🧠 Med Surg II Final — Neurological Flashcards

What subjective history should the nurse ask about during a neurological assessment?

Head injury, stroke, incoordination, dizziness, seizures, and memory issues.

What are the four levels of consciousness listed in the review?

Alert → Voice → Pain → Unresponsive.

What does "Alert" mean?

The patient is awake.

What does "Voice" mean?

The patient responds to verbal stimuli.

What does "Pain" mean?

The patient responds to painful stimuli.

What does "Unresponsive" mean?

The patient is completely unresponsive.

What four things are assessed for orientation?

Person, place, time, and situation.

What does orientation to "person" mean?

The patient knows who they and the healthcare provider are.

What does orientation to "place" mean?

The patient knows where they are.

What does orientation to "time" mean?

The patient knows the year, month, or day of the week.

What does orientation to "situation" mean?

The patient understands why they are there and what is happening.

What are the three components of the GCS?

Eye opening, best motor response, and best verbal response.

What is the maximum GCS score?

15.

Eye opening: What does a score of 4 mean?

Spontaneous.

Eye opening: What does 3 mean?

To voice.

Eye opening: What does 2 mean?

To pain.

Eye opening: What does 1 mean?

No eye opening.

Best motor response: What does 6 mean?

Obeys commands.

Best motor response: What does 5 mean?

Localizes pain.

Best motor response: What does 4 mean?

Withdraws from pain.

Best motor response: What does 3 mean?

Flexion.

Best motor response: What does 2 mean?

Extension.

Best motor response: What does 1 mean?

No motor response.

Best verbal response: What does 5 mean?

Oriented.

Best verbal response: What does 4 mean?

Confused.

Best verbal response: What does 3 mean?

Inappropriate words.

Best verbal response: What does 2 mean?

Incomprehensible sounds.

Best verbal response: What does 1 mean?

No verbal response.

What three things should the nurse assess when checking pupils?

Size, reactivity, and equality.

What does PERRL/normal pupillary response mean in the review?

When one pupil is exposed to light, the other pupil also constricts.

What can pinpoint pupils indicate?

Opiate administration or pons injury.

What can unilateral pupil dilation indicate?

Cranial nerve III compression.

What can bilateral pupil dilation indicate?

Midbrain injury; fixed dilation is very serious.

What can an irregularly shaped pupil indicate?

Orbital trauma.

What is the cerebellum responsible for?

Balance, posture, and coordination of voluntary muscles.

What does a broad-based gait suggest?

Cerebellar dysfunction.

What does a slow and unsteady gait suggest?

Poor cerebellar vermis function.

What can slurred speech indicate?

Cerebellar dysfunction

What does a 0+ DTR mean?

No response.

What does a 1+ DTR mean?

Sluggish or diminished.

What does a 2+ DTR mean?

Active/expected response.

What does a 3+ DTR mean?

Slightly hyperactive.

What does a 4+ DTR mean?

Brisk, hyperactive with clonus

What is a traumatic head injury?

Trauma or blunt force to the skull that causes damage to the brain.

What are important signs/symptoms of a head injury?

Confusion, agitation, visible head injury, sleepiness, and blown pupils.

What should the nurse monitor after a head injury?

Neurological changes/LOC, vital signs, headache, nausea/vomiting, CSF drainage, and pupil size.

What are possible complications of traumatic head injury?

Cerebral bleed, hematoma, increased ICP, infection, seizure, increased CO₂, and permanent damage.

What is a seizure?

Abnormal, sudden electrical activity in the brain.

What can happen during a seizure?

Uncontrollable involuntary muscle movements, staring/gazing with no response, and possible loss of consciousness.

What should the nurse do during a seizure?

Protect the patient from injury and DO NOT restrain them.

What should the nurse document about a seizure?

Time and duration and the patient's behavior before and after the episode.

What position should the patient be placed in after a seizure?

On their side to help drain secretions.

What is status epilepticus?

Epileptic spasms/seizures without rest periods, which can cause brain damage.

What are risk factors for seizures?

Genetic inheritance, brain trauma, tumors, toxicity, metabolic disorders, and infection.

What causes Parkinson's disease according to the review?

Decreased dopamine levels in the brain.

What are classic signs of Parkinson's disease?

Blank facial expression, slow/monotonous/slurred speech, rigidity, tremors, forward-tilted posture, reduced arm swing, and short shuffling gait.

What are important nursing considerations for Parkinson's disease?

Monitor swallowing and neurological status, assist with ambulation, and promote PT/OT.

What complications can occur with Parkinson's disease?

Falls, self-care deficits, depression, constipation, and poor posture.

What is a stroke?

A neurological deficit caused by a block of blood flow to the brain.

What are common signs of stroke?

One-sided weakness, facial drooping, confusion, slurred speech, and aphasia.

What diagnostic tests confirm and identify the type of stroke?

CT scan or MRI.

What is the priority for a patient experiencing a stroke?

Airway.

How should a stroke patient be positioned to help prevent aspiration?

On their side.

What is an ischemic stroke?

An obstruction of a blood vessel; the review states it accounts for about 87% of strokes.

What is a hemorrhagic stroke?

A weakened blood vessel ruptures; hypertension is a risk factor.

What is a TIA?

A temporary clot/temporary impairment of blood flow that resolves and serves as a warning sign of a possible stroke.

What is the basic pathology of MS?

Demyelination of axons in the central nervous system.

What are common signs/symptoms of MS?

Fatigue, weakness, ataxia, vertigo, tremors, blurred vision, emotional changes, decreased sensation, bowel/bladder disturbances, and positive Babinski reflex.

What are important nursing interventions for MS?

Energy conservation, promote independence while maintaining safety, and monitor bowel/urinary dysfunction.

What is meningitis?

Inflammation of the arachnoid and pia mater of the CNS.

What commonly causes meningitis?

Bacteria or viruses.

What test is used to identify the pathogen and help determine treatment?

CSF testing

What are important signs of meningitis?

Decreased LOC, red macular rash, and pain with neck flexion.

What should the nurse monitor for in meningitis?

Seizures and cranial nerve function

What is one major function of CSF?

Acts as a shock absorber/cushion for the brain and spinal cord.

What does CSF transport?

Nutrients to the brain and waste away from the brain.

Why is CSF important diagnostically?

It can be tested for the presence of certain disorders.

Can CSF be used to administer medications?

Yes

What is the normal ICP?

4–13 mm Hg

What pulse-pressure change can indicate increased ICP?

Widening pulse pressure.

Why is the HOB elevated with increased ICP?

To decrease ICP.

What medication pulls fluid from brain cells to reduce cerebral edema?

Mannitol.

What medication may be given with mannitol to enhance diuresis?

Furosemide (Lasix).

What steroid listed in the review decreases cerebral edema?

Dexamethasone (Decadron).

What temperature should be maintained in a patient with increased ICP according to the review?

Below 100.4°F.

What activities should be avoided because they can increase ICP?

Valsalva/straining, hip flexion, isometrics, unnecessary coughing/suctioning, sneezing, nose blowing, and restraints.

Why are stool softeners used in patients with increased ICP?

To prevent straining during bowel movements.

Why should nursing interventions be spaced out?

To reduce stimulation and help prevent increases in ICP

What are important signs/symptoms of myasthenic crisis?

Dysphagia, dysphasia, ptosis, diplopia, increased pulse/respirations/BP, respiratory distress, cyanosis, absent cough/swallow reflex, and decreased urine output.

Which finding in myasthenic crisis is especially concerning?

Respiratory distress/cyanosis and absent cough/swallow reflex, because airway and respiratory function are threatened.