term 3 Flashcards
What predisposes someone to developing meningitis?
sore throat for 3 days
pt with meningitis has photophobie, and a severe headache, Which nursing interventions will be most helpful to provide relief from symptoms
darken the room, administer analgesics, minimal interruptions to pt.
Which type of headache is most commonly associated with an aura?
migraine
a pt. makes an appt with a dr for recurrent headaches. Which instructions will the nurse give the pt prior to them having the appt.?
keep a headache diary, recording symptoms, timing and headache triggers
a pt who has had a generalized tonic clonic seizure is sound asleep 30 minutes after. Meals are about to be delivered. What action is most appropriate?
let the pt sleep during the postictal state and keep the meal warm
a pt with history of seizures is experiencing an aura and is concerned about an impending seizure. What are the nursing interventions in the correct orderwhich pts should be closely monitored for symptoms of increased ICP?
pt with high fever and severe headache, the pt in PACU after a crainectomy, pt with brain tumor admitted for radiation therapy
Which actions should the nurse take to help prevent IICP in a pt following a traumatic brain injury?
keep HOB elevated 30 degrees
a pt with history of seizures is experiencing an aura and is concerned about an impending seizure. What are the nursing interventions in the correct order?
1) help the pt lie down in a safe place 2)protect the pt from injury during the seizure 3) turn the pt on their side to sleep 4) doocument the events of the seizure
how much function can be expected in a pt with spinal cord injury at L2 level?
Paraplegic
may learn to walk with a brace
Pt is admitted folliwing a T4 spinal injury, when taking vitals the nurse notices the BP is elevated, and pt is restless. What is an appropriate action for the nurse to take?
check for a full bladder, it could be a sign of autonomic dysreflexia
the symptoms of Parkinson’s are caused by a depletion of which neurotransmitter?
Dopamine
. Which nursing interventions are appropriate for the pt with a neurodegenerative d/o with difficulty swallowing?
show the pt how to tuck their chin down to chest when swallowing
. A resident with Alzheimers is sitting in a corner crying saying that nobosy is paying attention. Which approach would best help the pt?
sit quietly by the pt and say “I’m here, youre not alone”
A pt with trigeminal neuralgia asks the nurse why carbamazepine (Tegretol) has been ordered. Which response is best?
anticonvulsants help relieve nerve pain.
a pt with amyotopic lateral sclerosis (ALS) expresses concern about not having enough breath to sing anymore. Which explanation by the nurse is best?
ALS causes weak muscles, if the repsiratory muscles are affected, breathing (and singing) could be compromised
A pt who is newly diagnosed with ALS says to the nurse “I don’t want to be kept alive on machines” Which nursing action is the best response?
Ask the pt if they have an advanced directive in place, and give the pt info about preparing them
When caring for a pt with Guillian-Barre syndrome, which nursing dx should take priority?
impaired gas exchange
Which nursing int. are appropriate for the pt with Bell’s palsy?
administer eye drops, apply eye patch, apply warm compresses, provide facial massage
Which meal is best for the pt with myasthenia gravis? (select all that apply question)
meat loaf, mashed potatoes and green beans (soft foods)
How will the visiting nurse caring for a pt with myasthenia gravis and severe muscle weakness know if interventions have been effective?
the pt is able to perform ADLs with SAO2 remaining at 95%
What functional classification of neurons carry impulses away from CNS to effectors?
motor (efferent) neurons
Which structure in the CNS regulates body temp?
hypothalamus
What are symptoms of IICP that should be reported immediately?
bradycardia, Increasing systolic BP with widening pulse pressure, irregular resps, commonly referred to as Cushings triad.
Normal effects of aging on the CNS
reduced blood flow to the brain, impaired short term memory, sleep disturbance, decreased acetylcholine
pt asks what to expect when she has an angiogram. Which response by the nurse is best?
a catheter will be placed in your femoral artery, and dye will be injected that will show up on xray
. what should be encouraged when a pt returns from a CT scan using a contrast medium?
Drinking fluids (to help excrete the dye)
Which of the following nursing interventions can prevent footdrop?
applying high top tennis shoes
What are modifiable risk factors for stroke?
diabetes, high cholesterol, obesity
what is the most important dx test that is completed imm. on the patients with symptoms of a stroke in the emergency dept.?
Head CT scan
how soon after the symptoms onset must a person who has had a stroke receive thrombolytic tx?
3 hours
pt is experiencing receptive aphasia. This means the pt has difficulty…
understanding language
a nurse is caring for a pt recovering from an ischemic stroke. Upon entering the room the nurse notes the pt has only eaten half the meal. What should the nurse do?
turn the plate 180 degrees and observe the pts response
The nurse is observing a new graduate performing an assessment on the Glascow coma scale. They should be assessing which 3 things?
eye opening
verbal response
motor response
a pt arrives at the ER for a closed head injury. Which assessment finding should be reported immediately to the physician?
vomiting
nurse is caring for a pt with a new dx of Parkinson’s. What are 2 common symptoms of a pt with parkinsons (select all that apply ?)
shuffling gait, dysphagia
Which assessment findings would indicate compromized neurovascular function (Select all that apply ?)
capillary refill time 6 seconds, numbness and tingling, blue discoloration to the skin
.a nurse is caring for a pt who has an injury to the left motor area of the cerebrum. Where would the nurse expect to see paralysis?
the right side of the body (crossing nerve tracts in the brain)
a pt has undergone a crainectomy for removal of a meningioma. What question would be appropriate in assessing a possible complication of the surgery
have you noticed any salty or sweet tasting drainage coming from the incision site?”
When planning care for a pt with ALS, a priority nursing intervention would inclute
maintain clear airway
A pt with a head injury has been ordered mannitol via IV. The pt is most likely to receive mannitol for what?
IICP
a nurse is caring for a pt dx with meningitis. the pt is extremely photophobic and her mother sits at her bedside crying. What should be included in this pts plan of care?
maintaining a calm relaxed environment
Which of the following concerns is a priority in a pt with an open head injury? (once bleeding has been controlled)
infection
pt has a seizure accompanied with incontinence. The pt sleeps for several hours afterward. What kind of seizure has the pt most likely experienced?
tonic-clonic
. a pt asks the nurse why she must lie flat after her lumber puncture. the nurse correctly answers the pt by saying…
you might get a bad headache if you sit up now”
a pt is being observice for ICP which classification of drugs besides corticosteroid and anticonvulsants, would the nurse expect the physician to order?
osmotic diuretics
When teaching a pt who is experiencing migraines, which of the following indicates the pt teaching has been successful?
the pt can identify triggers of the migraines
A pt is unable to respond appropriately and clearly. He is is oriented to time but unable to follow commands. What best describes their LOC?
confused
. What is the most common cause of autonomic dysreflexia? what are some other common causes?
full bladder; fecal impaction, kinked foley
when a . pt admitted with a GCS of 13 and 15. the nurse knows this indicates…
optimal cerebral functioning
what are late signs of ICP/
elevated temp, elevated bp, decreased pulse, decreased respirations
. a pt with Gullian-Barre syndrome may experience what ?
possible ascending paralysis
Trigeminal neuralgia affects which nerve?
5th cranial nerve (sensory) trigeminal nerve
.Bells palsy affects which nerve?
7th cranial nerve, (motor) facial nerve
ALS (Lou Gehrig’s Disease)
progressive motor neuron disorder, muscle weakness
parkinsons disease is caused by a depletion of ____ and an increase of _______
dopamine, aceytlcholine
Main nursing goal for parkinsons disease
maintain independence as long as possible
alzheimers disease key nursing intervention
patient safety
Multiple sclerosis
Destroys patches of myelin in brain and spinal cord, disrupt neuronal signals in CNS
results in muscle weakness, with exascerbations and remissions
pt teaching pts with MS
avoid extremes in temps. (extreme heat or cold), activities with frequent rest periods
Epideral hematoma
arterial; rapid, may lead to death (blood between the dura mater and skull) AKA “talk & drop injury)
Subdoral Hematoma
Slow venous bleeding between dura mater and arachnoid space. symptoms may take up to 24 hours after injury. pressure build up in brain.
. homonymous hemianopsia
lost visual field
Nursing interventions for cva
Airway!! Neuro checks Check for ICP I and o Bowel and bladder training ROM Communication system Safety measures
. CVA s/s
headache, confusion, vertigo, transient hemiparesis, temporary vision changes, syncope
Signs of IICP
changes in LOC, headache, pulillary changes, papilledema, decreased motor/sensory function
. Autonomic dysreflexia
spinal cord injury at t-6 or higher; triggered by sustained stimuli at t6 or below
Autonomic dysreflexia causes
full bladder or UTI, fecal impaction, pressure sores, restrictive clothing
.s/s of autonomic dysreflexia
inc. bp, flushed face, headache, JVD, decreased heart rate, diaphoresis
. Parkinson’s Disease s/s
tremors, bradykinesia, muscle rigidity
. Nursing interventions: pts with parkinson’s
provide assistance with ROM exercises, encourage pt to participate in ADL’s, keep env. free from clutter, promote independence as long as possible
Bell’s Palsy nursing interventions
assess pain level and response to interventions, teach pt to chew on unaffected side, may use eye patch to prevent injury to the eye
agnosis/agnosia
inability to recognize familiar objects
. nursing care for pt with MS
monitor respiratory rate, breath sounds, O2 sat, Elevate HOB, encourage pt to perform self care as much as possible, active/passive ROM
Things that may exascerbate Gullian Barre syndrome
recent immunizations/ recent viral infections
Partial Seizure (simple partial seizure)
repetitive purposeless behaviors ; pt appears to be in dream like state, no loss of consciuosness
Who are Absence seizure (Petit-mal) most often seen in ?
children and is manifested by staring that lasts several seconds
Tonic clonic seizure (grand-mal)
follows a typical progression: aura, Loss of consciousness, tonic phase, clonic phase, postoctical period
What is the clonic phase (grand mal seizure) signaled by ?
-contraction & relaxation of all muscles in a jerky rhythmic manner, -pt is often incontinent
What is the Postictal period?
period right after the seizure. usually involves fatigue, mental status changes, head ache, etc
How long does the tonic phase (grand mal seizures) last ?
30-60 seconds of rigidity, pupils fixed, dilated, hands jaw clenched, may be temporarily apneic
what can leakage from the nose or ear of spinal fluid indicate ?
icp & internal damage
what is important for patients with alzheimers ?
nutrition (finger foods)sandwich,milkshake
what clients are at risk for ICP ?
patients that had brain surgey
brain tumor
high temp and headache )
what are signs of meningitis and esiphilitis ?
high temperature and headache
what is bells palsy & and what can be givin for he dry eyes ?
like a stroke
half of the face is droop
artificial tears of eye drop
when a patient has meningitis ,what examination has to be done ?
a spinal tap
what triggers trigeminal neuralgia ?
extremes of hot and cold
what kind of water does a patient with trigemnila neuralgia has to use on face ?
room temp
luke warm room temp mouth wash
tootheths for sensitivity
what kind of food do trigeminal neuralgia patient eat ?
liquid diet or soft diet
What is status epilepticus ?
30 miniatures of repititive seizure activity without a return of conciousness
