Week 1: Neurology Flashcards
The nurse is assessing motor and sensory function of an unconscious client with a head injury. The nurse should use which technique to test the client’s peripheral response to pain?
a. Sternal rub
b. nail bed pressure
c. pressure on the orbital rim
d. squeeze the sternocleiomastoid muscle
Answer: b
rationale:
looking for the peripheral response (sternal rub is not recommended anymore and the other ones are not peripherally located)
The patient is semi rousable and swats with hand when pressure applied to location on body. would they be getting better or worse if they withdraw to pain response
worse. withdrawing and inability to locate pain is a sign of decreased mental status
the nurse is working in LTC and is taking report for a client diagnosed with Parkinson’s disease 3 years prior but is just moving to LTC now. client has been living home alone when friends and family advocated for LTC due to increased falls and weight loss. client presents with bradykinesia, tremors at rest , rigidity, and shuffles while mobilizing in his walker. he has a blank expression on his face and is drooling.
- What does the pt have?
- What 3 signs indicate early Parkinson’s?
- What signs indicate worsening Parkinson’s?
- Parkinsons
- Tremors, rigidity, bradykinesia
- blank expression, drooling, weight loss
After completing a full assessment the nurse is developing the plan of care for the client. which of the following would be most important to include SATA
- instruct the client to move slowly from laying to sitting
- Promote regular rest periods with frequent naps
- increase fluid intake to 2000 mL/day
- Limit the clients mobility to prevent falls
- provide small and frequent meals
answer: 1, 3, 5
rationale:
1 is to prevent orthodontist hypotension, 3 and 5 are to due with diet changes these patients can have
The nurse is instructing a client with Parkinson’s about preventing falls. which statements indicate need for further teaching?
- I can sit down to put on my pants and shoes
- I try to exercise every day and rest when tired
- I dont need to use my walker to go to the bathroom
4 my son remove all loose rugs - it is safe for me to take haloperidol
answer: 3, 5
rationale: 3 these mfs fall all the time they need their walking shit, 5 haliperidol causes drug induced Parkinson’s
The nurse is completing an assessment on a client with a TBI from a Basiliar skull fracture. the nurse is concerned there may be CSF leaking from the clients nose. Which of the following reported assessment findings indicates more education is needed?
- the fluid looks clear and is testing positive for glucose
- I saw the halo sign on gauze during my assessment
- the client is reporting a headache and stiff neck
- I asked the client to blow their nose so I can assess if it continues to leak
answer: 4
rationale: client with a TBI should not be bearing down (coughing, sneezing, nose blow) due to increasing ICP
The nurse is caring for a client with increased ICP from head injury. which trend in VS would indicate worsening condition?
- Increase temp, pulse and resps with decreased BP
- Increase temp, decrease pulse/resps increased BP
- decrease temp, use and bp with increased resps
Answer: 2
rationale widening pulse pressure is seen with this, decrease in pulse and increasing BP
The nurse is preparing the client for a lumbar puncture. which of following indicate correct understanding
- the client cannot have this test done with increased ICP
- position client on side with pillow in between knees
- inform client they can resume normal activity after
- encourage to drink fluids
Answer: 1 ,4
rationale 1 cannot have increased pressure (puncture) if ICP is high, drinking more fluids replaces the ones being lost
Which of the following is appropriate for a client at risk for increased ICP?
1. HOB 30-45 degrees
2. keep environment cool so they do not overheat
3. ensure they have stool softeners
4. flex the knee gatch on the bed and place pillows
5. limit intake to 1200mL/day
Answer: 1,3,5
rationale; keeps pressure from rising by sitting up, stool softeners prevents bearing down or pushing, fluid intake prevents fluid overload
Shivering can increase ICP!!
Which of the following would be appropriate to include with client care during acute phase of stroke
- monitor for seizures
- maintain BP 150/100
- place in high fowlers
- administer low oxygen therapy
answer: 1,2
rationale: seizures can happen from a sudden burst of electrical activity from a rupture (bad) and blood pressure can keep increasing leading to ICP, therefore keeping a consistent BP range is important
A cerebral angiography is ordered for a client. which of the following would be a priority to report to the MRP?
- client drank 1.5L of fluid in last day
- swelling in neck and difficulty swallowing
- pain and swelling in the calf
- the client is asking to keep the bed flat
answer: 2
rationale: could indicate a leak or bleed in the brain (stroke symptom) think airway
the nurse is assessing how well a client is adapting to functional status change after a stroke. which observation indicates that the client is adapting most sucessfully?
- gets angry at the caregiver for interrupting task
- experience bouts of depression/irritability
- uses modified utensils with difficulty
- consistently uses adaptive equipment in dressing self
answer: 4
rationale: the other ones r dumb
What measures should the nurse include in the PoC for a client with a spinal cord injury (above T6) to minimize the risk of autonomic dysreflexia? SATA
- keep linens wrinkle free under client
- prevent unnecessary pressure on lower limbs
- limit bladder catherization to every 12 hrs
- turn/position every 2 hours
answer: 1, 2, 4
rationale: preventing any unwanted stimulus
The nurse is completing a safety assessment on a client who is confused and a falls risk. Which of the following interventions is most appropriate?
- provide non slip mat for clients
- so not reorient the client too often
- ensure all four side rails are up to prevent falls
- maintain a toileting schedule
answer 4
A client is admitted to the hospital and is diagnosed with a pressure injury on their coccyx and has a wound VAC. The wound culture shows that methicillin-resistant Staphylococcus aureus (MRSA) is present. The VAC is due to be changed. What protective precautions should the nurse employ to prevent contraction of the infection during care?
- gloves and mask
- airborne precautions
- face shield and gloves
- contact precautions
answer 4
A client is scheduled for surgery and states to the nurse, “I’m not sure if I should have this surgery.” Which response by the nurse is most appropriate?
- dont worry we have the best surgeons
- tell me what concerns you have about this surgery
- why dont u want to have this surgery
- it is your decision
answer 2 (never choose why question)
The nurse is initiating a plan of care for a client admitted with pneumonia. Which intervention for cough enhancement should the nurse delegate to a nursing assistant?
- teaching client importance of hydration
- completing initial VS for admission document
- encouraging client to hold breath and cough
- reminding the client to use incentive spirometer every 1-2 hours while awake
answer 4 (they can not provide any teaching)
Which of the following is the earliest symptom of increased intracranial pressure (ICP)?
- nuchal rigidity
- constant headache
- babinski reflex
- vomiting without nausea
answer 2 (earliest sign LOC changes earliest symptom headache)
A client is hospitalized with a TBI (traumatic brain injury) and their ICP (intracranial pressure) is 21 mmHg. Which of the following interventions is most appropriate?
Reference- ICP <15 mmHg
- RL
- none ICP normal
- 3% NS
- 0.45 NS
answer 3 because sodium draws water (osmotic)
