VN 22 Test 7

Question 1

1. How would you assess the motor response of an unconscious client?

Answer 1

 A change in vital sign or assessment details with a patient with neurological disease. You need to notify the provider
 Comatose patient: you need to use motor stimulation to get your information
- Administer pain stimulation

Question 2

2.What is
A. Decorticate Posturing
B. Decerebrate Posturing
C. Flaccid

Answer 2

A. A position in which the arms are flexed, fists are clenched, and the legs are extended

B. When the extremities are stiff and rigid; decerebrate posturing is more serious than decorticate posturing

C. When the client makes no motor response

Question 3

3. What is a Glasgow Coma Scale? What does the scale consist of?

Answer 3

Eye opening response
4. Spontaneously
3. To speech
2. To pain
1. No response

Verbal response
5. Oriented to time, person and place
4. Confused
3. Inappropriate words
2. Incomprehensible sounds
1. No response

Motor Response
6. Obeys command
5. Moves to localized pain
4. Flex to withdraw from pain
3. Abnormal flexion
2. Abnormal extension
1. No response

Question 4

4. At what level is the client considered to be in a coma?

Answer 4

A score of 8 or less

Question 5

5. How do you check for neck rigidity? Brudzinski? Kernig? Nuchal rigidity?

Answer 5

 Brudzinski: head flex towards the chin and the knee and hopes goes up and flex is a positive sign
 Kernig: severe stiffness in the hamstrings is a positive sign
 Nuchal rigidity: stiff neck; head goes down towards the chest and there is resistance

Question 6

6. Manifestations of increased intracranial pressure?

Answer 6

 Decreasing level of consciousness (LOC) early manifestation
 Changes in pupils
 Stuporous, semi-comatose; confusion, restlessness, periodic disorientation
 Headache- more severe in the morning
 Cushing’s triad: a pulse rate that increases initially but then decreases, and a respiratory rate that is irregular
 Cheyne-Stokes respirations
 Other: vomiting, papilledema, decorticate or decerebrate posturing
 Pulse pressure; difference between systolic and diastolic ex. 140/40

Question 7

7. Nursing considerations for intracranial pressure

Answer 7

 Maintain head in midline at 30 degrees of elevation
 Maintain BP and ensure cerebral perfusion/fluids as ordered
 Maintain airway: monitor O2 levels
 Monitor neurologic status: change in LOC
 Seizure precaution
 Decreases stimuli-may sedate
 Indwelling catheter to monitor I&O
 Stool softener; Avoid straining
 Avoid hypothermia
 Avoid hypotonic solution: it will swell cells and increase ICP

Question 8

8. What is Cushing’s Triad?

Answer 8

 A pulse rate that increases initially but then decreases and a respiratory rate that is irregular

Question 9

9. What is meningitis and what is it caused by?

Answer 9

 An infection of the meninges which surround and protect the brain and spinal cord.
 Cause may be a virus, bacteria or fungi

Question 10

10. Meningitis manifestations

Answer 10

 Headache-excruciating
 High fever
 Nuchal rigidity
 Positive Brudzinski’s sign

Question 11

11. Phenytoin need to knows (medication)/ IV use/ Anticonvulsant

Answer 11

 Use for Seizures (anticonvulsant)
 Very marrow therapeutic range; Monitor levels ()?
 Can cause gingival hyperplasia; really good dental hygiene is important
 Cause can thrombocytopenia; watch for any bruising/ nose bleeding; if so notify the provider
 Monitor LFT for long term use

IV use: monitor IV site can cause irritation and watch for any infiltration

Anticonvulsant: they can decrease vitamin D which will affect calcium as well so we need to monitor electrolyte levels

Question 12

12. Levodopa need to know (medication)

Answer 12

 Use for Parkinson’s
 Protein can interfere with the absorption of levodopa. (Decrease protein intake); NO high protein diet

Question 13

13. Seizure nursing actions

Answer 13

 Keep them safe; position them on their side
 Good documentation: find out for any aura
 Postictal Phase; period after the seizure, very often will be very sleepy (may be irritable or agitated at that time)

Question 14

14. Seizure classifications

Answer 14

 Absence seizure: stares blankly, eyelids flutter, lack of prominent movement
 Myoclonic seizure: sudden, brief jerking
 Tonic-clonic seizure: muscle alternate between contraction and relaxation; jerking movement

Question 15

15. Post seizure nursing actions

Answer 15

Do you know what happened?
Did the nurse observe
 What type of body movement?
 Loss of consciousness
 How long was the seizure
 Was there an Aura?
 Asses for postictal
Ask for any Automatisms: repetitive, none purposeful actions

Question 16

16. Parkinson’s manifestations

Answer 16

 Muscle rigidity
-Tremors; pill rolling
- Bradykinesia- slow movement including slurred speech; masklike expression and decreased blinking
-Shufflinggait

Question 17

17. Guillan-Barre syndrome nursing considerations

Answer 17

 Assess signs of respiratory distres
-spirometer
-skin care
-change position every 2 hours
-ROM exercises to prevent muscle atrophy

Question 18

18. Guillan-Barre syndrome manifestations

Answer 18

 Weakness- that progresses
 Tingling in the arms and legs
 Paralysis
 Incontinence
 Other: Difficulty chewing, talking and swallowing

Question 19

19. ALS manifestations

Answer 19

 Progressive muscle weakness; wasting of the arms
-legs and trunk develop-atrophy
-client experiences episode of muscle fasciculations (twitching)
 If ALS affects the brain stem-difficulty speaking and swallowing,
-periods of inappropriate laughter and crying,
-respiratory failure
-total paralysis

Question 20

20. Encephalitis manifestations and diagnosis

Answer 20

Sudden fever,
severe headache,
-stiff neck,
-vomiting,
-drowsiness,
-tremors,
-seizures,
-spastic or flaccid paralysis,
-irritability,
-muscle weakness,
-lethargy,
-delirium,
-coma,
incontinence, visual disturbances

 Ask for any recent bug bites?

Question 21

21. Baclofen need to knows

Answer 21

 Is for Multiple Sclerosis and the therapeutic affect is to minimize symptoms like muscle spasticity and rigidity

Question 22

22. Brain tumor manifestations, focal

Answer 22

-headache (most common in the morning,
becoming increasingly severe and occurs more frequently as the
tumor grows),
-vomiting occurs without nausea or warning
-papilledema,
-seizures,
-speech difficulty,
-paralysis,
-double vision
other sensory loss,
-muscle weakness

 Focal symptoms: specific on one part of the brain
 Generalized symptoms: vomiting

Question 23

23. Brain tumor priority

Answer 23

 Prevent increased intracranial pressure

Question 24

24. Huntington’s Disease manifestations

Answer 24

 Choreiform movement (jerking movement/ rivaling)
-Mental apathy and emotional disturbances,
-grimacing
-Other: difficulty chewing and swallowing, speech difficulty, intellectual
decline, loss of bowel and bladder control; severe depression can lead
to suicide

Question 25

25. Valproic acid need to knows

Answer 25

 Use for seizures (Anticonvulsant)
 Watch for bruising, can cause thrombocytopenia

Question 26

26. Amantadine need to knows/ Selegiline

Answer 26

 Use for Parkinson’s
 Can cause insomnia and lightheadness

Selegiline: Avoid foods with high tyramine; cured meat, cheddar cheese

Client education with medication for Parkinson’s: A patient has symptoms of Parkinson’s for awhile but it took a while for the diagnosis and then get put on medication but instantly they get amazing results and decreased symptoms; usually after a couple of years the medication actually leans and is not as affect. Which can be honeymoon stage