Neurological Alterations in Acute Care

Practice practice flashcards for NRS 112 focused on neurological assessments, stroke recognition, seizure management, and clinical priorities in acute care.

What three physiological factors does brain tissue depend on to function properly?

Oxygen, Glucose, and Cerebral perfusion

According to the Glasgow Coma Scale (GCS), what score range indicates a 'Mild' injury category?

$$13-15$$

What is the score range for a 'Moderate' injury on the Glasgow Coma Scale (GCS)?

$$9-12$$

A Glasgow Coma Scale (GCS) score within which range is classified as 'Severe'?

$$3-8$$

What are the three specific categories assessed in the Glasgow Coma Scale (GCS)?

Eye opening, Verbal response, and Motor response

Describe the Level of Consciousness (LOC) continuum from most responsive to least responsive.

Alert → Confused → Lethargic → Obtunded → Stuporous → Coma

What are the four categorical causes of Altered Level of Consciousness (ALOC)?

Neurologic (e.g., stroke, trauma), Metabolic (e.g., hypoglycemia, renal failure), Toxicologic (e.g., opioids, alcohol), and Inflammatory/Infectious (e.g., sepsis, meningitis)

What specific findings are considered 'early' indicators of altered LOC?

Anxiety, Restlessness, Confusion, and Difficulty concentrating

Which findings indicate 'severe' neurological deterioration in a patient with altered LOC?

Fixed pupils, No eye opening, Abnormal posturing, and Coma

What is the clinical definition of a seizure?

An abnormal electrical discharge from cerebral neurons

What symptoms characterize the postictal phase after a seizure?

Confusion, Fatigue, Headache, and Decreased responsiveness

What nursing actions should be taken during a patient's seizure to ensure safety?

Stay with the patient, protect the head, remove hazards, time the seizure, and turn them to their side if possible

What three actions must a nurse avoid during a patient's seizure?

Do not restrain the patient, do not put anything in the mouth, and do not force oral medications or fluids

What percentage of all strokes are classified as Ischemic?

$$87\%$$

What percentage of all strokes are classified as Hemorrhagic?

$$13\%$$

What does the acronym BE FAST stand for in stroke recognition?

Balance, Eyes, Face, Arms, Speech, and Time

How many neurons are lost approximately every minute an untreated stroke proceeds?

$1.9$ million

Why are thrombolytics contraindicated in cases of Hemorrhagic stroke?

Thrombolytics are contraindicated because Hemorrhagic stroke involves a ruptured vessel and bleeding in the brain, which would be exacerbated by blood-thinning agents

What is the priority antidote to prepare for a known or suspected opioid overdose?

Naloxone

What are common neurologic assessment triggers for different age groups (Pediatric, Adult, Older Adult)?

Pediatrics: Febrile seizures and toxic ingestions; Adults: Trauma, stroke, and substance misuse; Older Adults: Stroke, delirium, medication toxicity, and new-onset seizures

What specific tasks can an RN delegate to Unlicensed Assistive Personnel (UAP) for a neurologic patient?

Obtaining vital signs, obtaining fingerstick blood glucose (after airway stability), setting up suction equipment, obtaining seizure pads, and assisting with fall precautions

What four clinical responsibilities can an RN NEVER delegate to a UAP?

Assessment, clinical judgment, interpretation, or evaluation of patient response

In a 'Clinical Judgment' scenario, what is the priority action for a patient presenting with new confusion and a blood glucose of $42\,mg/dL$?

Prioritize identifying and treating the hypoglycemia (glucose level)