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

Flashcards in Neuro Deck (86)
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1
Q

What is the most sensitive indicator of neuro status?

A

Level of consciousness.

Assess for restlessness, irritability, and confusion.

2
Q

What is the highest score on the Glasgow coma score?

A

15

At 15, the client is completely alert and oriented

  • eyes open spontaneously
  • verbalizes pain
  • oriented and converses

3
Q

What is the lowest score on the Glasgow coma scale?

A

3

At 3, the client is not responsive

  • eyes have no response
  • no response to pain
  • no verbal response

4
Q

At what Glasgow coma score is the client typically intubated?

(Immediate complication)

A

“Less than 8, intubate”

8 indicates a coma.

5
Q

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

A
  • 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
Q

What is decorticate and decerebrate posturing?

A

Both postures indicate a deteriorating condition in the brain.

7
Q

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

(Immediate complication)

A

Increased intracranial pressure (ICP)

Increased pressure in the brain due to edema.

8
Q

What is a late sign of increased intracranial pressure?

A
  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
Q

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

A
  • elevate HOB 30 to 40 degrees
  • don’t flex the neck or hips (keep body midline)
10
Q

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

A
  • avoid straining such as coughing, sneezing, and Valsalva’s maneuver
  • stool softeners daily
  • no toothbrushing; use soft swab
  • don’t shiver: keep client warm
11
Q

Why is there a fluid restriction with increased intracranial pressure?

A

Due to edema and extra fluids in the brain: fluids are restricted to less than 1200 mL per day to prevent more edema.

12
Q

Medications:

Increased intracranial pressure

A
  • 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
Q

How is intracranial pressure monitored?

A

With an ICP machine that measures the pressure in the brain.

14
Q

How are head injuries prevented?

A

By wearing a helmet when riding a motorcycle or bicycle.

15
Q

What is a concussion?

A

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

The client may or may not lose consciousness.

16
Q

What is an epidural hematoma?

(Immediate complication)

A

The most serious bleeding head injury. It occurs above the dura and is arterial blood (bleeds fast).

Client can rapidly progress into a coma.

17
Q

What is a subdural hematoma?

A

Occurs below the dura and is venous blood (bleeds slowly).

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

18
Q

What is an intracerebral hemorrhage?

(Immediate complication)

A

When a blood vessel within the brain has ruptured.

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

19
Q

What is always the concern after a head injury?

A

Increased intracranial pressure.

20
Q

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

A

Cerebral Spinal Fluid (CSF)

21
Q

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

A
  • 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
22
Q

How is a cerebral spinal fluid leak tested for?

A

Halo test

23
Q

What is a craniotomy?

A

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

24
Q

What are the priority interventions after a craniotomy?

A
  • make sure the client can breath (may be on a ventilator)
  • prevent increased ICP
25
Q

What is a seizure?

(Immediate complication)

A

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.

26
Q

Signs and symptoms:

Seizure

A
  • confusion
  • aura
  • sudden falls
  • staring
  • uncontrollable jerky movements
  • strange sensations and emotions
  • loss of consciousness or awareness
27
Q

Interventions:

During a seizure

A
  • 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
28
Q

Interventions:

After a seizure

A
  • turn client to the side so secretions can drain - possibly suction
  • assess respirations and oxygen reading
  • document time and duration of seizure
  • implement seizure precautions

Notify HCP.

29
Q

Teaching:

Seizure

A
  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
30
Q

What is the difference between a thrombotic CVA (cerebral vascular accident) and embolic CVA?

(Immediate complication)

A

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

An embolic CVA 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 CVAs, where a clot blocks oxygen and blood.

31
Q

What is a hemorrhagic CVA?

(Immediate complication)

A

It is caused by bleeding in the brain from hypertension or an aneurysm.

32
Q

What is the most common test to diagnose a CVA?

A

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.

33
Q

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

A

FAST

  • severe onset headache
  • one-sided face drooping
  • Arm weakness/ataxia
  • Speech difficulties
  • Time to call
34
Q

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

A

Thrombolytics are given to break up the blood clot.

35
Q

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

A

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.

36
Q

What is Neglect syndrome?

A

When the client is unaware of the existence of the paralyzed side.

Encourage activity on the neglected side.

37
Q

Define:

Agnosia

A

The inability to recognize familiar objects or people.

38
Q

Define:

hemiplegia paralysis

A

Paralysis on one side.

39
Q

Define:

Apraxia

A

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

40
Q

Define:

Expressive aphasia

A

When the client understands what is being said, but can’t communicate verbally.

The client cannot express information.

41
Q

Define:

Receptive aphasia

A

When the client cannot understand what is being said or written.

They cannot receive information.

42
Q

Define:

Hemianopsia

A

Blindness in half the visual field.

43
Q

Define:

Dysphagia

A

Difficulty swallowing.

44
Q

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

A

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

45
Q

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

A
  • thickened fluids
  • soft foods
46
Q

How is a client with dysphagia positioned when eating?

A
  • 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
  • no straws
47
Q

What are the interventions for a client with hemianopsia?

A
  • approach client from the unaffected side
  • place objects on the side that they can see on
48
Q

What do all these neuro diseases all have in common?

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

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.

49
Q

Describe:

Multiple sclerosis

A

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.

50
Q

Describe:

Myasthenia Gravis

A

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.

51
Q

What is an early sign of myasthenia gravis?

A

A droopy eyelid (Ptosis) and double vision.

52
Q

Describe:

What are the late signs of myasthenia gravis?

A
  • difficulty chewing, swallowing and breathing
  • respiratory paralysis and respiratory failure
53
Q

Medications:

Myasthenia gravis

A
  • pyridostigmine
  • neostigmine

end in -mine

54
Q

What is a myasthenic crisis?

(Immediate complication)

A

When the client doesn’t get enough of their medication (undermedicated), causing muscle weakness.

It usually occurs about 3 hours after med administration.

55
Q

What is a cholinergic crisis?

(Immediate complication)

A

When a client gets too much of their medicine (overmedicated), causing muscle weakness.

It usually occurs about 1 hour after med administration.

56
Q

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

A

Basically the same:

  • muscle weakness
  • dyspnea
  • dysphagia
  • bradycardia

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

57
Q

What is an edrophonium (Tensilon) test?

A

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
58
Q

What is the antidote to a cholinergic crisis?

A

Atropine sulfate (an anticholinergic)

59
Q

Describe:

Parkinson’s Disease

A

A neuromuscular weakness disease caused by the depletion of dopamine.

Dopamine is needed for good muscle control.

60
Q

What are the characteristic symptoms for Parkinson’s disease?

A
61
Q

What are the late signs of Parkinson’s disease?

A

Due to muscle weakness:

  • difficulty swallowing and speaking
  • drooling
62
Q

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

A
  • prevent falls
  • don’t rush client
  • provide frequent rest periods
  • assess the ability to chew and swallow
  • assess breathing
  • promote independence
63
Q

Describe:

Guillain-Barre Syndrome

Immediate complication

A

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.

64
Q

What is the priority assessment with Guillain-Barre syndrome?

A

Assess ability to breathe and respirations due to ascending paralysis.

65
Q

Is there a cure for Guillain Barre?

A

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.

66
Q

Describe:

Meningitis

(Immediate complication)

A

An infection in the brain and spinal cord.

67
Q

Risk factors:

Meningitis

A
  • skull fractures
  • brain or spinal surgery
  • upper respiratory infections
  • using nasal sprays
  • living in crowded areas
68
Q

How is meningitis diagnosed?

A

By lumbar puncture for a cerebral spinal fluid culture.

69
Q

What populations are most at risk of getting meningitis?

A

Those who live in crowded areas:

  • college dorms
  • prisons
  • group homes
70
Q

What are the infection control precautions for meningitis?

A

Droplet precautions.

Implement airborne and contact precautions.

71
Q

What are the characteristic signs and symptoms of meningitis?

A
  • fatigue/lethargy/headache
  • photophobia
  • decreased LOC
  • possible rash
72
Q

What is Kernig’s sign?

A

A sign of meningitis: when client lays supine, the leg stays flexed at the knee.

73
Q

What is Brudzinski’s sign?

A

A sign of meningitis: when the neck is flexed, the hip and knee involuntary flex also.

73
Q

If a client is found unconscious, what you should you do?

A

Check airway and pulse. Start CPR if needed.

74
Q

Interventions:

Meningitis

A
  • assess for increased ICP
  • seizure precautions
  • droplet precautions with pneumococcal meningitis
  • airborne precautions with other types of meningitis
  • give antibiotics and analgesics for pain
75
Q

Define:

Electromyography

A

A diagnostic test for neuromuscular diseases. A needle is inserted in the muscle and records electrical activity.

76
Q

Teaching:

Electromyography

A

No stimulants or sedatives 24 hours before procedure.

77
Q

Describe:

Trigeminal neuralgia

A

A sensory disorder of 5th cranial nerve that causes pain.

78
Q

What foods are avoided with trigeminal neuralgia?

A

Hot or cold foods.

These foods irritate the 5th cranial nerve.

79
Q

Describe:

Bell’s palsy

A

Facial paralysis caused by a lesion on the cranial nerve VII with paralysis of one side of the face.

This condition can get confused with an acute CVA.

80
Q

What can cause both trigeminal neuralgia and Bell’s palsy?

A
  • trauma
  • infection
  • hemorrhage
  • tumor

Treat the cause.

81
Q

Describe:

Migraines

A

Head pain with unknown cause but can be triggered by:
* caffeine
* red wine
* MSG
* weather changes

82
Q

Are migraines more common in men or women?

A

Women; mostly due to hormone changes and fluctuations.

83
Q

What are the characteristic signs and symptoms of migraines?

A
  • severe head pain or headache
  • nausea and vomiting
  • sensitivity to light
  • an “aura”
84
Q

Medications:

Migraines

A

NSAIDs, acetaminophen, antimigraine medications, botox

85
Q

Interventions:

Migraines

A
  • pain medicine
  • keep the room dark
  • wear sunglasses
  • CAM
  • avoid triggers