Neurological System (Exam One) Flashcards
What is the purpose of the myelin sheath?
Insulation for the neuron cells
What is the purpose of glial cells?
- Support neurons
- Protect neurons
- Nourish neurons
Damage to the frontal lobe changes an individuals what?
- Personality
- Judgement
Broca’s area is located in which lobe of the brain?
Frontal lobe
Wernicke’s area is located in which lobe of the brain?
Temporal lobe
Broca’s area is responsible for __________ language.
Expressing
Wernicke’s area is responsible for __________ language.
Understanding
If Broca’s area is damaged, what type of problem might occur?
Expressive aphasia
If Wernicke’s area is damaged, what type of problem might occur?
Receptive aphasia
On which side of the brain are language centers located, for most individuals?
Left side
If an individual has damage to the left side of their brain, such as a stroke or tumor, what is likely to be affected?
Speech
If an individual has a tumor located in the occipital lobe of the brain, what is likely to be affected?
Vision
What is the primary function of the hypothalamus?
Regulates body function
The brainstem regulates:
- Heart rate
- Breathing
- Blood pressure
- Swallowing
- Digestion
What would be the priority nursing assessment for a patient who has a experienced trauma to their brainstem?
- Oxygen saturation
- Respiratory assessment
What is the primary function of the cerebellum?
Provides smooth, coordinated body movement
A patient has experienced trauma to their cerebellum. The nurse should be most concerned about what?
- Falling
- Safety
Describe hydrocephalus.
Excessive build-up of fluid
What is considered the normal rate of cerebrospinal fluid production?
20 mL/hr
In regard to muscle tone, lower motor neuron lesions will cause what?
Flaccidity
In regard to muscle tone, upper motor neuron lesions will cause what?
Spasticity
What is considered a normal Babinski sign for children over age 2 and adults?
Flexion of toes downward
An adult patient has fanning of the toes when the nurse assess’s their Babinski reflex. Is this considered a normal of abnormal finding in an adult? What type of problem might this indicate?
- Abnormal
- Indicate a neural problem
Describe a clonus.
- Continual jerking
- Hypereflexia
Which cranial nerves are assess concurrently using the 6 cardinal fields test?
- Cranial nerve 3 (Oculomotor)
- Cranial nerve 4 (Trochlear)
- Cranial nerve 6 (Abducens)
Which cranial nerves control the gag reflex?
- Cranial nerve 9 (Glossopharyngeal)
- Cranial nerve 10 (Vagus)
If cranial nerve 9 (glossopharyngeal) and cranial nerve 10 (vagus) nerve are impaired, what is the primary nursing intervention?
Keep patient NPO
When assessing cranial nerve 3, constriction of the pupils does not occur. The nurse knows that this may be indicative of what?
Herniation
If the patient is a poor historian or unable to answer questions regarding their condition, who should the nurse get that information from?
- Family members
- Person at bedside
The nurse is assessing a patients sensory function. What type of question would the nurse want to ask this patient? What should the nurse avoid when asking this question?
- “Can you feel this?”
- Avoid using descriptors like sharp or dull
What diagnostic test is used to assess for electrical activity of the brain or seizures?
Electroencephalogram (EEG)
The nurse knows they must assess for what if the patient is receiving any type of diagnostic test that uses contrast medium, such as a myelogram?
Shellfish allergy
What is the primary nursing assessment for a patient who has had a cerebral angiography?
- Bleeding
- Blood pressure
- Heart rate
What position is the patient positioned in during a lumbar puncture?
Lateral position
When should a lumbar puncture not be performed?
If increased intracranial pressure is suspected
What is the normal appearance of cerebrospinal fluid?
Clear
What is the normal amount of pressure of cerebrospinal fluid?
9 - 18 cm/H2O
What is the normal amount of white blood cells in cerebrospinal fluid?
0 - 5 WBC/mm3
What is the normal amount of glucose in cerebrospinal fluid?
50 - 75 mg/dL
What is the normal amount of total protein in cerebrospinal fluid?
15 - 40 mg/dL
The nurse is caring for a patient who is admitted after a head injury. When would the nurse obtain most of the data related to this patient’s mental status?
A. While observing patient behaviors
B. During the nursing health history
C. While asking specific problem-solving questions
D. While reviewing answers on a written mental examination
B. During the nursing health history
Intracranial pressure is balanced by:
- Brain tissue
- Blood
- Cerebrospinal fluid
What is considered a normal amount of pressure inside of the skull?
5 - 15 mm/Hg
Should excess blood be shunted to the brain if the patient has a head injury?
No
The nurse knows the brain needs a constant supply of what in order to maintain cerebral blood flow?
- Oxygen
- Glucose
What is the priority nursing intervention for a patient with cerebral edema, hyponatremia, and a headache?
Administer 3% or 5% hypertonic saline
What is the most sensitive and reliable indicator of a patients neurological status?
Level of consciousness
A fixed unilateral, dilated pupil that is unresponsive to light may be indicative of what?
- Herniation of the brain
- Medical emergency!
If a patient arrives at the emergency department (ED) orientated upon initial assessment, but become disoriented after 30 minutes, what is the priority nursing intervention?
- Further assessment
- Call the physician
List the three components of Cushing’s triad.
- Bradycardia
- Hypertension
- Irregular breathing
Cushing’s triad is a sign of what?
- Brainstem compression
- Medical emergency!
An increase in temperature is an indication of an increase in what?
Intracranial pressure
What diagnostic test is the gold standard for monitoring intracranial pressure?
Ventriculostomy
What is a serious complication of a ventriculostomy?
Infection
What does the ventriculostomy measure?
Pressure within the ventricles
A normal intracranial pressure waveform resembles a what?
Staircase
