Med/Surg Chapter 41 Flashcards

Questions and Answers

What is paroxysmal nocturnal dyspnea?

Which complication of a lumbar puncture should alert the nurse to urgently contact the health care provider?

Weak pedal pulses

Increased thirst

Nausea and vomiting (correct)

Hives on the chest

Which statement should the nurse include when discussing the plan of care with a client recovering from SPECT?

We will be monitoring your renal functions closely.

You are radioactive and must use a private bathroom.

Frequent assessments of the injection site will be completed.

You may return to your previous activity level immediately. (correct)

How should the nurse document a client displaying decorticate posturing?

Decorticate posturing Signup and view all the answers

Which action should the nurse take if Babinski's sign is noted in an adult client?

Contact the provider with this abnormal finding. Signup and view all the answers

What Glasgow Coma Scale score should be documented for a client who opens his eyes to speech, mumbles in response to questions, and follows simple commands?

12 Signup and view all the answers

Which clinical manifestations should the nurse expect for a client with a medulla injury?

Inability to shrug shoulders Signup and view all the answers

Which clinical manifestations should the nurse assess for a temporal lobe injury?

Difficulty with sound interpretation Signup and view all the answers

For which clinical manifestations should the nurse assess after administering sympathetic stimulating medication?

Increased heart rate Signup and view all the answers

Which newly identified assessment findings should alert the nurse to urgently communicate with the health care provider?

Decerebrate posturing Signup and view all the answers

Which actions should the nurse take to prepare a client for a CT scan with iodine-based contrast?

Evaluate the client's renal function. Signup and view all the answers

Which assessment findings should be identified as normal changes in the nervous system related to aging?

Slower processing time Signup and view all the answers

Which statements should the nurse include when delegating care for an older adult client to UAP?

Encourage the client to use a cane when ambulating. Signup and view all the answers

Which action should the nurse take when providing education about newly prescribed medications to a client with left temporal lobe damage?

Sit on the client's right side and speak into the right ear. Signup and view all the answers

Which intervention should the nurse include in the care plan for a client who has a hypoactive response to deep tendon reflexes?

Provide the client with assistance when ambulating. Signup and view all the answers

Which statement should the nurse include in teaching an 80-year-old client with diminished touch sensation?

Look at the placement of your feet when walking. Signup and view all the answers

Which client statement confirms that the client's remote memory is intact?

I ate oatmeal with wheat toast and orange juice for breakfast. Signup and view all the answers

A nurse assesses a client who demonstrates a positive Romberg's sign with eyes closed but not with eyes open. Which condition does the nurse associate with this finding?

Difficulty with proprioception Signup and view all the answers

How should the nurse respond when a client asks why they should take deep breaths during an electroencephalography?

Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity. Signup and view all the answers

Which assessment should the nurse complete after a client recovering from cerebral angiography via the right femoral artery?

Palpate bilateral lower extremity pulses. Signup and view all the answers

Which priority question should the nurse ask a client scheduled for magnetic resonance angiography?

Do you have allergies to iodine or shellfish? Signup and view all the answers

Which priority intervention should the nurse implement for a client with renal insufficiency scheduled for a CT scan with contrast medium?

Obtain a prescription for intravenous fluids. Signup and view all the answers

Which condition should alert the nurse to contact the provider and cancel an MRI procedure?

Internal insulin pump Signup and view all the answers

Which statement should the nurse include when teaching a client scheduled for a positron emission tomography scan of the brain?

Avoid caffeine-containing substances for 12 hours before the test. Signup and view all the answers

How should the nurse respond to a client worried about caring for young children due to deteriorating neurologic functions?

Give me more information about what worries you, so we can see if we can do something to make adjustments. Signup and view all the answers

Which intervention should the nurse include in the care plan for an 83-year-old client with age-related sensory perception changes?

Ensure that the path to the bathroom is free from equipment. Signup and view all the answers

Which client statement indicates a correct understanding of the teaching about MRI?

I can return to my usual activities immediately after the MRI. Signup and view all the answers

What action should the nurse take next after an older adult client correctly identifies a sharp sensation on the right hand when touched with a pin?

Touch the pin on the same area of the left hand. Signup and view all the answers

Which statement should the nurse include in discharge teaching for a client with cerebellar function impairment?

Ask a friend to drive you to your follow-up appointments. Signup and view all the answers

Which statement should the nurse include when delegating care for a client with cranial nerve II impairment?

Tell the client where food items are on the breakfast tray. Signup and view all the answers

Which assessment finding should alert the nurse to contact the health care provider before a lumbar puncture?

Shingles on the client's back Signup and view all the answers

Study Notes

Assessment of Nervous System

Left Temporal Lobe Damage: Educating clients requires sitting on their right side to communicate effectively, as hearing is impacted in the left ear.
Hypoactive Reflexes: Clients with decreased reflex responses may need assistance with ambulation to prevent falls, highlighting the importance of safety in motor/sensory care.
Diminished Touch Sensation: Clients should be instructed to visually monitor foot placement to avoid injury from terrain changes due to reduced sensitivity.
Memory Assessment: Recent memory is confirmed by recalling verifiable recent events, like a meal, whereas other types of memory (remote or immediate) are assessed differently.
Romberg's Sign: A positive result (swaying with eyes closed) indicates proprioceptive issues, with vision compensating for balance.
Hyperventilation and EEG: Deep breaths cause cerebral vasoconstriction, potentially increasing seizure activity; client education should clarify this during an EEG.
Cerebral Angiography: Post-procedure care includes assessing lower extremity pulses for circulation, and noting that bedrest is typically required post-angiography.
Magnetic Resonance Angiography (MRA): Allergies to iodine or shellfish should be checked to assess risk for dye reactions during the procedure.
Contrast in CT Scan: Clients with renal insufficiency require intravenous fluids to help excrete contrast medium used during scans.
MRI Contraindications: Metal devices such as insulin pumps should be flagged as they can interfere with MRI results and safety.
Positron Emission Tomography (PET) Scan: Advise clients to avoid caffeine before the test, as it can alter brain activity readings.
Client Concerns: When clients express worries about caregiving roles due to neurological issues, it’s essential to explore and address specific fears before providing additional resources.
Safety Needs in Older Adults: Ensuring clear and hazard-free paths in environments for elderly clients addresses potential sensory impairments and falls.
Post-MRI Activity: Clients can resume normal activities immediately post-MRI as there are no dyes or radioactive materials involved.
Pain Discrimination Assessment: If a client accurately identifies pain sensations on one side, further testing on the opposite side is warranted for comprehensive evaluation.
Cerebellar Function Impairment: Clients should not drive due to risks associated with impaired coordination and balance.
Delegation of Care: When delegating to unlicensed assistive personnel, emphasize the importance of guiding clients with visual impairments about their food arrangement.
Lumbar Puncture Precautions: Skin infections near the puncture site, like shingles, necessitate communication with the healthcare provider before proceeding with the LP.
LP Complications: Immediate communication with a provider is critical for symptoms indicating increased intracranial pressure, such as nausea and vomiting following a lumbar puncture.
SPECT Considerations: Clients should be informed about any necessary precautions related to radiopharmaceutical agents used in scans, particularly regarding potential radioactive exposure.### Renal Function Monitoring
Close monitoring of renal functions is necessary after certain procedures.
Radioisotopes from SPECT are eliminated via urine; no special precautions needed post-procedure.
Follow-up assessments of the injection site post-procedure are not required.

Decorticate vs. Decerebrate Posturing

Decorticate posturing indicates interruption in corticospinal pathways; a sign of deterioration in condition.
Decerebrate posturing characterized by external rotation and extension of extremities.
Immediate notification to the healthcare team is essential for abnormal posturing assessments.

Babinski's Sign

Babinski's sign is abnormal in clients over 2 years, indicating central nervous system issues.
Immediate provider notification is necessary for abnormal findings related to plantar reflexes.
Other assessments for pain and perfusion are less critical than addressing the abnormal sign.

Glasgow Coma Scale Assessment

A score of 12 shows the client opens eyes to speech, mumbles responses, and obeys commands.
The assessment of neurological status is vital for tracking a patient’s condition.

Clinical Manifestations from Medulla Injury

Expect impaired swallowing, inability to shrug shoulders, and loss of gag reflex due to CNS nerve damage.
Loss of smell and visual changes are not typically linked to medulla injuries.

Temporal Lobe Injury Assessments

Assess for memory loss, difficulty with sound interpretation, and speech difficulties following a temporal lobe injury.
Personality changes and taste impairments are associated with other brain regions.

Sympathetic Nervous System Stimulation

Clinical manifestations include increased heart rate and force of contraction.
Other signs would generally involve increased respiratory rate and blood pressure.

Urgent Communication in Neurological Changes

Report significant changes such as a Glasgow Coma Scale score of 8, decerebrate posturing, or diminished cognition.
These are critical indicators necessitating immediate intervention.

Preparing for Iodine-Based CT Contrast

Confirm informed consent, assess allergies (especially to iodine/shellfish), and evaluate renal function.
Other assessments like breath sounds or hemoglobin levels are not commonly impacted by the CT scan.

Normal Aging Changes in the Nervous System

Slower processing time and changes in sleep patterns are normal as individuals age.
Long-term memory loss and increased sensory perception do not typically correspond with normal aging functions.

Delegation of Care for Older Adults

Schedule care tasks when the client is alert and encourage mobility aids such as canes.
Emphasize patient safety by encouraging foot placement awareness while walking.
Clinical assessments and teaching should remain responsibilities of the nurse, not delegated.

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Description

Test your knowledge on the assessment of the nervous system with these flashcards focused on Chapter 41. This quiz addresses the essential considerations when educating clients about medications, especially those with brain injury-related challenges. Enhance your understanding of effective communication strategies and patient care.