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Flashcards in Neurology Deck (20):
0

What is Guillian-Barré syndrome?

Gillian-Barre syndrome is an autoimmune

1

A pt with Meniere's Dz complains of...

Meniere's Dz S/S tinnitus in both ears, vertigo, and hearing loss

2

What ate the nsg interventions for a pt returning from a cerebral attentional?

Pressure dressing q 4h over wound (femoral artery), pt kept flat with affected extremity immobilized and straight for duration of Rx bed rest (4-24h)

3

NMS S/S (early s/s)

FEVER:

F = FEVER
E = ENCEPHALOPATHY
V = VITALS UNSTABLE
E = ELEVATED ENZYMES (CK)
R = RIGIDITY OF MUSCLES

early = stiffness, fever, sweating, tremors

4

What are the symptoms of a pt with R-sided CVA:

R-sided CVA = impaired judgment, impulsive, and left side hemiplegia = high safely risk

5

What are some interventions to decrease ICP

Administer mannitol (decreases cerebral edema), maintain neutral neck alignment & elevate HOB (to enhance venous return), space out activities

6

How do you move a pt with hemiplegia to a wheelchair

Move the pt toward his unaffected side to help brace himself, tell the pt to lean forward before standing, assist the pt to stand by braving the affected knee and foot

7

What is Amyotrophic Lateral Sclerosis (ALS)

Amyotrophic Lateral sclerosis is a progressive motor neutron dz that's incurable and leads to death

8

What are the S/S of amyotrophic lateral sclerosis

ALS is a steady decline in muscle strength which eventually leads to RR failure

9

What are the symptoms of Parkinson's Dz?

Muscle rigidity, mask-like expression, shuffling gait

10

What are NSG interventions for a CVA pt on a dysphagia diet

Sit pt 90 degrees, offer thicken liquids (thin liquids increase risk of aspiration), check weak side for pockets of food

11

Myasthenia Gravis S/S

Muscle weakness that worsens with effort sand improves with rest, administrating Pyridostigmine which is an anticholinesterase, oropharyngeal weakness, have suction nearby

12

Meningitis S/S

103 fever, nuchal rigidity, pain on extension of legs, all leading to altered cerebral perfusion = increased ICP

13

A pt with a brain tumor will show what S/S

HA that's worse in the morning, vomiting, papilledema, SZ, ALOC, altered vision

15

How would NSG assess for hemorrhage post hypophysectomy

Frequent swallowing indicates hemorrhage into the sinuses from surgical removal of the pituitary gland

16

The nurse is admitting a client who is newly diagnosed with a frontal lobe brain tumor. Which statement made by a spouse may provide important information about this diagnosis and should be communicated to the health care provider?

A: It sees our sex life is nonexistent over the past 6 mo

B: In the morning & evenings he CO that reading is next to impossible bc the print is blurry

C: I find the mood swings & the change from being a calm person to being angry all the time hard to deal with

D: His breathing rate is usually below 12

C: I find the mood swings & the change from being a calm person to being angry all the time hard to deal with

The frontal lobe of the brain controls affect, judgment and emotions. Dysfunction in this area results in findings such as emotional lability, changes in personality, inattentiveness, flat affect and inappropriate behavior.

17

A nurse listens to report on an 80 year-old client diagnosed with middle-stage Alzheimer's disease. What information suggests the nurse should do an immediate follow-up, rather than delegate any care to an unlicensed assistive person (UAP)?

A: A 10 mm Hg drop in systolic blood pressure

B: Minimal response to voice and touch of the peripheral areas of the body

C: Increase in heart rate by 10 beats per minute

D: Change in the color of the fingertips from pink to pallor

B: minimal response to voice and touch of the peripheral areas of the body

A change in level of consciousness (LOC) indicates an acute change in the client's condition and is probably unrelated to the client's diagnosis. A client in the middle stages of Alzheimer's disease is still responsive to environment and to stimuli and the nurse should expect a response that is greater than "minimal to voice and touch." This change would require a detailed assessment by the nurse. Recall that the RN cannot delegate any task to the LPN or UAP unless the client's condition is stable and/or there's a low likelihood of an emergency. A change in the LOC indicates this client is not stable.

18

The nurse observes a client who is exhibiting seizure activity. Which observation is most important in providing information that will enhance further direction of treatment?

A: Note the time from beginning to end
B: Identify the pattern of breathing
C: Determine if loss of bowel or bladder control occurs
D: Observe the sequence and types of movement

D: Observe the sequence and types of movement

It is a priority to note, and then record, what movements are seen during a seizure because the diagnosis and subsequent treatment are often determined by the type of seizure activity. This question is asking for a priority so ALL of the options are correct.

19

An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident (CVA) has had a blood pressure of 160/100 to 180/110 over the past two hours. The nurse has also noted increased lethargy since admission. Which of the following new findings should the nurse report immediately to the provider?

A: Muscle weakness
B: Rapid pulse
C: Incontinence
D: Slurred speech

D: Slurred speech

Changes in speech patterns and level of conscious are indicators of potential continued intracranial bleeding or extensions of a stroke. Further diagnostic testing may be indicated. Recall the word "FAST" with stroke findings: "F" is for changes in the face such as drooping of corner of the eye or mouth, "A" is for a drifting down of one arm when the arms are raised to shoulder height, "S" is for slurred speech and "T" is to telephone 911.

20

The nurse is planning care for a client with a cerebral vascular accident (CVA). Which approach planned by the nurse would be most effective in the prevention of skin breakdown?

A: Pad the bony prominences
B: Massage reddened bony prominence
C: Reposition every two hours if in bed
D: Place client in the wheelchair for four hours daily

C: Reposition every two hours if in bed

Clients who are at risk for skin breakdown develop fewer pressure ulcers when turned every two hours. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of potential injury is maintained. If the client is in a wheelchair, a shift of the weight should be done every hour. Massage of reddened bony prominences is no longer recommended as a result of evidence-based research.