turning the client’s head from side to side.
The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply.
1.
Head midline
2.
Neck in neutral position
3.
Head of bed elevated 30 to 45 degrees
4.
Head turned to the side when flat in bed
5.
Neck and jaw flexed forward when opening the mouth
Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure from elevating. The head of the client at risk for or with increased intracranial pressure should be positioned so that it is in a neutral, midline position. The head of the bed should be raised to 30 to 45 degrees. The nurse should avoid flexing or extending the client’s neck or turning the client’s head from side to side.
Visualize each of the positions identified in the options and identify those that will promote venous drainage from the cranium.
The physical appearance of CSF drainage is that of a halo.
TRUE OR FALSE
TRUE
The nurse is assessing the nasal dressing on a client who had a transsphenoidal resection of the pituitary gland. The nurse notes a small amount of serosanguineous drainage that is surrounded by clear fluid on the nasal dressing. Which nursing action is most appropriate?
Notify the health care provider (HCP)
Cerebrospinal fluid (CSF) leakage after cranial surgery may be detected by noting drainage that is serosanguineous surrounded by an area of straw-colored or pale drainage.
The physical appearance of CSF drainage is that of a halo. If the nurse notes the presence of this type of drainage, the HCP needs to be notified. The remaining options are inappropriate nursing actions.
Recalling the risk of CSF leakage after this type of surgery will direct you to the correct option.
In Meniere’s disease, what is the goal of treatment?
And whiat dietary changes are sometimes prescribed for this?
The goal of treatment is To reduce the endolymphatic fluid
Dietary changes, such as salt and fluid restrictions, that reduce the amount of endolymphatic fluid are sometimes prescribed for the client with Ménière’s disease. The client should be instructed to consume a low-sodium diet and restrict fluids as prescribed
__________________could indicate the presence of a cerebrospinal fluid leak
bloody or clear drainage
The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate?
1.
Insert nasal packing.
2.
Document the findings.
3.
Contact the health care provider (HCP).
4.
Monitor the client’s blood pressure and check for signs of increased intracranial pressure.
Bloody or clear drainage from either the nasal or the auditory canal after head trauma could indicate a cerebrospinal fluid leak. The appropriate nursing action is to notify the HCP, because this finding requires immediate intervention. The remaining options are inappropriate nursing actions in this situation
Recalling that bloody or clear drainage could indicate the presence of a cerebrospinal fluid leak will assist in directing you to the correct option.
Bloody or clear drainage from either the nasal or the auditory canal after head trauma could indicate a _________________. This requires _________intervention.
cerebrospinal fluid leak; immediate
A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item?
1.
A walker
2.
Eyeglasses
3.
A hearing aid
4.
A bath thermometer
The cochlear division of cranial nerve VIII is responsible for hearing. Clients with hearing difficulty may benefit from the use of a hearing aid. The vestibular portion of this nerve controls equilibrium; difficulty with balance caused by dysfunction of this division could be addressed with use of a walker. Eyeglasses would correct visual problems (cranial nerve II); a bath thermometer would be of use to clients with sensory deficits of peripheral nerves, such as with diabetic neuropathy.
Focus on the subject, function of cranial nerve VIII. Knowing that this nerve has two parts may help you remember that it is involved with the two functions of the ear (hearing and balance). This will assist you in eliminating options 2 and 4. Regarding the remaining options, focus on the word cochlear, and recall that the cochlear division is responsible for hearing. This will direct you to the correct option.
What are the two parts of the cranial nerve VIII, the vestibulocochlear nerve
Knowing that this nerve has two parts may help you remember that it is involved with the two functions of the ear (hearing and balance). the cochlear division is responsible for hearing. The vestibular division controls equilibrium.
The cochlear division of cranial nerve VIII is responsible for hearing. Clients with hearing difficulty may benefit from the use of a hearing aid. The vestibular portion of this nerve controls equilibrium; difficulty with balance caused by dysfunction of this division could be addressed with use of a walker.
The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approaches by the nurse would be helpful in assisting this client? Select all that apply.
1.
Providing sensory cues
2.
Giving simple, clear directions
3.
Providing a stable environment
4.
Keeping family pictures at the bedside
5.
Encouraging family members to visit at the same time
Clients with cognitive impairment from neurological dysfunction respond best to a stable environment that is limited in amount and type of sensory input. The nurse can provide sensory cues and give clear, simple directions in a positive manner. Confusion can be minimized by reducing environmental stimuli (such as television or multiple visitors) and by keeping familiar personal articles (such as family pictures) at the bedside.
Remember that the client who is confused can handle only limited amounts of information at one time.
The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which activities would be appropriate components of the care plan for this client? Select all that apply.
1.
Keep suction equipment at the bedside.
2.
Elevate the head of the bed 30 degrees.
3.
Keep the client lying in a supine position.
4.
Keep the head and neck in good alignment.
5.
Administer prescribed respiratory treatments as needed.
The nurse maintains a patent airway for the client with difficulty breathing by keeping the head and neck in good alignment and elevating the head of the bed 30 degrees unless contraindicated. Suction equipment is kept at the bedside if secretions need to be cleared. The client should be kept in a side-lying position whenever possible to minimize the risk of aspiration.
Focus on the subject, care of a client with difficulty breathing. Remember that a client with respiratory difficulty can breathe easier if the head of the bed is elevated. Next, select options 1 and 4 because these are safe nursing actions. In addition, option 1 addresses suctioning, which refers to maintaining a patent airway and option 5 addresses keeping the airway patent. This leaves option 3, which is an unsafe nursing action and is incorrect.
The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client and family?
Families often need assistance to cope with the illness of a loved one. The nurse should explain all equipment, treatments, and procedures and should supplement or reinforce information given by the health care provider.
Family members should be encouraged to touch and speak to the client and to become involved in the client’s care to the extent they are comfortable.
The nurse should allow the family to stay with the client to the extent possible and should encourage them to eat and sleep adequately to maintain strength. The nurse can help family members of an unconscious client by assisting them to work through their feelings of grief.
Members of the family of an unconscious client with increased intracranial pressure are talking at the client’s bedside. They are discussing the client’s condition and wondering whether the client will ever recover. The nurse intervenes on the basis of which interpretation?
1.
It is possible the client can hear the family.
2.
The family needs immediate crisis intervention.
3.
The client might have wanted a visit from the hospital chaplain.
4.
The family could benefit from a conference with the health care provider.
Some clients who have awakened from an unconscious state have remembered hearing specific voices and conversations. Family and staff should assume that the client’s sense of hearing is intact and act accordingly. In addition, positive outcomes are associated with coma stimulation–that is, speaking to and touching the client. The remaining options are incorrect interpretations.
Focus on the subject, psychosocial support measures for family. The nurse should not infer that the client wants a visit from the chaplain from observing the family speaking over the client at the bedside, so option 3 should be eliminated first. The family demonstrates no evidence of crisis and seems to be well informed; this eliminates options 2 and 4.
Clients with cognitive deficits after head injury may benefit from referral to a _____________________, who specializes in evaluating and treating cognitive problems.
neuropsychologist
The neuropsychologist plans an individual program of therapy and initiates counseling to help the client reach maximal potential. The neuropsychologist works in collaboration with other disciplines that are involved in the client’s care and rehabilitation.
The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively?
1.
Head of bed flat, head and neck midline
2.
Head of bed flat, head turned to the nonoperative side
3.
Head of bed elevated 30 to 45 degrees, head and neck midline
4.
Head of bed elevated 30 to 45 degrees, head turned to the operative side
After supratentorial surgery, the head is kept at a 30- to 45-degree angle. The head and neck should not be angled either anteriorly or laterally but rather should be kept in a neutral (midline) position. This promotes venous return through the jugular veins, which will help prevent a rise in intracranial pressure
Focus on the subject, client positioning following craniotomy. This question tests knowledge of differences in positioning of the craniotomy client with an infratentorial versus a supratentorial incision. Remember that with supratentorial surgery the head is kept up and with infratentorial surgery the head is kept down. Remember though that surgeon’s prescriptions regarding positioning are always followed. Regarding the remaining choices, recalling how to position the head for optimal venous drainage will help you to select the correct option over option 4.
with supratentorial surgery the head is kept _____________and with infratentorial surgery the head is kept ___________. Remember though that surgeon’s prescriptions regarding positioning are always followed
up; down
The nurse is assessing fluid balance in a client who has undergone a craniotomy. The nurse should assess for which finding as a sign of overhydration, which would aggravate cerebral edema?
1.
Unchanged weight
2.
Shift intake 950 mL, output 900 mL
3.
Blood urea nitrogen (BUN) 10 mg/dL (3.6 mmol/L)
4.
Serum osmolality 280 mOsm/kg H2O (280 mmol/kg)
After craniotomy the goal is to keep the serum osmolality on the high side of normal to minimize excess body water and control cerebral edema.
The normal serum osmolality is 285 to 295 mOsm/kg H2O (285 to 295 mmol/kg). A higher value indicates dehydration; a lower value indicates overhydration.
Stable weight indicates that there is neither fluid excess nor fluid deficit. A difference of 50 mL in intake and output for an 8-hour shift is insignificant. The BUN of 10 mg/dL (3.6 mmol/L) is within normal range and does not indicate overhydration or underhydration.
After craniotomy the goal is to keep the serum osmolality on the___________ side of normal to minimize excess body water and control cerebral edema.
The normal serum osmolality is _____________mOsm/kg H2O . A _____________value indicates dehydration; a ___________value indicates overhydration.
high; 285 to 295 mOsm/kg H2O (285 to 295 mmol/kg)
higher; lower
an easy way to remember serum osmolality trends is “high is dry.” Because the converse also is true, a low value indicates excess body water (overhydration).
The postcraniotomy client typically is sensitive to __________________-. Control of environmental noise by others will be helpful for this client. __________-are a potential complication that may occur for up to 1 year after surgery. For this reason, the client must diligently take anticonvulsant medications. The client and family are encouraged to keep track of the doses administered.
loud noises and can find them excessively irritating; Seizures
The family should learn seizure precautions and should accompany the client during ambulation if dizziness or seizures tend to occur. The suture line is kept dry until sutures are removed to prevent infection.
many clients after craniotomy have increased sensitivity to or are irritated by ______________–
loud noises.
The nurse has made a judgment that a client who had a craniotomy is experiencing a problem with body image. The nurse develops goals for the client but determines that the client has not met the outcome criteria by discharge if the client performs which action?
1.
Wears a turban to cover the incision
2.
Indicates that facial puffiness will be a permanent problem
3.
Verbalizes that periorbital bruising will disappear over time
4.
States an intention to purchase a hairpiece until hair has grown back
Look for the option that indicates a maladaptive response. Options 1 and 4 both indicate adaptive responses and are therefore eliminated. Knowing that facial edema and bruising are temporary will help you to choose the correct option over option
After craniotomy, clients may experience difficulty with altered personal appearance. The nurse can help by listening to the client’s concerns and by clarifying any misconceptions about facial edema, periorbital bruising, and hair loss (all of which are temporary).
The nurse can encourage the client to participate in self-grooming and use personal articles of clothing. Finally, the nurse can suggest the use of a turban, followed by a hairpiece, to help the client adapt to the temporary change in appearance.
A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem?
1.
Altered breathing pattern
2.
Increased likelihood of injury
3.
Ineffective oxygen consumption
4.
Increased susceptibility to aspiration
Altered breathing pattern indicates that the respiratory rate, depth, rhythm, timing, or chest wall movements are insufficient for optimal ventilation of the client.
This is a risk for clients with spinal cord injury in the lower cervical area.
Ineffective oxygen consumption occurs when oxygenation or carbon dioxide elimination is altered at the alveolar-capillary membrane. Increased susceptibility to aspiration and increased likelihood of injury are unrelated to the subject of the question.
NCLEX strategy
The correct option is the only one that addresses the client’s feelings.
Believe that you can do this
a primary goal in aneurysm precautions is to limit the amount of _____________-(in any form) that the client receives and prevent increased __________-(ICP).
stimulation; intracranial pressure
The nurse is planning to put aneurysm precautions in place for a client with a cerebral aneurysm. Which nursing measures would be implemented? Select all that apply.
1.
Provide physical aspects of care.
2.
Prevent pushing or straining activities.
3.
Limit caffeinated coffee to 1 cup per day.
4.
Keeping the lights on in the client’s room.
5.
Maintain the head of the bed at 15 degrees.
Aneurysm precautions include placing the client on bed rest (as prescribed) in a quiet setting. Stimulants such as caffeine and nicotine are prohibited; decaffeinated coffee or tea may be used. Lights are kept dim to minimize environmental stimulation. Any activity that increases the blood pressure or impedes venous return from the brain is prohibited, such as pushing, pulling, sneezing, coughing, or straining. The nurse provides physical care to minimize increases in blood pressure. For the same reason, visitors, radio, television, and reading materials are prohibited or limited.
______________ is a stabbing, burning, and often severe pain due to an irritated or damaged nerve
Neuralgia
The nurse is caring for a client diagnosed with trigeminal neuralgia. The client asks the nurse, “Why do I have so much pain?” Which is the appropriate response by the nurse?
1.
“It’s a local reaction to nasal stuffiness.”
2.
“It’s due to a hypoglycemic effect on the cranial nerve.”
3.
“Release of catecholamines with infection or stress leads to the pain.”
4.
“Pain is due to stimulation of the affected nerve by pressure and temperature.”
The paroxysms of pain that accompany this neuralgia are triggered by stimulation of the terminal branches of the trigeminal nerve.
Symptoms can be triggered by pressure from washing the face, brushing the teeth, shaving, eating, or drinking. Symptoms also can be triggered by thermal stimuli, such as a draft of cold air.
To manage constipation, the client should take in a ______________________. A fluid intake of ______________mL/day is recommended. The client should initiate a bowel movement on an _____________basis and should sit on the toilet or commode. This should be done approximately __________minutes after the largest meal of the day to take advantage of the gastrocolic reflex. A glycerin suppository, bisacodyl suppository, or digital stimulation may be used to initiate the process. ____________ and ____________should be avoided whenever possible because they lead to dependence.
high-fiber diet, bulk formers, and stool softeners; 2000; every-other-day; 45; Laxatives and enemas
The gastrocolic reflex is a physiological reflex that controls the motility of the lower gastrointestinal tract following a meal. As a result of the gastrocolic reflex, the colon has increased motility in response to the stretch of the stomach with the ingestion of food.
A client has a difficulty with the ability to flex the hips. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item?
1.
Walker
2.
Slider board
3.
Raised toilet seat
4.
Adaptive eating utensils
A raised toilet seat is useful if the client does not have the mobility or ability to flex the hips. The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. A slider board is used in transferring a client from a bed to a stretcher or wheelchair. Adaptive eating utensils may be beneficial if the client has partial paralysis of the hand.
Think about how each item in the options would be helpful to the client. The walker would help the client maintain balance. A slider board would help with transferring from one place to another, such as from a bed to a chair. Next, remember that adaptive eating utensils are used in clients with loss of fine motor coordination, such as those with stroke.
The nurse is assessing the client’s gait and notes it is unsteady and staggering. Which description should the nurse use when documenting the assessment finding?
1.
Spastic
2.
Ataxic
3.
Festinating
4.
Dystrophic or broad-based
An ataxic gait is characterized by unsteadiness and staggering. A spastic gait is characterized by stiff, short steps with the legs held together, hip and knees flexed, and toes that catch and drag. A festinating gait is best described as walking on the toes with an accelerating pace. A dystrophic or broad-based gait is seen as waddling, with the weight shifting from side to side and the legs far apart.
An ___________gait is characterized by unsteadiness and staggering.
ataxic
A _________gait is characterized by stiff, short steps with the legs held together, hip and knees flexed, and toes that catch and drag.
spastic
A _____________–gait is best described as walking on the toes with an accelerating pace.
festinating
A _______or ___________gait is seen as waddling, with the weight shifting from side to side and the legs far apart.
dystrophic or broad-based
A client with a neurological impairment experiences urinary incontinence. Which nursing action would be most helpful in assisting the client to adapt to this alteration?
1.
Using adult diapers
2.
Inserting a Foley catheter
3.
Establishing a toileting schedule
4.
Padding the bed with an absorbent cotton pad
A bladder retraining program, such as use of a toileting schedule, may be helpful to clients experiencing urinary incontinence.
A Foley catheter should be used only when necessary because of the associated risk of infection. Use of diapers or pads is the least acceptable alternative because of the risk of skin breakdown.
Because use of a Foley catheter carries the risk of infection and use of diapers or pads carries the risk of skin breakdown, the only acceptable option is the toileting schedule
A client with a neurological problem is experiencing hyperthermia. Which measures would be appropriate for the nurse to use in trying to lower the client’s body temperature? Select all that apply.
1.
Giving tepid sponge baths
2.
Applying a hypothermia blanket
3.
Covering the client with blankets
4.
Administering acetaminophen per protocol
5.
Placing ice packs over the client’s abdomen and in the axilla and groin
Focus on the subject, measures to lower client’s body temperature. It may be helpful to look at this question from the standpoint of the relative body surface area that would be benefited by each of the measures identified in the options. Tepid sponge baths and a hypothermia blanket would affect a good portion of the client’s skin to reduce heat. Acetaminophen is a medication that has an antipyretic effect. Ice packs are an incorrect option because they would affect the skin only in the areas of placement, providing less generalized cooling with increased risk of shivering.
Standard measures to lower body temperature include removing bed covers, providing cool sponge baths, using an electric fan in the room, administering acetaminophen, and placing a hypothermia blanket under the client. Ice packs are not used because they could cause shivering, which increases cellular oxygen demands, with the potential for increased intracranial pressure.
Standard measures to lower body temperature include ______________________________________
Why are ice packs not used ?
removing bed covers, providing cool sponge baths, using an electric fan in the room, administering acetaminophen, and placing a hypothermia blanket under the client. Ice packs are not used because they could cause shivering, which increases cellular oxygen demands, with the potential for increased intracranial pressure.
The MRI scanner is a hollow tube that gives some clients a feeling of _________________. ____________objects must be removed before the procedure so that they are not drawn into the magnetic field. The client may eat and may take all prescribed medications before the procedure. If a contrast medium is used, the client may wish to eat lightly if he or she has a tendency to become nauseated easily. The client lies supine on a padded table that moves into the imager. The client must lie ________during the procedure. The imager makes tapping noises during the scanning. The client is alone in the imager, but the nurse can reassure the client that the technologist will be in voice communication with the client at all times during the procedure.
claustrophobia; Metal; still
The unconscious client is positioned on ______________-during mouth care to prevent ________________.
the side; aspiration
The nurse is administering mouth care to an unconscious client. The nurse should perform which actions in the care of this person? Select all that apply.
1.
Use products that contain alcohol.
2.
Position the client on his or her side.
3.
Brush the teeth with a small, soft toothbrush.
4.
Cleanse the mucous membranes with soft sponges.
5.
Use lemon glycerin swabs when performing mouth care.
The unconscious client is positioned on the side during mouth care to prevent aspiration. The teeth are brushed at least twice daily with a small toothbrush. The gums, tongue, roof of the mouth, and oral mucous membranes are cleansed with soft sponges to avoid encrustation and infection. The lips are coated with water-soluble lubricant to prevent drying, cracking, and encrustation. The use of products with alcohol and lemon glycerin swabs should be avoided because they have a drying effect.
Standard mouth care procedures include use of a toothbrush and soft sponges, so these options may be selected first. Knowing that the unconscious client is at risk for aspiration tells you that option 2 also is correct. This leaves options 1 and 5 as incorrect because repeated use of products containing alcohol or lemon glycerin products could dry and crack the oral mucous membranes.
Increased risk for aspiration is a condition in which an individual is at risk for entry of gastrointestinal (GI) secretions, oropharyngeal secretions, or solids or fluids into tracheobronchial passages.
Conditions that place the client at risk for aspiration include _________________________________
reduced level of consciousness, depressed cough and gag reflexes, and feeding via a GI tube.
Which intervention should the nurse include in a postoperative teaching plan for a client who underwent a spinal fusion and will be wearing a brace?
1.
Tell the client to inspect the environment for safety hazards.
2.
Inform the client about the importance of sitting as much as possible.
3.
Inform the client that lotions and body powders can be used for skin breakdown.
4.
Instruct the client to tighten the brace during meals and to loosen it for the first 30 minutes after each meal.
The client must inspect the environment for safety hazards. The client is instructed in the importance of avoiding prolonged sitting and standing.
Powders and lotions should not be used because they may irritate the skin.
The client should be taught to loosen the brace during meals and for 30 minutes after each meal. The client may have difficulty eating if the brace is too tight. Loosening the brace after each meal will allow adequate nutritional intake and promote comfort.
note that the correct option addresses safety and is the umbrella option.
The nurse is preparing to care for a client after a lumbar puncture. The nurse should plan to place the client in which best position following the procedure?
1.
Prone in semi Fowler’s position
2.
Supine in semi Fowler’s position
3.
Prone with a small pillow under the abdomen
4.
Lateral with the head slightly lower than the rest of the body
After the procedure, the client assumes a flat position. If the client is able, a prone position with a pillow under the abdomen is the best position.
This position helps reduce cerebrospinal fluid leakage and decreases the likelihood of post–lumbar puncture headache
The student nurse develops a plan of care for a client after a lumbar puncture. The nursing instructor corrects the student if the student documents which incorrect intervention in the plan?
1.
Maintain the client in a flat position.
2.
Restrict fluid intake for a period of 2 hours.
3.
Assess the client’s ability to void and move the extremities.
4.
Inspect the puncture site for swelling, redness, and drainage.
After the lumbar puncture the client remains flat in bed for at least 2 hours, depending on the health care provider’s prescriptions.
A liberal fluid intake is encouraged to replace the cerebrospinal fluid removed during the procedure, unless contraindicated by the client’s condition.
The nurse checks the puncture site for redness and drainage and assesses the client’s ability to void and move the extremities.
Recalling that cerebrospinal fluid is removed during this procedure and recalling the importance of fluid intake after the procedure will direct you to the correct option
What is a myelogram?
a type of radiographic examination that uses a contrast medium to detect pathology of the spinal cord, including the location of a spinal cord injury, cysts, and tumors.
The nurse is monitoring a client who has returned to the nursing unit after a myelogram. Which client complaint would indicate the need to notify the health care provider (HCP)?
1.
Backache
2.
Headache
3.
Neck stiffness
4.
Feelings of fatigue
Headache is relatively common after the procedure, but neck stiffness, especially on flexion, and pain should be reported because they signal meningeal irritation.
The client also is monitored for evidence of allergic reactions to the dye such as confusion, dizziness, tremors, and hallucinations. Feelings of fatigue may be normal, and back discomfort may occur because of the positions required for the procedure.
The normal intracranial pressure is ____________mm Hg.
5 to 15
a widening pulse pressure and bradycardia are signs of ______________reflex.
Cushing’s
The nurse in the neurological unit is monitoring a client for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing’s reflex. The nurse determines that the presence of this reflex is obtained by assessing which item?
Cushing’s reflex is a late sign of increased ICP and consists of a widening pulse pressure (systolic pressure rises faster than diastolic pressure) and bradycardia.
Cushing’s reflex is a_____________ sign of increased ICP and consists of a ____________________
late; widening pulse pressure (systolic pressure rises faster than diastolic pressure) and bradycardia.
The nurse is assisting the neurologist in performing an assessment on a client who is unconscious after sustaining a head injury. The nurse understands that the neurologist would avoid performing the oculocephalic response (doll’s eyes maneuver) if which condition is present in the client?
1.
Dilated pupils
2.
Lumbar trauma
3.
A cervical cord injury
4.
Altered level of consciousness
A cervical cord injury
In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll’s eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as that for the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem. Contraindications to performing this test include cervical-level spinal cord injuries and severely increased intracranial pressure.
In an unconscious client, ________________are an indication of brainstem activity and are tested by the oculocephalic response. When the doll’s eyes maneuver is intact, the eyes move in the ____________ direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as that for the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem.
Contraindications to performing this test include ______________________
eye movements; opposite; cervical-level spinal cord injuries and severely increased intracranial pressure.
recall that with a cervical injury, the head is not turned but maintained in a _____________position.
midline
The nurse is performing the oculocephalic response (doll’s eyes maneuver) on an unconscious client. The nurse turns the client’s head and notes movement of the eyes in the same direction as the head. How should the nurse document these findings?
Abnormal
In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll’s eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem.
What does an abnormal response to the oculocephalic response (dool’s eye maneuver) indicate?
An abnormal response indicates a disruption in the processing of information through the brainstem.
The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function will yield the best information about these cranial nerves?
1.
Eye movements
2.
Response to verbal stimuli
3.
Affect, feelings, or emotions
4.
Insight, judgment, and planning
Eye movements are under the control of cranial nerves III, IV, and VI.
Level of consciousness (response to verbal stimuli) is controlled by the reticular activating system and both cerebral hemispheres.
Feelings are part of the role of the limbic system and involve both hemispheres.
Insight, judgment, and planning are part of the function of the frontal lobe in conjunction with association fibers that connect to other areas of the cerebrum.
The nurse is reviewing the medical records of a client admitted to the nursing unit with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note that which is documented in the assessment data section of the record?
1.
Sudden loss of consciousness occurred.
2.
Signs and symptoms occurred suddenly.
3.
The client experienced paresthesias a few days before admission to the hospital.
4.
The client complained of a severe headache, which was followed by sudden onset of paralysis.
Cerebral thrombosis does not occur suddenly.
In the few hours or days preceding a thrombotic brain attack (stroke), the client may experience a transient loss of speech, hemiplegia, or paresthesias on 1 side of the body.
Signs and symptoms of thrombotic brain attack (stroke) vary but may include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke (brain attack) experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage.
Divalproex sodium is what type of medication ?
it can cause fatal ______________
An anticonvulsant; heptatotoxicity
The nurse in the health care clinic is providing medication instructions to a client with a seizure disorder who will be taking divalproex sodium. The nurse should instruct the client about the importance of returning to the clinic for monitoring of which laboratory study?
1.
Electrolyte panel
2.
Liver function studies
3.
Renal function studies
4.
Blood glucose level determination
Divalproex sodium, an anticonvulsant, can cause fatal hepatotoxicity. The nurse should instruct the client about the importance of monitoring the results of liver function studies and ammonia level determination
Trigeminal neuralgia is characterized by spasms of __________that start ___________and last for seconds to minutes. The pain often is characterized as _________or as similar to an electric shock. It is accompanied by spasms of facial ____________ that cause twitching of parts of the face or mouth, or closure of the eye.
pain; suddenly; stabbing; muscles
The home care nurse is performing an assessment on a client with a diagnosis of Bell’s palsy. Which assessment question will elicit specific information regarding this client’s disorder?
1.
“Do your eyes feel dry?”
2.
“Do you have any spasms in your throat?”
3.
“Are you having any difficulty chewing food?”
4.
“Do you have any tingling sensations around your mouth?”
Bell’s palsy is a one-sided facial paralysis caused by compression of the facial nerve. Manifestations include facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulties.
What is Bell’s Palsy ?
Bell’s palsy is a one-sided facial paralysis caused by compression of the facial nerve. Manifestations include facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulties.
Auditory association and storage areas are located in the ______________lobe and relate to understanding spoken language.
The _____________lobe contains areas related to vision.
The _____________controls voluntary muscle activity, including speech, and an impairment can result in expressive aphasia.
The ____________lobe contains association areas for concept formation, abstraction, spatial orientation, body and object size and shape, and tactile sensation.
temporal; occipital; frontal; parietal
The nurse develops a plan of care for a client with a brain aneurysm who will be placed on aneurysm precautions. Which interventions should be included in the plan? Select all that apply.
1.
Leave the lights on in the client’s room at night.
2.
Place a blood pressure cuff at the client’s bedside.
3.
Close the shades in the client’s room during the day.
4.
Allow the client to drink 1 cup of caffeinated coffee a day.
5.
Allow the client to ambulate 4 times a day with assistance
Read each option in terms of whether it would cause stimulation or increased intracranial pressure, which can lead to rupture.
Aneurysm precautions include placing the client on bed rest in a quiet setting.
The use of lights is kept to a minimum to prevent environmental stimulation. The nurse should monitor the blood pressure and note any changes that could indicate rupture. Any activity, such as pushing, pulling, sneezing, or straining, that increases the blood pressure or impedes venous return from the brain is prohibited. The nurse provides physical care to minimize increases in blood pressure. Visitors, radio, television, and reading materials are restricted or limited. Stimulants, such as nicotine and coffee and other caffeine-containing products, are prohibited. Decaffeinated coffee or tea may be used.
The nurse is providing instructions to a client who will be taking phenytoin. Which statement, if made by the client, would indicate an understanding of the information about this medication?
1.
“I need to perform good oral hygiene, including flossing and brushing my teeth.”
2.
“I should try to avoid alcohol, but if I’m not able to, I can drink alcohol in moderation.”
3.
“I should take my medication before coming to the laboratory to have a blood level drawn.”
4.
“I should monitor for side effects and adjust my medication dose depending on how severe the side effects are.”
gingival hyperplasia is a side effect of this medication
Phenytoin is an anticonvulsant used to treat seizure disorders. The client also should see a dentist at regularly scheduled times because gingival hyperplasia is a side effect of this medication. The client should perform good oral hygiene, including flossing and brushing the teeth.
The client should avoid alcohol while taking this medication. The client should also be instructed that follow-up serum blood levels are important and that, on the day of the scheduled laboratory test, the client should avoid taking the medication before the specimen is drawn.
The client should not adjust medication dosages.
cerebral thrombosis does not occur _____________-, and in the few days or hours preceding the thrombotic stroke, the client may experience a
suddenly ; transient loss of speech, hemiparesis, or paresthesias on 1 side of the body.
The nurse is performing an assessment on a client with a diagnosis of thrombotic stroke (brain attack). Which assessment question would elicit data specific to this type of stroke?
1.
“Have you had any headaches in the past few days?”
2.
“Have you recently been having difficulty with seeing at nighttime?”
3.
“Have you had any sudden episodes of passing out in the past few days?”
4.
“Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?”
Cerebral thrombosis (thrombotic stroke) does not occur suddenly. In the few days or hours preceding the thrombotic stroke, the client may experience a transient loss of speech, hemiparesis, or paresthesias on 1 side of the body. Signs and symptoms of this type of stroke vary but may also include dizziness, cognitive changes, or seizures.
Headache is rare, but some clients with stroke experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage. The client does not complain of difficulty with night vision as part of this clinical problem. In addition, most clients do not have repeated episodes of loss of consciousness.
The nurse is creating a plan of care for a client with dysphagia following a stroke (brain attack). Which should the nurse include in the plan?
1.
Thicken liquids.
2.
Assist the client with eating.
3.
Assess for the presence of a swallow reflex.
4.
Place the food on the affected side of the mouth.
5.
Provide ample time for the client to chew and swallow.
Liquids are thickened to prevent aspiration.
The nurse should assist the client with eating and place food on the unaffected side of the mouth. The nurse should assess for gag and swallowing reflexes before the client with dysphagia is started on a diet. The client should be allowed ample time to chew and swallow to prevent choking.
_____________________is a loss of half of the visual field.
Homonymous hemianopsia
What medication class if used to treat trigeminal neuralgia ?
Trigeminal neuralgia is characterized by spasms of pain that start suddenly and last from seconds to minutes. The pain often is described as either stabbing or similar to an electric shock. It is accompanied by spasms of the facial muscles that cause twitching of parts of the face or mouth, or closure of the eye. It is treated by giving antiseizure medications, such as gabapentin, and sometimes tricyclic antidepressants. These medications work by stabilizing the neuronal membrane and blocking the nerve.
antiseizure medications work in this condition by blocking the nerve
The nurse is providing instructions to the client with trigeminal neuralgia regarding measures to take to prevent the episodes of pain. Which should the nurse instruct the client to do?
1.
Prevent stressful situations.
2.
Avoid activities that may cause fatigue.
3.
Avoid contact with people with an infection.
4.
Avoid activities that may cause pressure near the face.
The pain that accompanies trigeminal neuralgia is triggered by stimulation of the trigeminal nerve. Symptoms can be triggered by pressure such as from washing the face, brushing the teeth, shaving, eating, or drinking. Symptoms also can be triggered by stimulation by a draft or cold air.
Assessment findings for Bell’s Palsy
Bell’s palsy is a one-sided facial paralysis caused by the compression of the facial nerve (cranial nerve VII). Assessment findings include facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulty.
Desired outcomes for nursing interventions to prevent cold discomfort and the development of accidental hypothermia include the following: hands and limbs are ________; body is________ and not curled; body temperature is greater than _______°F (36.1°C); the client is not ______; and the client has no complaints of feeling ____.
warm; relaxed; 97; shivering; cold
The nurse is preparing a plan of care for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On assessment, the nurse notes that the client is severely dysphagic. Which intervention should be included in the care plan for this client? Select all that apply.
1.
Provide oral hygiene after each meal.
2.
Assess swallowing ability frequently.
3.
Allow the client sufficient time to eat.
4.
Maintain a suction machine at the bedside.
5.
Provide a full liquid diet for ease in swallowing.
A client who is severely dysphagic is at risk for aspiration. Swallowing is assessed frequently. The client should be given a sufficient amount of time to eat. Semisoft foods are easiest to swallow and require less chewing. Oral hygiene is necessary after each meal. Suctioning should be available for clients who experience dysphagia and are at risk for aspiration.
Recall that liquids are most difficult to swallow in the client with dysphagia.
TRUE OR FALSE
liquids are most difficult to swallow in the client with dysphagia.
TRUE
Semisoft foods are easiest to swallow and require less chewing
The nurse is reviewing the record for a client seen in the health care clinic and notes that the health care provider has documented a diagnosis of amyotrophic lateral sclerosis (ALS). Which initial clinical manifestation of this disorder should the nurse expect to see documented in the record?
1.
Muscle wasting
2.
Mild clumsiness
3.
Altered mentation
4.
Diminished gag reflex
The initial symptom of ALS is a mild clumsiness, usually noted in the distal portion of one extremity. The client may complain of tripping and drag one leg when the lower extremities are involved. Mentation and intellectual function usually are normal. Diminished gag reflex and muscle wasting are not initial clinical manifestations.
The nurse in the neurological unit is caring for a client with a supratentorial lesion. The nurse assesses which measurement as the most critical index of central nervous system (CNS) dysfunction?
1.
Temperature
2.
Blood pressure
3.
Ability to speak
4.
Level of consciousness
Level of consciousness is the most critical index of CNS dysfunction. Changes in level of consciousness can indicate clinical improvement or deterioration. Although blood pressure, temperature, and ability to speak may be components of the assessment, the client’s level of consciousness is the most critical index of CNS dysfunction.
