Medical-Surgical Nursing: Nervous System Practice Exam Flashcards

Flashcards covering neurologic assessment, acute intracranial issues, stroke, chronic neurologic conditions, and spinal cord injuries based on Medical-Surgical Nursing test bank content.

When admitting a 20-year-old acutely confused patient with a head injury, how should the nurse obtain the health history?

The nurse should ask family members about the patients health history because the patient is a poor historian.

What clinical finding is expected in a patient with a lower motor neuron lesion?

Flaccidity of the affected muscles.

Which primary function is controlled by the posterior temporal lobe?

Understanding written and oral language (integrating visual and auditory input for language comprehension).

Which vital sign change should the nurse monitor for in a patient taking Propranolol (Inderal)?

Bradycardia, due to inhibition of the sympathetic nervous system.

How does a nurse assess the function of the Trigeminal (CN V) and Facial (CN VII) nerves together?

By touching a cotton wisp strand to the cornea to test the corneal reflex.

What is the priority nursing intervention for a patient with impaired Functioning of the glossopharyngeal (CN IX) and vagus (CN X) nerves?

Withhold oral fluid or foods to prevent aspiration.

Why should a nurse question a lumbar puncture order for a patient with a recent head injury and suspected increased intracranial pressure (ICP)?

A lumbar puncture could lead to brain herniation due to the sudden release of pressure.

Which brain region is likely damaged if a patient can move their feet but is unable to respond verbally?

The frontal lobe, specifically Broca's area responsible for expressive speech.

What is the primary safety risk for a patient with a dysfunction of the cerebellum?

The risk for falls due to impaired coordination and balance.

What does a positive Romberg test indicate regarding a patient's physical status?

The patient has difficulty maintaining balance with the eyes closed, indicating a risk for falls.

Which diagnostic test is standard for assessing seizure disorders?

Electroencephalography (EEG).

What is the priority nursing assessment after a patient undergoes cerebral angiography?

Checking pulse and blood pressure frequently to monitor for bleeding at the catheter insertion site.

What is the normal white blood cell (WBC) count in cerebrospinal fluid (CSF)?

$4\,cells/mL$.

What are the components of Cushing's triad, and what do they indicate?

Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes; they indicate increased intracranial pressure and imminent brain herniation.

Describe decorticate posturing.

Internal rotation, adduction, and flexion of the arms in response to stimuli.

What is the primary goal of administering IV Mannitol (Osmitrol) to a head-injured patient?

To reduce cerebral edema and decrease Intracranial Pressure (ICP).

Calculate the Glasgow Coma Scale (GCS) score: eyes open to verbal stimulation (3), curses when stimulated (3), pushes away a painful stimulus (5).

$11$.

What is the recommended head of bed (HOB) elevation for a patient with increased intracranial pressure?

$30\,degrees$.

How should a nurse test clear nasal drainage in a patient with a head injury to check for a dural tear?

Check the drainage for glucose content to confirm it is Cerebrospinal Fluid (CSF).

What is the definitive treatment for an epidural hematoma?

Rapid surgery (craniotomy) to remove the hematoma and prevent herniation.

What is a major indicator of postconcussion syndrome 6 weeks after a concussion?

Decreased short-term memory.

What is the recommended vaccination to prevent meningitis in adolescents and college freshmen?

Neisseria meningitidis (meningococcal) vaccine.

Calculate the Cerebral Perfusion Pressure (CPP) for a blood pressure of $106/52\,mm\,Hg$ and an ICP of $14\,mm\,Hg$.

$CPP = 56\,mm\,Hg$ (Normal range is $60$ to $100\,mm\,Hg$).

What is the significance of a PbtO2 level of $14\,mm\,Hg$?

It is below the normal range of $20$ to $40\,mm\,Hg$, indicating brain ischemia.

What is the first action a nurse should take for a head-injured patient with a serum sodium Level of $116\,mEq/L$?

Administer IV $5\%\,hypertonic\,saline$ to correct hyponatremia and reduce cerebral edema.

What medication is prioritized to inhibit platelet aggregation after a Transient Ischemic Attack (TIA)?

Oral low-dose aspirin therapy.

Which brain hemisphere is affected if a patient exhibits difficulty comprehending language and right-sided paralysis?

The left hemisphere.

What is the first diagnostic test used to rule out hemorrhagic stroke before administering tPA?

Noncontrast computed tomography (CT) scan.

What is the single most important modifiable risk factor for stroke?

Hypertension.

Which adverse effect of Phenytoin (Dilantin) requires an inspection of the oral mucosa?

Gingival hyperplasia.

What information is vital for a patient starting Dalfampridine (Ampyra) for Multiple Sclerosis?

The patient must not have impaired renal function (elevated serum creatinine).

What technique helps a patient with Parkinson's disease initiate leg movement when experiencing bradykinesia?

Rocking the body from side to side.

Why is Sumatriptan (Imitrex) contraindicated in patients with a history of myocardial infarction?

Triptans cause coronary artery vasoconstriction.

What are the characteristic symptoms of Autonomic Dysreflexia in a spinal cord injury patient?

Severe pounding headache and high blood pressure, often triggered by a distended bladder or fecal impaction.

Which nursing assessment is the highest priority for a patient with Guillain-Barré syndrome?

Monitoring respiratory rate and effort to detect imminent respiratory failure.