Neurological Problems Flashcards
Patient has neurological problems and has declined from alert to lethargic. What is the best action
- Preform complete neurological assessment
- Assess cranial nerves
- Contact rapid response team
- Reassess in 30 minutes
- Contact rapid response team
Decline in LOC and orientation is the earliest and most reliable indication central neurological function has declined.
Medical emergency.
Try acting out the responses to see which ones make sense
SATA that are true of migrane headaches
- Food tyramine, alcohol & aged cheese, avoid.
- Avoid Nitroglycerin & nifedipine ( Calcium channel blocker and Antihypertensive drug) also treats angina
- Abortive therapy is used to eliminate pain during the aura
- Potential side effect of meds Triptan: First-line treatments sumatriptan & rizatriptan: Includes Rebound Headaches
- Complementary therapies bio feed back and relaxation maybe helpful
- Estrogen therapy should be continued as prescribed
- Food tyramine, alcohol & aged cheese, avoid.
- Nitroglycerin & nifedipine ( Calcium channel blocker and Antihypertensive drug) also treats angina
- Abortive therapy is used to eliminate pain during the aura
- Potential side effect of meds Triptan: First-line treatments sumatriptan & rizatriptan: Includes Rebound Headaches
- Complementary therapies bio feed back and relaxation maybe helpful
Which is incorrect to instruct to the family of a seizure patient
- Avoid consumption of all alcohol
- Wear medical alert bracelet always
- Protect your loved ones airway during the seizure
- It’s OK to take OTC meds
- It’s OK to take OTC meds
Always discuss OTC meds with HCP
Reestablish bladder training. Which may stimulate client to void.
- Stroking inner thigh
- Pull pubic hair
- Initiate intermittent straight catherization
- Pour warm water over perineum
- Tapping the bladder stimulate detrusor muscle
- Remind client to void every hour while awake
Reestablish bladder training. Which may stimulate client to void.
- Stroking inner thigh
- Pull pubic hair
- Initiate intermittent straight catherization
- Pour warm water over perineum
- Tapping the bladder stimulate detrusor muscle
Reestablish bladder training. Which may stimulate client to void. - Stroking inner thigh
- Pull pubic hair
- Pour warm water over perineum
- Tapping the bladder stimulate detrusor muscle
Don’t
3. Initiate intermittent straight catherization (Doesn’t Stimulate client to void)
6. Remind client to void every hour while awake (Too often Doesn’t help when they are asleep)
Client with Glasgow Coma Scale was 5 now it’s 2. What is the best interpretation of this findings
- Improving
- Declining
- Client will need intubation & Mechanical ventilation
- Medication regime will need adjustment
- Declining
Scored 3 Coma - 15 Fine
3 areas Eye opening, Verbal response, Motor response
Decline of 2 points should be reported to HCP
MS tells UAP “too tired to take a bath”
Priority nursing concern
- Fatigue
- Inability to perform ADL
- Decreased mobility
- Muscular weakness
Fatigue
Why shouldn’t a client with a hemorrhagic stroke be given alteplase?
Alteplace (clot buster) is used for ischemic stroke not hemorrhagic
It will make bleeding worse
Right sided stroke will lean to this side?
How will vision be affected?
Which side will be weaker?
How will a nurse assistant dress and undress them
Left side weakness / also ignore food on left side
Both eyes affected- left field of vision on both
POW Put on Weak
Toss Take off strong side
When should antibiotics be given to a suspected meningitis case?
Before diagnosis & after culture collection
Encephalitis with new onset generalized tonic-colonic seizures. Which are best to assign a LPN
- Observe & document onset & duration of any seizure activity
- Admin phenytoin 200 mg PO q3D
- Teach client need for frequent toothbrushing & flossing
- Develop discharge plan & referral to epilepsy foundation
- Assessing for adverse effects caused by new antiseizure medications
- Turning client to side to prevent aspiration
- Observe & document onset & duration of any seizure activity (Any nursing staff member can observe onset & duration of seizure)
- Admin phenytoin 200 mg PO q3D
- Turning client to side to prevent aspiration
Dont
3 Teach client need for frequent toothbrushing & flossing
4. Develop discharge plan & referral to epilepsy foundation
5. Assessing for adverse effects caused by new antiseizure medications
First to implement in tonic clonic seizure
- Turn client on side
- Give lorazepam 2mg IV
- Admin oxygen via nonrebreather
- Assess LOC
- Turn client on side
Then - Give lorazepam 2mg IV
63 with MS, oral temp 101.8, and flank pain.
What is a possible issue
Polynephritis secondary to UTI.
Frequent in MS patients, MS effects bladder function.
UTI may lead to sepsis
Can a UAP help a client with prescribed strengthening exercises
Yes, if they have already been taught by proper authorities and are part of the care plan
Client glioblastoma receiving dexamethasone 4mg IV push q6h
Which is biggest concern
- Client no longer recognizes family
- BS 234
- REports constant headache
- Noncompliance with therapeutic plan
1.Client no longer recognizes family
Glioblastoma = malignant tumor affecting the brain or spine.
70 yr alcoholic who became lethargic, confused, and incontinent last week after a fall arrived at ED today. What is the priority
- Place client on alcohol withdrawal protocol
- Transport to radiology dep for CT scan.
- Make referral to social worker
- Give client phenytoin 100mg PO
- Transport to radiology dep for CT scan.
Even though alcoholic priority here is the symptoms he is showing from the fall.
