Exam 3 Neuro Flashcards
(148 cards)
1
Q
Why would you need an NG tube for epidural hematoma
A
abdominal distention which could lead to IICP
2
Q
What does ptt mean
A
pain temperature, sensation loss below the level of the lesion. Has to cross over.
3
Q
When should you do quad cough
A
before a meal or 2 hours after meal. (4x/day)
this is for aspiration pneumonia, SCI
4
Q
CD 4 Levels for HIV positive & AIDS patient
A
CD4 level below 200
5
Q
Characteristics of epidural hematoma
A
- emergency
- loss of consciousness, lucid period, progresses to coma
6
Q
Manifestations of neurogenic shock
A
bradycardia, hypotension
7
Q
What are the 3 components of ICP
A
- brain tissue
- cerebral blood flow (CBF
- CSF
8
Q
What is IgG
A
tissue fluid and plasma, activates complememnts. Usually autoimmune.
found in blood and extracellular fluid control infection of body tissues. Binds many kinds of pathogens such as viruses, bacteria, and fungi, IgG protects the body from infection
9
Q
Craniall Nerve VII
A
innervates muscles of expression
10
Q
Seizure characteristics
A
- metabolic disorder, alcohol withdrawal
- electrolyte disturbances, heart disease
- oxygen, suction (for aspiration)
- anticonvulsion- bleeding risk, can’t drive
11
Q
What determines if client is “brain dead”
A
no eye activity, cold caloric test
12
Q
Normal Level for ICP
A
10-15 mmHG
13
Q
Who should nurse refer for client diagnosed with a brain tumor
A
social worker
14
Q
What types of drugs do rehabilitation facilities not take
A
Intravenous
15
Q
This type of hematoma forms slowly and results from a venous bleed
A
subdural hematoma
16
Q
Post Op Craniotomy things to watch for
A
- may be intubated, arterial and central venous lines
- Vasodilate- CO2 - due to bleeding risk first 24 hrs
- avoid extreme head rotation
- risk for IICP.
- relieve pain
17
Q
Name your priorities for head injury and dehydrated patient
A
- complete neuro assessment
- notify the physician
- assess specific gravity
- start iv fluids and administer desmopressin
This is Diabetes Insipidus
18
Q
What does rheumatoid arthritis and SLE have in common
A
joint stiffness and pain
19
Q
First line of defense for increase ICP
A
Hyperventilation, because CO2 causes vasodilation which make it worse
20
Q
Positioning for infratentorial surgery
A
flat or 30-45 degrees.
21
Q
The brain stem is made up of 3 components
A
midbrain, pons, medulla
22
Q
how is HIV tested
A
- blood test with ELISA
- if positive another ELISA
- then Western Blot
23
Q
How is range of motion performed
A
with another person, maintains mobility and flexibility while pt on bed rest
24
Q
autonomic dsyreflexia intervention
A
straight cath every 4-8 hours
25
Nutrition prior to having EEG
can eat but no caffeine
26
Sjogren syndrome
dry eyes and dry mucous membranes
27
overall characteristics of autoimmune
fatigue/weakness. Eat well, sleep well.
28
What organ specificallly is concerning for SLE
kidney, proteinuria
29
Nursing interventions autonomic dysreflexia
elevate HOB, 45 degrees, notify physician, determine cause
30
Pre op pituitary tumor instruction
do not blow nose for 2 weeks after surgery, could leak CSF fluid
31
What is the action of phentoin (dilantin)
Decreases synaptic transmission antiarrthythmic, limits seizure by altering ion transport
32
What is a priority problem for client diagnosed with RA?
Alteration in comfort due to chronic pain
33
Frontal Lobe
* broca's area for speech.
* Moral Emotions, reasoning judgment concentration, abstraction
34
What preprocedure should nurse implement prior to EEG
stay awake for 24 hours. Goal is to have a seizure, flashing lights, hyperventilation will induce.
35
Technical position to put patient in for spinal cord injury suspected
leaning forward with head over the knees. Neck should be immobilized prior to x-rays
36
What is the most common brain tumor
infratentorial, located posterior (cerebellum or brainstem)
37
Preventitive nursing measures for brain injury
oxygenation, bladder and urine output, dressing, pad and side rails
38
What is areflexic (flaccid bladder)
lost ability to contract and easily stretching. Allow large amounts of urine to accumulate. Bladder can overflow and leak (SIADH). SCI sacral spinal cord. Cred method
39
If you are a first responder for a head injury, what would you implement first
stabilize client's cervical spine. Always assume head injury has a spinal injury
40
Diet for SLE
limit sodium and protein intake (should be well balanced)
41
Prevention of head injury
helmets, seatbelts car seats,
42
If a client has slow breathing what does that cause
acidotic, build up of CO2, pressure
43
Pre op Craniotomy
* Hair will be clipped or shaved
* awaken with a dressing and a drain on head
* **headache and facial swelling for 2-3 days after surgery**
* baseline neuro assessment
44
Intervention for minimizing risk for seizure activity undergoin diagnostic studies after having several episodes of sezure
Cabamazepine Tegretol 200 mg, twice a day
45
teaching when taking immunosuppressive
class C drug, should not get pregnant.
46
Nursing Dx for Spinal Cord Injury
* Ineffective breathing pattern r/t respiratory muscle fatique
* Impaired skin integrity r/t immobility
* impair urinary elimination
* constipation r/t neurogenic bowel
* risk for autonomic dyreflexia
47
What is an example of natural immunity
breastfeeding
48
In a client with RA what assessment requires immediate intervention
signs of depression
49
Lumbar puncture, aseptic or sterile
aseptic
50
Prevent injury during lumbar puncture
do not move during insertion, lie on side curling forward so that kneees are flexed toward the chest.. DOES NOT USE DYES TO INJECT IN THE BODY.
51
Nursing Dx for Head Injury
* Risk for ineffective cerebral tissue perfusion r/t interrupted CBF (hematoma)
* Hyperthermia r/t metbaolism, infection hypothalamic injury
52
Discharge teaching with dilantin/phenytoin
brush teeth after every meal to avoid gingival hyperplasia
53
Prevention Tx with RA
exercise, increase muscle strenth, improves joint stability, preserve joint motion/flexibility, boosting aerobic condition.
54
What is hyperreflexic bladder
overactive, holds less than urine than before SCI. Frequent small urinations. Upper Motor Neuron.
Recommendation: Valsalva Maneuver
55
Discharge teaching for craniotomy
* may need to take anticonvulsants for up to 12 months after surgery
* adverse drug reactions should be reported (drowsiness, confusion)
56
Who can help finding employment after spinal cord injury?
Rehabilitation commission
57
Manifestation of basilar skull fracture
* Battle's sign (bruising mastoid)
* Bulging of tympanic membranes
* CSF
* tinnitus or hearing difficulty
* rhinorrhea
* facial paralysis
* deviation of gaze
* vertigo
58
Cranial Nerve II
Optic Nerve, sensory repsoniible for vision. Use the snellen chart to assess for visual acuity. Or visual field in four places.
59
CREST syndrome and SLE
* **C**alcium deposits
* **R**aynauds phenomenon
* **E**sophageal dysmotility
* **S**clerodactyly (fingers stiffen)
* **T**elangiectasis (spider like hemangiomas
60
Halo Sign and Closed Head injury
CSF leakage. Monitor and inform the physician, not an emergency though.
61
Nursing Care for autonomic dysreflexia
sitting position, catheter to re-establish patency, check rectum for fecal mass, admiin IV antiHTN (slowly)
62
headache treatment
transduction, NSAIDS, heat, or cold
modulation: yoga, herbs acupuncture
63
Rehabilitation for spinal cord injury, medical nursing implementation
DVT risk, physical immobility, SQ anticoagulants (Lovenox)
64
What drug do you give for Autonomic dysreflexia
hydralazine/apresoline IV--vasodilate, alpha blocker
65
Early Signs of ICP
pupils fixed, Inc BP, Ataxia (can't move), Uneven gate, 8 GCS, Rapid/deep breathing
66
What is important characteristic to know about TBI
it is a process not an event. Risk for urinary retention or constipation.
67
where does sensory lie in brain
dorsal root (white matter)
68
69
What is the term called for RA sign?
ulnar drift
70
Why do we taper steroid medication
because adrenal stops producing cortisol, allows adrenal to gradually start producing again.
71
Leading cause of seizures in the elderly
CVA
72
Nursing Dx for ICP
* Ineffective Cerbral Tissue Perfusion
* Impaired Physical Mobility
73
Head ache issue arise from
vessel issues, constricted or dilated
74
What is an important goal for a client diagnosed with a brain tumor and has self care deficit
client can perform adl's with assistance
75
If someone has a low GCS score, why should be clean their eyes
corneal irritation
76
When is lumbar puncture contraindicated
IICP can lead to brain herniation
77
pathophysiology of autoimmune
auto-antibodies, directed against cellular DNA
78
Teaching for a brain tumor patient that has diminished gag reflex
direct food and fluid toward the unaffected side
79
In a spinal cord injury what causes headch and high blood pressure,
bladder distention
80
Vital Signs for increasing ICP
high temp, high bp, low pulse, low respirations
81
What is SLE
autoimmune disease may have genetic or hormonal component. Exaggerated production of antibodies.
82
83
Cushings triad
systolic hypertension, widening pulse pressure, bradycardia, bounding pulse, irregular respirations)
84
Discharge instruction for epileptic client
* Record seizure activity, avoid over the counter medications, check serum levels regularly
85
Risks for intracranial hematoma aspiration (epidural, subdural, intracerebral)
infection, seizures, immobility, cerebral edema, permanent neurologic deficitys, coma, death
86
Procedures for Rheumatoid Arthritis
arthrocentesis, tissue biopsy, blood studies (ESR, CPT)
87
Spinal Cord Injury Proper technique for CPR
jaw thrust maneuver
88
risk for intracerebral hemorrhage
needs craniotomy, control icp, blood clot
89
population with head injury
15-24 years
90
What is a conceptual pupil response
crossed reflex in which light directed at one eye causes contraction of *both eyes*
91
Anticonvulsant medication for posttraumatic seizure
Dilantin (phentoin)
92
Why is a craniotomy peformed
* To expose brain for tx
* ventricular shuntin, tumor/ absecc,excision, hematoma aspiration, anurysm clipping
93
Diagnostic test for SLE
CBC and antinuclear antibody tests
## Footnote
*anemia, leukopeia, thrombocytopenia*
94
What should you monitor when administering phytoin
vital signs and cardiac status
95
Dopamine (Intropin)
**Indication:** Improve BP, CO, and Urine Output (neurogenic shock)
**Action** renal vasodilation
**Class**- adrenergic, vasopressor
**Nursing**: irritation at IV site, beta blocker may counteract effects, hemodynamic values,
96
What could be a discrete symptom of ICP
unusual sleepiness
97
Nursing intervention to prevent valsalva maneuver
instruct pt to exhale when turning or moving in bed
98
In a person with RA what do movable nodules in SQ tissue represent
rapidly **progressive** destruction of affected tissue
99
Nurse intervention for patient experiencing vertigo
(Menier's disease) pt in bed with pillow on either side of head.
100
If nurse sees someone having a seizure what action should nurse implement first
note the first thing the client does during the seizure
101
What can sun exposure trigger for patient with SLE
itchy discoid rash
102
What is the primary goal for SLE
maintenatce of organ function. Can cause MI, pericarditis, pneumonia, and pleural effusion.
103
What are the 3 most common complications in pts with neuro disorders?
* respiratory infection, UTI, infected pressure ulcers
104
What should you observe after concusiion
changes in level of consciousness, difficulty awakening, lethargy, dizziness, confusion, irritability
105
Why do you need to take NSAIDS on a full stomach
can cause ulcers
106
Manifestations of spinal shock
flaccid paralysis, loss of reflex activity below the level of injury, **bradycardia, hypotension**, paralytic ileus
107
Hematoma treatment
think blood, bleeding edema, mannitol, respiratory acidosis or alkalosis.
108
Complication for a craniotomy
diabetes insipidous (monitor i/os), increased ICP, hemorrhage, infection, respiratory compromise
109
What is the most serious type of hematoma
epidural hematoma
110
Occiptal Lobe
visual area
111
Can client who is unconcious eat?
No, NPO
112
If a patients body is rigid and making guttural sounds. Legs are contracting and relaxing, which action do you take first?
Ease the client to the floor
113
Skin Care and SLE
dry skin by *patting*, risk for abrasians and breakdown. Use mild soap
114
Treatment for ICP
* Ventilation
* IV flud therapy
* Mannitol (osmotic diuretic)
* sedation and anesthesia
* Stool softener
115
Discharge instruction for pt with hypophysectomy
* sleep with HOB elevated
* keep humidiefier in the room
* use caution when perfomring oral care
* notify HCP if developing a cold or fever
116
Characteristics of cognitive improvement
able to stay on task, judment, memory, reasoning
117
Priority Nursing Actions for Autonomic Dysreflexia
1. raise hob
2. loosen tight clothing
3. check bladder distention or noxious stimulus
4. administer antihypertensive medication
118
Where does autonomic dysreflexia get stimulated
*below* level fo SCI
119
Where is suprtentorial tumor located
anterior 2/3rds of the brain, mainly *cerebrum (thought, action)*
120
Raynaud's phenomenon
causes some areas of your body — such as your fingers and toes — to feel numb and cold in response to cold temperatures or stress. In Raynaud's disease, smaller arteries that supply blood to your skin narrow, limiting blood circulation to affected areas (vasospasm)
## Footnote
*autoimmune disorders*
121
Cushing's Triad
decreasing pulse, alteres respirations, increased BP. Late sign of ICP
122
Normal Size of pupil
2-5 mm
123
Neurogenic shock treatment
dopamine, vasopressing, epinephrine, atropine
124
Positioning for Suprtentorial surgery
elevated 30 degrees to promote venous outflow through jugular veins
125
Parietal lobe
* taste, pain, temperature, pressure
* spatial perception
126
Cranial Nerves III, IV, VI
eye movement.
127
Late signs of ICP
fixed dilated pupils, decreased HR, Widening Pulse Pressure, Decerebrate, Decorticate, Less than 8 GCS, slow breathing
128
Which 4 nerves are affected to incrase in ICP
optic II, oculomotor III, trochlear IV, abducens V
129
Temporal Lobe
* auditory center
* Wernicke's area for sensory and speech
130
Who would you referr a RA patient to
occupational therapist to utilize hands
131
emotional and visceral patterns for survival. Learning and memory.
132
What antigen should be matched for organ transplantation
human leukocyte antigen
Risks are rejection and infection.
133
When does autonomic dysreflexia occur?
spinal cord lesions **above t6** after spinal shock has subsided. reaction to overstimulation
134
Where does motor senses lie in brain
ventral root
135
Cranial Nerve V
sensation to the face and innervation to the muscle of mastication
136
What should you assume regarding unconcious patient and hearing
assume they can hear
137
A client has HIV, what is urgent to tell a HCP
dehydration, tented skin
138
CSF contains what 2 things
proteina and glucose
139
Risk with aspirin
otoxicity, tinnusitis
140
Reactions with autonomic dysreflexia
vasoconstriction increasing BP, throbbing headache, diaphoresis (*above level of injury)*, bradycardia, goose bymps, spots in the visual field, anziety, anausea
141
What do absense seizure look like
brief episodes of consciousness. Blank stare for a few seconds
142
Epidural Hematoma Nursing Interventions
* HOB *no more* than 30 degrees
* sedative for agitation
* NO narcotics
* Stool softeners
143
HIV diet
high calorie, high protein, low residue
144
S/Sx of Autonomic Dysreflexia
nasal stuffiness, dilated pupils or blurred vision, sweating, goose pumps (piloerection)
145
S/Sx of autonomic dysreflexia
pounding headache, sweating, nasal congestion, piloerection, hypertension
146
Post Op Craniotomy
* gradually increase level of activity
* monitor neuro status
* watch for pupil changes, weakness, headach and change in LOC (signs of IICP)
* residual neuro deficits, family support
147
First action if you see csf drainage for ear or nose
check for glucose
148
Post op Lumbar Puncture
lie flat 4-8 hours
