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NCLEX-RN (5) Adult Health > Neuro > Flashcards

Flashcards in Neuro Deck (72)
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1

What is the most sensitive indicator of neuro status?

Level of consciousness

Assess for restlessness, irritability, and confusion.

2

What is the highest score on the Glasgow coma score?

Glasgow coma score: 15 is the highest score

  • at 15, the client is completely alert and oriented
    • eyes open spontaneously
    • verbalizes pain
    • oriented and converses

3

What is the lowest score on the Glasgow coma scale?

Glasgow coma score: 3 is the lowest score

  • at 3, the client is not responsive
    • eyes have no response
    • no response to pain
    • no verbal response

4

At what Glasgow coma score is the client typically intubated?

Immediate complication

"Less than 8, intubate"

8 indicates a coma.

5

Unconscious clients are completely dependent on caregivers. What are the priority safety concerns?

  • assure an airway: may be on a ventilator
  • tube feedings:  prevent aspiration
  • turn every 2 hours: to prevent pressure ulcers
  • prevent falls: by keeping side rails up and bed in low position
     

6

What is decorticate and decerebrate posturing?

Both postures indicate a deteriorating condition in the brain.

7

What life-threatening condition are clients at risk for after a head injury, stroke, or brain surgery?

Immediate complication

Increased intracranial pressure (ICP)

Increased pressure in the brain due to edema.

8

What is a late sign of increased intracranial pressure?

Late sign of increased ICP is:

  1. increased systolic blood pressure
  2. widened pulse pressure
    • big difference between systolic and diastolic pressure
  3. bradycardia
    • due to compensation of a high BP

9

What position is a client placed in to prevent increased intracranial pressure?

  • elevate HOB 30 to 40 degrees
  • don't flex the neck or hips (keep body midline)

10

What common actions should the client avoid to prevent increased intracranial pressure?

  • avoid straining such as coughing, sneezing, and Valsalva's maneuver
  • don't shiver: keep client warm

11

Why is there a fluid restriction with increased intracranial pressure?

Increased ICP is due to edema and extra fluids in the brain:

  • fluids are restricted to less than 1200 mL per day to prevent more edema

12
Medications:

Increased intracranial pressure

  • anticonvulsants: to prevent seizures
  • muscle relaxers: to prevent shivering
  • antihypertensives: to maintain cerebral perfusion
  • steroids: to decrease edema and inflammation
  • osmotic diuretic (mannitol): to decrease edema

13

How are head injuries prevented?

Head injuries are prevented by wearing a helmet when riding a motorcycle or bicycle.

 

14

What is a concussion?

A concussion is when there is a jarring movement of the brain inside the skull.

The client may or may not lose consciousness.

15

What is an epidural hematoma?

Immediate complication

An epidural hematoma is the most serious bleeding head injury

  • It occurs above the dura and is arterial blood (bleeds fast)

Client can rapidly progress into a coma.

16

What is a subdural hematoma?

subdural hematoma occurs below the dura and is venous blood (bleeds slowly).

It can resolve on its own or be life-threatening.

17

What is an intracerebral hemorrhage?

Immediate complication

An intracerebral hemorrhage is when a blood vessel within the brain has ruptured.

It can occur from a traumatic brain injury (TBI) or cerebral aneurysm.

18

What is always the concern after a head injury?

Increased intracranial pressure

19

What fluid can leak out of the ears or nose after a head injury?

cerebral spinal fluid (CSF)

 

20

What are the interventions if cerebral spinal fluid is leaking out of the nose or ears?

  • do not suction the nose and don't allow the client to blow their nose
  • if drainage is coming out of the ear, don't clean it, just put a sterile dressing over the ear.
  • tell client not to cough

21

How is a cerebral spinal fluid leak tested for?

Halo test

22

What is a craniotomy?

A craniotomy is a surgery of the brain to remove blood or a tumor.

23

What are the priority interventions after a craniotomy?

  • make sure the client can breath (may be on a ventilator)
  • prevent increased ICP

24

What is a seizure?

Immediate complication

A seizure is a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in behavior, movements or feelings, and in levels of consciousness.

Epilepsy is a seizure disorder of two or more seizures or a tendency to have recurrent seizures.

25
Signs and symptoms:

Seizure

  • confusion
  • aura
  • sudden falls
  • staring
  • uncontrollable jerky movements
  • strange sensations and emotions
  • loss of consciousness or awareness

26
Interventions:

During a seizure

  • maintain airway and DON'T put anything in the mouth
  • place client on floor and protect head and body
  • don't restrain the client
  • loosen clothing
  • note the type of seizure
  • give anticonvulsant IV to stop seizure

27
Interventions:

After a seizure

  • turn client to the side so secretions can drain - possibly suction
  • document time and duration of seizure

Notify HCP.

28
Teaching:

Seizure

  1. take medication for life
    • may need to monitor medication blood levels
  2. avoid substances and situations that cause seizures
    • avoid alcohol, excessive stress, fatigue, strobe lights

29

What is the difference between a thrombotic stroke and embolic stroke?

Immediate complication

A thrombotic stroke is caused by a blood clot that develops in the brain.

An embolic stroke is caused by a blood clot or plaque debris that develops somewhere else in the body and then travels to the brain.

Both types are considered ischemic strokes, where a clot blocks oxygen and blood.

30

What is a hemorrhagic stroke?

Immediate complication

A hemorrhagic stroke is caused by bleeding in the brain from hypertension or an aneurysm.

31

What is the most common test to diagnose a stroke?

The test to diagnose a stroke is a CT scan to see if it's caused from a blood clot or from bleeding.

There are different interventions based on the type of stroke.

32

What are the characteristic signs and symptoms of an acute stroke?

FAST

  • Face drooping
  • Arm weakness
  • Speech difficulties
  • Time to call

33

What medications are given if the client is having a stroke from a blood clot?

Thrombolytics are given to break up the blood clot.

34

Would thrombolytics be given to a client having a hemorrhagic stroke?

NEVER. The client will bleed more.

Never give thrombolytics to a client having a hemorrhagic stroke or to a client who is actively bleeding. Make sure the CT scan is completed to determine what kind of stroke it is before thrombolytics are given.

35

What is Neglect syndrome?

Neglect syndrome is when the client is unaware of the existence of the paralyzed side.

36
Define:

Agnosia

Agnosia is the inability to recognize familiar objects or people.

37
Define:

Apraxia

Apraxia is the inability to carry out physical movements, even though having the desire and ability to perform them.

38
Define:

Expressive aphasia

Expressive aphasia is when the client understands what is being said, but can't communicate verbally.

The client cannot express information.

39
Define:

Receptive aphasia

Receptive aphasia is when the client cannot understand what is being said or written.

They cannot receive information.

40
Define:

Hemianopsia

Hemianopsia is blindness in half the visual field

41
Define:

Dysphagia

Dysphagia is difficulty swallowing.

42

What is a common referral due to risk of dysphagia in stroke clients?

The speech therapist comes and sees the client to evaluate the gag reflex and swallowing, in order to recommend a diet.

43

What is the typical recommended diet for a client with dysphagia?

  • thickened fluids
  • soft foods

44

How is a client when dysphagia positioned when feeding?

Feeding position for dysphagia:

  • sit client high up in bed
  • put head and neck slightly forward and chin tucked
  • put food in the back of the mouth on the unaffected side to prevent trapping of food

45

What are the interventions for a client with hemianopsia?

  • approach client from the unaffected side
  • place objects on the side that they can see on

46

What do all these neuro diseases all have in common?

  • multiple sclerosis
  • myasthenia gravis
  • Parkinson's disease
  • Guilain-Barre syndrome

All the clients with these neuro diseases have fatigue and muscle weakness (including respiratory muscle weakness)

Assess for difficulty with breathing, swallowing, and prevent falls.

47
Describe:

Multiple sclerosis

Multiple sclerosis is a muscle weakness disease of the CNS due to demyelination of the neurons.

The cause is unknown, but more common between the ages of 20 - 40.

 

48
Describe:

Myasthenia Gravis

Myasthenia gravis is an autoimmune disease that causes muscle weakness due to a defect in nerve impulse transmission.

There is not enough secretion of acetylcholine and too much secretion of cholinesterase.

 

49

What is an early sign of myasthenia gravis?

Early sign of myasthenia gravis: a droopy eyelid (Ptosis) and double vision.

 

50
Describe:

What are the late signs of myasthenia gravis?

  • difficulty chewing, swallowing and breathing
  • respiratory paralysis and respiratory failure

51
Medications:

Myasthenia gravis

  • pyridostigmine
  • neostigmine

end in -mine

52

What is a myasthenic crisis?

Immediate complication

A myasthenic crisis is when the client doesn't get enough of their medication (undermedicated), causing muscle weakness.

It usually occurs about 3 hours after med administration.

53

What is a cholinergic crisis?

Immediate complication

A cholinergic crisis is when a client gets too much of their medicine (overmedicated), causing muscle weakness.

It usually occurs about 1 hour after med administration.

54

What are the symptoms of a cholinergic crisis (overmedicated) and myasthenic crisis (undermedicated)?

The symptoms for cholinergic crisis and myasthenic crisis are basically the same:

  • muscle weakness
  • dyspnea
  • dysphagia
  • bradycardia

The similar symptoms make it difficult to determine quickly if the client is undermedicated or overmedicated.

 

55

What is an edrophonium (Tensilon) test?

An edrophonium (Tensilon) test is used to determine if the client is in a myasthenic crisis or cholinergic crisis:

  1. it's a myasthenic crisis if edrophonium is given and strength improves
    • client needs more medicine
  2. it's a cholinergic crisis if edrophonium is given and the weakness gets worse.
    • client needs less medicine

56

What is the antidote to a cholinergic crisis?

Antidote to a cholinergic crisis: atropine sulfate (an anticholinergic)

57
Describe:

Parkinson's Disease

Parkinson's disease is a neuromuscular weakness disease caused by the depletion of dopamine.

Dopamine is needed for good muscle control.

58

What are the characteristic symptoms for Parkinson's disease?

 

 

59

What are the late signs of Parkinson's disease?

Late signs of Parkinson's disease are due to muscle weakness:

  • difficulty swallowing and speaking
  • drooling

60

What are the basic interventions for most neuromuscular disorders that cause muscle weakness?

  • prevent falls
  • don't rush client
  • provide frequent rest periods
  • assess the ability to chew and swallow
  • assess breathing
  • promote independence

61
Describe:

Guillain-Barre Syndrome

Immediate complication

Guillain-Barre Syndrome occurs after an infection where the immune system overacts and destroys the myelin sheath (the part that connects nerves).

The client gets ascending paralysis, eventually affecting the respiratory muscles.

 

 

62

What is the priority assessment with Guillain-Barre syndrome?

Assess ability to breathe and respirations due to ascending paralysis.

63

Is there a cure for Guillain Barre?

No. There is no known cure for Guillain Barre, but client may get immunoglobin therapy to boost the immune system - the client will be on a ventilator. 

Most clients recover within 1 year.

64
Describe:

Meningitis

Immediate complication

Meningitis is an infection in the brain and spinal cord

65
Risk factors:

Meningitis

  • skull fractures
  • brain or spinal surgery
  • upper respiratory infections
  • using nasal sprays

66

How is meningitis diagnosed?

Meningitis is diagnosed by lumbar puncture for a cerebral spinal fluid culture.

67

What populations are most at risk of getting meningitis?

Populations most at risk for meningitis are those who live in crowded areas:

  • college dorms
  • prisons
  • group homes

68

How is meningitis transmitted?

  • airborne droplet nuclei that go over long distances and remain suspended in the air for long periods
  • direct contact

Implement airborne and contact precautions.

69

What are the characteristic signs and symptoms of meningitis?

  • fatigue
  • photophobia
  • decreased LOC
  • possible rash

70

What is Kernig's sign?

Kernig's sign is a sign of meningitis:

  • when client lays supine, the leg stays flexed at the knee.

71

What is Brudzinski's sign?

Brudzinski's sign is a sign of meningitis:

  • when the neck is flexed, the hip and knee involuntary flex also

 

72
Interventions:

Meningitis

  • assess for increased ICP
  • seizure precautions
  • droplet precautions with pneumococcal meningitis
  • airborne precautions with other types of meningitis
  • give antibiotics and analgesics for pain