50 Questions
When assessing motor response in a comatose client, which action is appropriate?
Observing the client's response to painful stimuli
What is the purpose of the Romberg test?
Assess motor response in a conscious client
After an electroencephalogram (EEG), what is the most appropriate post-procedure activity for the client?
Allow the client to wash hair and rest
What is the purpose of monitoring sensitivity to temperature, touch, and pain in a comatose client?
Assess sensory function
What is the priority nursing action during a seizure?
Protect client from injury
What is the priority nursing action after a lumbar puncture?
Position client flat and provide adequate fluids
Which assessment technique is used to evaluate sensitivity to heat, cold, touch, and pain?
Using a safety pin to stroke client's fingers
What is a significant sign of rising intracranial pressure in a client with multiple fractures and closed head injury?
Lethargy
What is a complication of bacterial meningitis that can lead to damage to nerves facilitating vision and hearing?
Damage to nerves facilitating vision and hearing
What are absence seizures in children characterized by?
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
Which action is not a priority during a seizure?
Restrain the client
What is not a symptom associated with increasing intracranial pressure?
Stiff neck
What is a potential complication of bacterial meningitis?
Damage to nerves facilitating vision and hearing
What are signs of increasing intracranial pressure in a client with head trauma?
Elevated systolic blood pressure and widening pulse pressure
What is the purpose of the Glasgow Coma Scale (GCS)?
To measure level of consciousness (LOC)
When is lumbar puncture ordered in neurological care?
To measure CSF pressure in a client presenting post-seizure
What does assessment of the movement of the tongue relate to?
Cranial nerve XII, the hypoglossal nerve
What does a GCS score of 9 indicate?
The need for emergency attention
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's motor response?
When the client makes no motor response to stimuli
How is sensation in the upper extremity assessed?
Placing a warm cotton ball on the client's arm
What do nerve conduction studies measure?
The 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
Which cranial nerve is responsible for hearing and balance?
Cranial nerve VIII
What is the function of the sympathetic nervous system?
Responsible for the body's response to emergency situations
What is the concern regarding cloudy cerebrospinal fluid (CSF) during a lumbar puncture?
Indication of infection
How is the Romberg test conducted to assess balance and neurologic deficits?
Client stands with feet close together and eyes closed
What is myelin?
Fatty substance covering axons
What is the purpose of tapping the lower portion of the neck during a physical examination?
Assessing neck rigidity
What imaging technique uses radiofrequency waves to produce images of tissue?
Magnetic resonance imaging (MRI)
What is the role of the parasympathetic nervous system during an emergency?
Conserves body energy
What is the purpose of using shampoo to remove the paste from electroencephalogram electrodes attached to the head?
To ensure electrode conductivity
When is the nurse advised to measure the client's level of consciousness (LOC), heart rate, and pulse rate?
Unless advised by the health care provider
What does a computed tomography (CT) scan produce?
Thin 'slices' of the body area
What is the function of the endocrine system?
Regulates metabolic processes
What is the primary focus in caring for Parkinson disease?
Maintaining a safe environment
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
What is a normal finding in intracranial pressure (ICP)?
Glasgow Coma Scale of 15
What is beneficial in diagnosing encephalitis secondary to West Nile virus?
Exposure to mosquito bites
What is used to decrease swelling in the brain cells with increasing ICP?
Hypertonic saline solutions
What is the characteristic gait in Parkinson disease?
Propulsive gait
What is used to manage symptoms of muscle spasticity and rigidity in clients diagnosed with neuromuscular disorders?
Baclofen
What is the priority in the management of symptoms in Bell palsy?
Ophthalmic lubricant and protection of the eye
What are important assessment findings in a client with bacterial meningitis?
Cloudy cerebral spinal fluid and purpura of hands and feet
What is a symptom of ALS?
Muscle weakness of the arms
What is the characteristic of a propulsive gait in Parkinson disease?
A tendency to take increasingly quicker steps while walking
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 practices and care with this quiz. Covering topics such as cranial nerves, diagnostic procedures, neurological assessments, and specific nursing interventions, this quiz will help reinforce your understanding of neurological nursing care.
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