Neuroglial, ICP, Stroke, and Neurological Disorder Care: Key Concepts

What should you do if a neuroglial patient shows a change in cognition?

Notify the physician immediately using SBAR.

How should you position a patient with increased ICP from a traumatic brain injury?

Position the head of bed at 30 degrees to promote venous drainage.

What symptoms might you see in a client with a brain tumor due to tissue compression?

Headache, decreased LOC, pupillary changes, visual changes, vomiting, restlessness.

What findings would you expect in a patient with acoustic neuroma?

Hearing loss and balance problems (CN VIII involvement).

What is the immediate action for a CNS disorder with irregular respiratory patterns?

Ensure a clear airway to support proper breathing.

What type of seizure involves rigidity followed by relaxation?

Generalized (tonic-clonic) seizure.

What should you educate a patient with a migraine about alcohol consumption?

Alcohol causes vasodilation of blood vessels, which can increase ICP/migraines.

What actions should you take for a patient with a traumatic brain injury at risk for DVT?

Administer anticoagulants, reposition every 2 hours, apply SCDs.

What actions should you take when planning care for a patient with herpes simplex encephalitis?

Monitor for seizures, administer IV acyclovir slowly, maintain bedrest.

What interventions should you apply for increased ICP in a client with a TBI?

Monitor ABGs, monitor Glasgow Coma Scale, elevate HOB ≥30°.

What assessment findings are common in a patient with bacterial meningitis?

Neck stiffness, light sensitivity, muscle aches.

What lifestyle modifications can help prevent seizure activity in a patient with epilepsy?

Avoid alcohol and triggers, do not abruptly stop meds.

What is the priority for a patient with a T6-T7 fracture to prevent autonomic dysreflexia?

Prevent bladder distension.

What is the priority post-op for a patient with trigeminal neuralgia scheduled for decompression surgery?

Monitor for facial motor and sensory deficits.

What assessment finding is the priority for a patient with a subdural hematoma?

Sudden deterioration in LOC and focal neurologic deficits.

What is the priority for a patient with Guillain-Barré experiencing rapid progression of weakness?

Airway/respiratory support due to respiratory failure risk.

What is the most appropriate goal for a patient with a right hemispheric stroke?

Improve spatial-perceptual orientation.

What action should you take first for a patient with new symptoms of MS?

Start steroid therapy (IV methylprednisolone).

What should your education for a patient diagnosed with a hemorrhagic stroke involve?

Control blood pressure (priority after stroke/thrombolytics).

How do you differentiate between aseptic and septic meningitis?

Aseptic = viral / Septic = bacterial (droplet precautions for bacterial).

What should you do if a patient is unable to follow verbal commands during a neurological assessment?

Use alternative communication (pictures/communication board).

What is the priority intervention for a patient with an epidural hematoma?

Elevate head of bed 30 degrees.

What clinical manifestations may indicate Parkinson's disease?

Muscle rigidity, mask-like face, propulsive gait.

What nursing interventions are appropriate for a patient with sudden onset of right-sided weakness and slurred speech?

Passive range-of-motion to the affected side.

What general prevention education should you provide to prevent viral encephalopathies?

Avoid triggers & infections.

What priority actions should be taken for a client with Bell's palsy having trouble keeping the affected eye closed?

Tape eye shut at night, use eye drops.

What are the signs and symptoms of a hemispheric stroke?

Weakness, slurred speech, facial droop, aphasia.

What actions help prevent complications post-microdiscectomy?

Log roll the patient.

What preparation is needed for a patient for an EEG?

Avoid caffeine before EEG.

What should you do first for a patient experiencing severe pain?

Assess pain first, then give analgesics.

What are the late signs of increased intracranial pressure?

Increased systolic BP, bradycardia, irregular respirations (Cushing's triad).

What diagnostic tool is used to diagnose Creutzfeldt-Jakob disease (CJD)?

EEG (electroencephalogram).

What strategies can you implement for a patient with Parkinson's having problems with ambulation and balance?

Allow extra time for movement, assist with ADLs, maintain safety with mobility.

What assessment finding in a patient with a supratentorial lesion requires immediate intervention?

Pupillary changes & impaired extraocular movements.

What actions or interventions are best for a patient with Parkinson's experiencing progressive muscle weakness?

Assist with ADLs.

What should discharge teaching for a patient with epilepsy include?

Do not discontinue medication / maintain schedule.

What should you do first with a patient in a myasthenic crisis?

Ensure airway and respiratory support first.

What post-op medication is most appropriate for a patient with a brain tumor undergoing supratentorial surgery?

Phenytoin (prevents seizures).

What is the most appropriate nursing diagnosis for a patient with ALS being discharged?

Impaired physical mobility / progressive neuromuscular decline.

What nursing assessments will address diabetes insipidus after increased ICP?

Administer vasopressin & monitor fluid balance.

How do you calculate the mL/hr for a dobutamine infusion?

19 mL/hr.

How do you calculate the flow rate for normal saline solution?

31 gtt/min.

What is the mL/hr for a nitroprusside infusion for a patient weighing 80 kg?

7 mL/hr.

What nursing intervention is best for a client with a left middle cerebral artery ischemic stroke experiencing a visual field deficit?

Place the call light on the client's left side.

What is the first intervention for a client with a hemorrhagic stroke experiencing increased intracranial pressure?

Administer mannitol as prescribed.

Which diagnostic tool is used to detect vasospasm in a client with suspected arteriovenous malformation (AVM)?

Transcranial doppler.

What is the most appropriate goal for a client with a right hemispheric stroke?

The client will exhibit improved spatial-perceptual orientation within one week.

What assessment finding in a client with a subdural hematoma requires immediate intervention?

Sudden deterioration in level of consciousness and focal neurologic deficits.

What is the priority intervention to prevent autonomic dysreflexia in a client with a T6-T7 fracture?

Preventing bladder distension.

What lifestyle modifications should a nurse recommend to a client with epilepsy to prevent seizure activity?

Avoid alcoholic beverages and other seizure triggers; do not abruptly stop taking anticonvulsant medications.

What actions should a nurse take to maintain normal intracranial pressure (ICP) in a client with a traumatic brain injury?

Monitor arterial blood gas values; elevate the head of the bed at least 30 degrees; monitor neurological status using the Glasgow Coma Scale.

What actions should a nurse take to prevent venous thromboembolism (VTE) in a client with a traumatic brain injury?

Administer anticoagulant therapy as prescribed; reposition client in bed every 2 hours; apply sequential compression devices (SCDs).

What effect does alcohol have on blood vessels according to a nurse's teaching on migraine headaches?

Alcohol causes vasodilation of the blood vessels.

What type of seizure involves rigidity followed by alternating muscle relaxation and contraction?

Generalized seizure.

What is the nurse's immediate action for a patient with a CNS disorder and irregular respiratory patterns?

Ensure a clear airway to support proper breathing.

Which brain area is likely involved in vision problems after a coup-contrecoup injury?

Occipital lobe.

After a middle cerebral artery stroke, what area is likely compromised if a patient has difficulty understanding spoken words?

Wernicke's area.

How should a nurse position a patient with signs of increased intracranial pressure (ICP) after a traumatic brain injury?

Position the head of bed at thirty degrees to promote venous drainage.

What immediate action should a nurse take upon observing a decline in a stroke patient's condition?

Notify the physician immediately using SBAR.

What intervention should a nurse prioritize before surgery according to the preoperative checklist?

Check the client's vital signs before surgery.

What sign of infection should a nurse emphasize to a client after surgery?

Redness and warmth at the incision site.

What action should a nurse take to ensure informed consent for a patient who speaks limited English?

Utilize an interpreter to explain the consent form clearly.

What should a nurse do if a patient mentions they ate breakfast before surgery?

Notify the provider in anticipation of delaying the procedure.

What should a nurse do if they observe a team member breaking sterile technique during surgery?

Request a time out to discuss the breach immediately.

What should be done immediately after a breach is identified?

Request a time out to discuss the breach.

How should a breach be documented?

Document the breach in the nurse's notes for later review.

What behavior should be reported to the supervisor?

Report the team member's behavior.

What is an expected finding in a client with a left middle cerebral artery ischemic stroke?

Right-sided weakness and aphasia.

What assessments should be prioritized for a client with stroke symptoms?

Neurological assessment including NIH Stroke Scale, Temperature, Blood pressure, Heart rate.

What orders should the nurse anticipate for immediate treatment of a stroke client?

Peripheral IV access, Intravenous labetalol, Intravenous alteplase, Continuous cardiac monitoring, Swallow evaluation, Aspiration precautions.

What are the risk factors for ischemic stroke in this client?

Hypertension, Smoking, Hyperlipidemia, Atrial fibrillation.

What should the nurse do if a postoperative client has low urine output?

Notify the health care provider.

What should the nurse do first for a client exhibiting signs of hypopharyngeal obstruction?

Perform a head-tilt chin-lift maneuver to open the airway.

What is the most important action to prevent wound dehiscence?

Ensure the client avoids excessive strain on the surgical site.

What should be monitored after administering succinylcholine?

Potential malignant hyperthermia.

When should surgery for a perforated gastric ulcer be scheduled?

Without delay (Emergency).

When is the best time to provide teaching for a client scheduled for open hemicolectomy?

As soon as possible, and before the surgical procedure.

What classification does a surgical procedure to reduce a spinal tumor fall under?

Palliative.

What intervention should be implemented to prevent a spinal headache after spinal anesthesia?

Keep the client positioned supine.

What intervention should the nurse take to prevent hypothermia in the operating room?

Administer warmed IV fluids.

What should the nurse do first for a client experiencing nausea and vomiting during the intraoperative period?

Turn the client's head to the left side to prevent aspiration.

What condition is a client with a recent history of head trauma most likely experiencing if they exhibit disorientation and restlessness?

Delirium

Which preoperative medication is appropriate for a client with a brain tumor to reduce the risk of postoperative seizures?

Phenytoin

What should the nurse include in discharge teaching for a client with a history of epilepsy?

Maintain a consistent medication schedule to keep drug levels constant.

What assessment finding in a client with a supratentorial lesion indicates the need for immediate intervention?

Pupillary changes and impaired extraocular movements.

Which medication should be administered to a client exhibiting signs of diabetes insipidus after a transsphenoidal approach for pituitary tumor removal?

Vasopressin

What is the best action for a nurse if a client scheduled for an EEG consumed coffee and cola prior to the test?

Inform the healthcare provider and discuss the possibility of postponing the EEG.

What does it suggest if a client with a recent stroke exhibits one arm slowly pronating and drifting downward during a motor function assessment?

A possible lesion on the opposite side of the pronating arm.

What nursing intervention is most appropriate for a client with sudden onset of right-sided weakness and slurred speech from a left hemispheric ischemic stroke?

Assist with passive range-of-motion exercises to the affected side.

What does the nurse suspect if a client with a history of hypertension and stroke exhibits decreased level of consciousness and new headache?

The patient is experiencing increased intracranial pressure.