62 Questions
What does a Glasgow Coma Scale (GCS) score of 7 or less indicate?
Comatose state
When is lumbar puncture ordered in a client presenting post-seizure?
To measure CSF pressure
What does assessment of the movement of the tongue relate to?
Cranial nerve XII
What does a delayed response to stimulation and drowsiness indicate?
Somnolent state of consciousness
When is a GCS score of 9 indicative of the need for emergency attention?
When it indicates a severe alteration in consciousness
What do unequal, pinpoint, or absent pupillary responses indicate?
Neurologic concern
When is a pretest dose of antihistamine administered to clients?
With allergy history to reduce manifestations of an allergic reaction
When is flaccidity documented in a client?
When the client makes no motor response to stimuli
How is assessment of sensation in the upper extremity conducted?
Placing a warm cotton ball on the client's arm
What do nerve conduction studies measure?
Speed of nerve impulse along peripheral nerves
What are appropriate nursing actions to assess level of consciousness?
Stroking the client's hand and moving the client's shoulder
What is the priority nursing action during a seizure?
Protect the client from injury
What is the priority nursing action after a lumbar puncture?
Position the client flat and provide adequate fluids
Which complication can result from bacterial meningitis?
Damage to nerves facilitating vision and hearing
What is a significant sign of rising intracranial pressure?
Lethargy
How are absence seizures in children characterized?
Brief loss of consciousness and subtle movements
What are signs of increasing intracranial pressure in a client with head trauma?
Elevated systolic blood pressure and widening pulse pressure
What is the priority nursing action for a client with severe myasthenia gravis exacerbation?
Administering medications at exact intervals
What is the purpose of using a safety pin to stroke a client's fingers?
To evaluate sensitivity to touch
What is the purpose of using cold water on a client's arm?
To evaluate sensitivity to heat and cold
Which action can lead to damage to nerves facilitating vision and hearing in bacterial meningitis?
Complications of bacterial meningitis
What is a sign of increasing intracranial pressure in a client with head trauma?
Widening pulse pressure
Is a stiff neck a symptom associated with increasing intracranial pressure?
No, it is not a symptom associated with increasing intracranial pressure
What is the purpose of shampooing after removing electroencephalogram electrodes?
To remove the paste left from the electrodes
Which cranial nerve is responsible for hearing and balance?
Cranial nerve VIII
What is the concern related to cloudy cerebrospinal fluid (CSF) during a lumbar puncture?
Cloudy CSF may indicate an abnormality
What is the purpose of the Romberg test in neurological assessment?
To assess balance and neurologic deficits
Which system regulates energy expenditure and the body's response to emergency situations?
Sympathetic nervous system
What does a computed tomography (CT) scan primarily provide?
Thin 'slices' of the body area
What is the function of myelin in the nervous system?
Covering of axons and insulation for nerve impulses
When is assessing neck rigidity important in a client's physical examination?
In a suspected neurologic disorder
What is the role of the parasympathetic nervous system during an emergency?
To conserve body energy
What does a magnetic resonance imaging (MRI) use to produce images of tissue?
Radiofrequency waves
Why is it important not to measure the client's LOC, heart rate, or pulse rate without healthcare provider advice?
To avoid unnecessary interference with medical orders
What is the purpose of tapping the lower portion of the neck during a physical examination?
To detect sensation and assess for neck rigidity
What is the appropriate nursing action to collect motor response data from a comatose client?
Observing the client's response to painful stimuli
What is the most appropriate post-procedure activity for a client who undergoes an electroencephalogram (EEG)?
Allow the client to wash hair and rest
What is the purpose of the Romberg test in neurological assessment?
Assessing equilibrium in a noncomatose client
What does monitoring sensitivity to temperature, touch, and pain assess in a comatose client?
Sensory function
Which assessment findings are important for a client with bacterial meningitis?
Cloudy cerebral spinal fluid and purpura of hands and feet
What is the primary focus in caring for Parkinson disease?
Maintaining a safe environment
Which solution is used to decrease swelling in the brain cells with increasing intracranial pressure (ICP)?
Isotonic normal saline
What is the first action for a client with a brain tumor complaining of a headache upon awakening?
Elevate the head of the bed
What is used to manage symptoms of muscle spasticity and rigidity in clients diagnosed with neuromuscular disorders?
Baclofen
Which findings are normal in intracranial pressure (ICP)?
Glasgow Coma Scale of 15 and brisk pupil response
What can be beneficial in diagnosing encephalitis secondary to West Nile virus?
Exposure to mosquito bites
What is commonly used to decrease brain swelling in clients with increasing intracranial pressure (ICP)?
Isotonic normal saline
What is the main symptom of ALS (Amyotrophic Lateral Sclerosis)?
Muscle weakness of the arms
What is the priority in the management of symptoms in Bell palsy?
Ophthalmic lubricant and protection of the eye
What is encouraged in the management of Parkinson disease?
Prevention of communicable diseases and establishing a balanced nutrition
What is the first action for a client with a brain tumor complaining of a headache upon awakening?
Elevate the head of the bed
Which solution is used to decrease swelling in the brain cells with increasing intracranial pressure?
Isotonic normal saline
What is the primary focus in caring for Parkinson's disease?
Maintaining a safe environment
Which medication is used to manage symptoms of muscle spasticity and rigidity in clients diagnosed with neuromuscular disorders?
Baclofen
What are important assessment findings for a client with bacterial meningitis?
Purpura of hands and feet
What is used to diagnose encephalitis secondary to West Nile virus?
Exposure to mosquito bites
What are normal findings in intracranial pressure (ICP)?
Brisk pupil response
What is the initial symptom of ALS?
Muscle weakness of the arms
What is the priority in the management of symptoms for Bell's palsy?
Providing ophthalmic lubricant and protecting the eye
What is the characteristic gait in Parkinson's disease?
Propulsive gait
What is the recommended fluid for decreasing swelling in brain cells with increasing intracranial pressure?
Hypertonic saline
What is the initial action for a client with a brain tumor experiencing headache upon awakening?
Elevate the head of the bed
Study Notes
Neurological Nursing Practice
- Clients are advised against taking sedative drugs and caffeine-related drinks before EEG, so there is no need to provide them after the test.
- The sympathetic nervous system regulates energy expenditure and is responsible for the body's response to emergency situations.
- Cranial nerve VIII is responsible for hearing and balance, while cranial nerve II is the optic nerve.
- A computed tomography (CT) scan is used to obtain thin "slices" of the body area, while MRI uses radiofrequency waves to produce images of tissue.
- Cloudy cerebrospinal fluid (CSF) is a concern during a lumbar puncture (LP) as normal CSF is clear and colorless.
- Shampoo is used to remove the paste from electroencephalogram electrodes attached to the head.
- In the Romberg test, the client stands erect with feet close together and eyes closed to assess balance and neurologic deficits.
- Myelin is the covering of axons and is a fatty substance that covers some axons in the CNS and PNS.
- Assessing neck rigidity is important in the physical examination of a client with a suspected neurologic disorder.
- Tapping the lower portion of the neck helps in detecting sensation and assessing for neck rigidity.
- The parasympathetic nervous system works to conserve body energy during an emergency, while the endocrine system regulates metabolic processes.
- The nurse should not measure the client's LOC, heart rate, or pulse rate unless advised by the health care provider.
Neurological Nursing Care Summary
- Generalized pain is not significant with ICP unless related to complaint of headache, especially upon awakening
- Glasgow Coma Scale of 15 and brisk pupil response are normal findings in ICP
- Isotonic normal saline, lactated Ringer’s, or hypertonic saline solutions are used to decrease swelling in the brain cells with increasing ICP
- The first action for a client with a brain tumor complaining of a headache upon awakening would be to elevate the head of the bed
- For a client with bacterial meningitis, cloudy cerebral spinal fluid and purpura of hands and feet are important assessment findings
- Exposure to mosquito bites can be beneficial in diagnosing encephalitis secondary to West Nile virus
- Baclofen is used to manage symptoms of muscle spasticity and rigidity in clients diagnosed with neuromuscular disorders
- ALS usually begins with muscle weakness of the arms and progresses
- In Bell palsy, ophthalmic lubricant and protection of the eye are priority in the management of symptoms
- The primary focus in caring for Parkinson disease is on maintaining a safe environment
- Parkinson disease often has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking and an inability to stop abruptly without losing balance
- Prevention of communicable diseases and establishing a balanced nutrition is encouraged in Parkinson disease management
Test your knowledge of neurological nursing care with this summary quiz. Identify important assessment findings, prioritize nursing actions, and understand management strategies for conditions such as increased intracranial pressure, brain tumors, meningitis, encephalitis, neuromuscular disorders, and Parkinson's disease.
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