Neuro, CVA, Spinal Injury

Question 1

what is the neural synapse?

Answer 1

the space between the axons of one neuron and the dendrites of the next neuron

Question 2

What is an abnormal neurological finding in an 88 year old?

Answer 2

dizziness and problems with balance

Question 3

What is the most reliable indicator of neurological status?

Answer 3

level of consciousness

Question 4

How would you classify a patient who is stuperous, but reacts by withdrawing from painful stimuli?

Answer 4

semi comatose

Question 5

what is a normal Babinski response?

Answer 5

toes curl down

Question 6

what should a nurse assess on a patient scheduled for an angiogram?

Answer 6

allergy to shellfish

Question 7

if a severe head injured patient assumes a posture of flexed upper extremities, with plantar flexed lower extremities, what would that indicate?

Answer 7

increasing ICP with decorticate posture

Question 8

when caring for a 90 year old patient with a closed head injury, know what a nurse would immediately report, related to increased intracranial pressure.

Answer 8

BP elevations, increase in systolic with little or no associated increase in diastolic. widening pulse pressure

Question 9

if a patient with a generalized convulsive disorder has the following nursing diagnosis: “deficient knowledge, related to lack of information about side effects of Dilantin”, what goal and outcome criteria would be most appropriate for the patient?

Answer 9

take meds with food to decrease nausea and vomiting.

Question 10

what is a positive Brudinski sign, what will show in a patient with meningitis?

Answer 10

flexion of both hips when the neck is flexed by the nurse

Question 11

When assessing a patient with ICP/cerebral edema, how would the nurse know that the drug “Mannitol” was effective for ICP?

Answer 11

increased urine output

Question 12

what would a nurse implement for a patient to prevent a headache after a lumbar puncture?

Answer 12

lay them flat after the procedure

Question 13

3 classic signs of Cushing’s triad

Answer 13

hypertension, bradycardia, and a widening pulse pressure

Question 14

in a patient with MS who has a nursing diagnosis of: knowledge deficit, related to conservation of energy, how would the nurse evaluate a positive outcome to the goal of teaching with what the patient tells the nurse?

Answer 14

I will rest in between my periods of activity.

Question 15

if a patient fell and hit their head and blacked out for a while, and the nurse suspects an epidural hematoma what would the nurse be diligent in assessing?

Answer 15

drowsiness

Question 16

An intervention related to eating, that should be added to a nursing care plan, to support nutritional intake, in a patient with Parkinson’s disease?

Answer 16

thicken liquids to make it easier to swallow

Question 17

if a patient with Parkinson’s disease states that his current drug regimen of L-dopa and Sinemet are no longer controlling the symptoms, what would the nurses best response be?

Answer 17

other drugs can be combined to increase the effectiveness

Question 18

If a Parkinson’s patient is considering taking St. John’s Wort, in addition to Sinemet and L-dopa, what is the best response for the nurse to give the patient?

Answer 18

it can interfere with the effectiveness of their medication

Question 19

In a patient with Guillain-Barre syndrome, who is experiencing impaired breathing patterns, because of neuromuscular failure, what would indicate to the nurse that the patient needs to be suctioned?

Answer 19

increase pulse and adventitious breath sounds

Question 20

a family member asks the nurse what an appropriate gift for a patient with Parkinson’s disease would be, what is the most useful reply?

Answer 20

Satin sheets or a wheelchair

Question 21

when a patient falls to the floor with generalized seizure, what should the nurse do?

Answer 21

the head can be cradled or turn to one side to maintain a patent airway.

Question 22

What can the nurse do when caring for a patient post craniotomy, to help reduce ICP?

Answer 22

elevate the head of the bed

Question 23

in caring for an unconscious patient, who had a head injury 10 days ago, how should the nurse position the patient’s limbs ( to prevent what?)

Answer 23

prevent flexation, lay them flat

Question 24

what should a nurse do before giving an enteral feeding to a patient?

Answer 24

elevate the head of the bed

Question 25

If a patient has weakness of the right side and impaired reasoning after having a CVA, what area did the CVA occur in?

Answer 25

left

Question 26

what patient is at greatest risk for a CVA

Answer 26

African American male 55-65

Question 27

if a patient experiences a TIA and was prescribed warfarin (coumadin) what would be the effective therapeutic lab values for the PT and INR?

Answer 27

PT is 1.5 to 2.0 times normal and the INR is 2.0 - 3.0

Question 28

what would the nursing teaching plan for a patient with a TIA include regarding OTC medications?

Answer 28

daily aspirin dose prevents blood clots

Question 29

a patient recovering from a CVA asks the nurse the purpose of coumadin, what does the nurse tell the patient?

Answer 29

prevents blood clots

Question 30

what is the nursing priority immediately after a CVA?

Answer 30

airway maintenance

Question 31

how does a nurse recognize when the acute phase of a CVA has ended?

Answer 31

vital signs return to normal 24 - 48 hours

Question 32

in a patient with CVA, several days ago, know how many hours the drug "plasminogen activator" (tPA) should be used after the onset of symptoms?

Answer 32

3 hours

Question 33

why is a lumbar puncture a most helpful diagnostic tool for a new patient who has had a CVA?

Answer 33

it will tell you if the stroke is hemorrhagic or embolic

Question 34

in a patient who has suffered a hemorrhagic stroke, is placed on a protocol of 60 mg of Nimodipine (calcium channel blocker) every 4 hours, if the patient's pulse is 82 beats/minute before administration of the medication, what should the nurse do?

Answer 34

give the medication

Question 35

During the acute phase of CVA, a risk for falls related to paralysis is present, what nursing intervention will best protect the patient from injury?

Answer 35

side rails up

Question 36

since pneumonia is the most frequent cause of death after a stroke, what intervention would be contraindicated in the acute care of a patient with a hemorrhagic CVA?

Answer 36

forceful cough discouraged

Question 37

what nursing intervention will help preserve joint mobility in the acute phase of a CVA?

Answer 37

ROM and support affected joints, splint

Question 38

A patient in the acute phase of an embolic CVA had the following order: 400 unites of heparin per hour IV. the heparin is in a solution of 5000 units/100ml normal saline. what should the nurse set the electronic IV monitor at? how many milliliters per hour?

Answer 38

8 ml

Question 39

how does a nurse on assessment know that a patient with a CVA is in transition to the rehabilitation phase?

Answer 39

no neurologic deficits

Question 40

What is Homonymous Hemianopia and how should the nurse arrange the patients environment if the patient had a CVA?

Answer 40

half of the field of vision is lost, put things on the unaffected side.

Question 41

if a nurse is using the nursing diagnosis: imbalanced nutrition, related to dysphagia, with the goal of adequate nutrition, what appropriate outcome criterion would the nurse use?

Answer 41

maintain body weight

Question 42

if a patient is in the rehab phase after a CVA and accidentally knocks an adapted plate from the table and burst into tears, what would be the nurses best response?

Answer 42

how can we fix it

Question 43

what is the most helpful family teaching for a patient who is in the rehab phase after a CVA, regarding altered sensation

Answer 43

make frequent assessments of the area for signs of pressure and to protect it from injury

Question 44

what post hospital option would provide the most comprehensive assistance to a patient who is recovering from a CVA?

Answer 44

rehab

Question 45

why can Hyperglycemia occur in a patient after a stroke, what is this in response to?

Answer 45

stress

Question 46

what level does the spinal cord extend to from the brainstem?

Answer 46

2nd lumbar

Question 47

if a patient sustains a C5 compression fracture and can move only his head and has flaccid paralysis of all extremities, is the paralysis permanent?

Answer 47

you can't tell until the spinal shock is gone

Question 48

what nursing assessment would indicate resolution of spinal shock

Answer 48

appearance of spastic involuntary movement of extremities

Question 49

what nursing assessment in the ER would show that a patient's spinal cord injury is below C4?

Answer 49

unlabored respirations

Question 50

inability of a patient to dorsiflex his/her foot against the resistance of a nurses hand confirms cord damage at what level?

Answer 50

L5

Question 51

how does a nurse move the impaired leg of a patient with an SCI to avoid stimulating muscle spasms

Answer 51

support the knee and ankle when moving

Question 52

when recording findings of muscle strength, the nurse records a 2 for the right arm. what does that show for the muscles of the arm?

Answer 52

muscles move when supported against gravity

Question 53

what technique would a nurse use when opening the airway in a newly admitted patient with an SCI?

Answer 53

jaw thrust

Question 54

which neurological deficit the Brown sequard syndrome results in

Answer 54

ipsilateral loss of motor function with contralateral loss of pain and temperature perception

Question 55

level of independence for a patient with c8 transection?

Answer 55

upper extremities, manage use of normal wheelchair

Question 56

if a paraplegic excitedly reports seeing his foot move when he was being turned, how would the nurse explain

Answer 56

reflexive movement

Question 57

after spinal shock resolves and the patients indwelling catheter is removed, what does the nurse tell the patient about how to expect the bladder to empty?

Answer 57

bladder will be spastic and spontaneously empty

Question 58

purpose of Gardner Wells tongs

Answer 58

keep cervical vertebrae aligned

Question 59

what is the major advantage of the halo device over the Gardner Wells tongs

Answer 59

patient can be taken out of bed

Question 60

why a patient with a spinal cord injury would receive the medication methylprednisone

Answer 60

reduce the damage to the cellular membrane

Question 61

what are the signs and symptoms of autonomic dysreflexia?

Answer 61

nasal congestion, facial flushing and a pounding headache, diaphoresis

Question 62

when a nurse recognizes autonomic dysreflexia in a patient with SCI, what is the immediate nursing intervention?

Answer 62

inspect indwelling catheters, relieve distended bladder, fecal impaction removed if necessary. topically relieve pain or itching

Question 63

if no urinary output has occurred in a patient who underwent a laminectomy 2 hours earlier, what should the nurse do?

Answer 63

intermittent catheterization

Question 64

how should a nurse respond to a sci patient with a nursing diagnosis of sexual dysfunction related to altered body function

Answer 64

with thoughtful discussion and counseling

Question 65

what does rehab do for a patient with an sci

Answer 65

help them achieve the highest level of independence

Question 66

what nursing interventions would be for prevention of contractures in a patient with an sci

Answer 66

splinting

Question 67

if a patients family is concerned with lack of bowel function two days after a sci, what is the best response

Answer 67

bowel function usually returns after 3 days

Question 68

if a sci has a cat scan with contrast medium, what should the nurse have the patient do after the scan

Answer 68

drink plenty of fluids

Question 69

if a patient sustains a sci at level c4 will the patient ever be free of the ventilator

Answer 69

no, c1-c4 need mechanical ventilation