Neurological Nursing Concepts Flashcards

These flashcards cover key nursing concepts related to neurological assessments, interventions, medication management, and patient education.

What is the most important intervention for a patient with moderate-stage Alzheimer's disease?

Construct a consistent routine to provide a structured environment.

Which nursing assessment is the priority for a patient with a brainstem infarction?

Respiratory rate and rhythm.

What is the best position for a patient after a lumbar puncture to prevent headaches?

Position the patient supine with the head of the bed flat.

What should the nurse instruct a patient before a CT scan of the head?

You will need to lie still throughout the procedure.

How do tremors in Parkinson's disease typically behave?

Tremors decrease with voluntary movement.

What activity should a nurse encourage a Parkinson's patient to practice for better posture?

Walk with a marching step.

What is the primary education point for a family of a patient in late-stage ALS?

The patient's ability to move the upper and lower limbs may be affected.

Which symptom is expected in a patient with myasthenia gravis?

Ptosis.

What factor may rule out the safe use of triptans for migraine treatment?

Client has angina.

What side effects should a nurse monitor for in a patient taking carbidopa-levodopa?

Urinary retention, orthostatic hypotension, and nausea/dry mouth, diaphoresis.

What early sign should a care plan for a client at risk for increased ICP specify monitoring for?

Disorientation and restlessness.

Which interventions help prevent joint deformities in a patient who had an ischemic stroke?

Place client in a prone position for 20 minutes per day and assist flexing the thigh, place patient’s hand in pronation.

What dietary instructions should be emphasized for a patient with multiple sclerosis?

Maintain fluid intake of at least 1500 mL each day, high fiber foods in diet, add supplemental calcium and vitamin D to diet, encourage small soft frequent meals.

What will be a focus of nursing care for a patient with Guillain-Barré syndrome?

Assessment of advancing paralysis and provision for ventilation support, maintain adequate nutrition and prevent complications of immobility.

What should the nurse teach a patient prescribed pyridostigmine (Mestinon) for myasthenia gravis?

Take this drug on an empty stomach for best absorption, seek immediate care if trouble swallowing, dose may change frequently based on symptoms.

a nurse is caring for a client with a recent history of migraines. what aspect of the clients current status may rule out safe use of triptans?

Patient has angina

The home health nurse assesses the patient with Parkinsons disease who has just been placed on carbidopa-levodopa. What side effects should the nurse be alert for when assessing this patient?

Urinary retention, diaphoresis, orthostatic hypotension, nausea/ dry mouth

The nurse has created a plan of care for a client who is at risk for increased ICP. The client's care plan should specify monitoring for what early sign of increased ICP?

Disorientation/restlessness

The nurse is caring for a patient with Huntington's chorea. Which symptoms typically would be seen in the patient with this disease?

Fidget, restless, constant movement, dementia, difficulty swallowing.

A nurse is assessing a client with multiple sclerosis. Which clinical manifestations are expected?

Dysarthria, fatigue, nystagmus, ptosis

The ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture?

Bruising over mastoid

A client is brought to the ED by her family after falling off the roof. The care team suspects and epidural hematoma, prompting the nurse to prepare for which priority intervention?

making surgical openings in the skull

A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when the patient fell she was "knocked out," but came to and "seemed okay." Now she is complaining of a severe headache and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention?

Emergency craniotomy

A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?

Bradycardia and HTN

A patient diagnosed with Bell's palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions?SATA **

Apply a protective eye shield at night, wear sunglasses during daytime, facial exercise to maintain muscle tone

A nurse is taking care of a patient with newly diagnosed parkinson's disease. Which statement by the nurse indicates good understanding of the medication therapy? SATA **

Benztropine is contraindicated in a patient with narrow angle glaucoma, entacapone should be given with levodopa, tyramine foods should be avoided while taking selegiline

A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect should the nurse monitor?

Bradycardia

A patient admitted with possible stroke has been aphasic for 2 hours and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question?

Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.

When caring for a patient who experienced a T2 spinal cord transection 24 hours ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)?

Urinary catheter care, continuous cardiac monitor, maintain warm room temp, administer H2 receptor blockers

When assessing patient with bacterial meningitis, the nurse obtains the following data. Which finding requires the most immediate intervention?

Patient’s blood pressure is 88/42 mm Hg

The nurse educator is reviewing the assessment of cranial nerves. What should the educator identify as the specific instances when cranial nerves should be assessed? Select all that apply.

When LOC is decreased, with brainstem pathology

A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the client's neurologic examination is normal. About what drug should the nurse plan to teach the client?

Clopidogrel (Plavix)- ASPIRIN

During the examination of an unconscious patient, the nurse observes that the patient's pupils are fixed and dilated. What is the most plausible clinical significance of the nurse's finding?

Indicates midbrain injury level

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication?

provide a board of commonly used needs and phrases

A patient is being given a medication that stimulates her parasympathetic system. Following administration of this medication, the nurse should anticipate what effect?

Constricted pupils

The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment?

Lumbar puncture

A patient has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication?

Vigilant monitoring of fluid balance

A nurse assesses a client recovering from a cerebral angiography via the client's right femoral artery. Which assessment should the nurse complete?

Palpate bilateral lower extremity pulses

A patient with suspected meningitis is scheduled for a lumbar puncture. Before the procedure, the nurse will plan to

Help patient to lateral position, obtain informed consent

The emergency room nurse is assessing a newly admitted patient with a head injury. The nurse observes clear drainage from the nose. Which action should the nurse perform first?

Test fluid with glucose accucheck or dextrostix

A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care?

Keep HOB elevated at least 30 degrees

Which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol (Osmitrol) has been effective for an unconscious patient?

ICP + Urine output

What should a nurse do when a client experiences a cluster headache?

Expect unilateral tearing of the eye and miosis, unilateral ptosis.

teaching about management of migraine headaches has been effective when the patient says which of the following?

I will lie down someplace dark and quiet when the headaches begin, I should avoid taking St. John’s Wort if I start sumatriptan, I can repeat Sumatriptan in 2 house if headache continues

A nurse assesses clients on a medical-surgical unit. Which clients should the nurse identify as at risk for secondary seizures? (Select all that apply.)

26 year old with left temporal brain tumor

38 year old male with alcohol withdrawal program

42 year old football player with TBI

72 year old with hemorrhagic stroke

A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this client's plan of care? (Select all that apply.)

Suction equipment at bedside, keep bed rails up all times, ensure IV access present

The nurse is caring for a patient with spinal cord injury. Which of the following clinical manifestations related to spinal shock? SATA

Bradycardia, hypotension, atonic bladder, paralytic ileus, muscular flaccid

A nurse asks a client to take deep breaths during an electroencephalography. The client asks, Why are you asking me to do this? How should the nurse respond?

Hyperventilation causes vasoconstriction and increases likelihood of seizure activity

Hyperventilation produces cerebral vasoconstriction and alkalosis, which increases the likelihood of seizure

activity. The client is asked to breathe deeply 20 to 30 times for 3 minutes. The other responses are not accurate.

A 20-yr-old male patient is admitted with a head injury after a collision while playing football. After noting that the

patient has developed clear nasal drainage, which action should the nurse take?

Check for glucose content

Which finding should the nurse expect when assessing a patient who is experiencing a cluster headache?

Unilateral ptosis, ipsilateral lacrimation, nasal congestion

A nurse assesses a client who is experiencing a cluster headache. Which clinical manifestations should the nurse

expect to find? (Select all that apply.)

Miosis, ipsilateral tearing, rhinorrhea/nasal congestion, ptosis, eyelid edema, facial sweating

A nurse assesses clients on a medical-surgical unit. Which clients should the nurse identify as at risk for secondary

seizures? (Select all that apply.)

A 26-year-old woman with a left temporal brain tumor

b. A 38-year-old male client in an alcohol withdrawal program

c. A 42-year-old football player with a traumatic brain injury

Which nursing actions should be included in the plan of care for a patient after cerebral angiography? (Select all that

apply.)

Monitor for BP/pulse frequently, watch for bleeding, assess person, place and time, sandbags over femoral artery bed rest 12 hours

A nurse assesses a client recovering from a cerebral angiography via the client's right femoral artery. Which assessment should the nurse complete?

Palpate bilateral lower extremity pulses, check pulse bilaterally, keep immobilized after procedure, cap refill etc.

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical

nursing unit. Which equipment should the nurse have available in the patient’s assigned room?

O2, suction, padded side rail

A nurse cares for a client who is experiencing status epilepticus medication should the nurse prepare to administer?

Lorazepam (Ativan) followed by phenytoin (long acting)

The nurse is assisting a patient with agnosia after a CVA. Which intervention is most appropriate?

Showing the patient a spoon while calling it by name and describing its purpose.

After evacuation of an epidural hematoma, a patient’s intracranial pressure (ICP) is being monitored with an

intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health

care provider?

b. Temperature of 101.6° F

A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care?

Reposition q2H, elevate 30-45 degrees

What should the nurse include in a rehabilitation plan as an appropriate goal for a 30-yr-old patient with a C6 spinal

cord injury?

b. Propel a manual wheelchair on a flat surface.

What should the nurse include in a rehabilitation plan as an appropriate goal for a 21-yr-old patient with a C4 spinal

cord injury?

Total care/full assist

A nurse is teaching a client with chronic migraine headaches. Which statement related to complementary therapy should the nurse include in this clients teaching?

Avoid St. John’s wort, use a dark room, q2 Tristan’s if not going away

The nurse describes a concussion as a closed head injury in which:

There is amnesia related to the incident

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations

should the nurse correlate with neurogenic shock? (Select all that apply.)

O2 sat: 90%, 32 HR, AOx2, 20ml/hr Urine output, 80/50 BP

Signs of spinal shock?

Hypotension, bradycardia, muscular flaccidity, paralytic ileus, atonic bladder

A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this clients plan

of care? (Select all that apply.)

a. Tape a halo wrench to the clients vest.

b. Assess the pin sites for signs of infection.

E. Assess chest/back for skin breakdown

A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects?

Visit the dentist every 3-6 months because of risk of gingival hyperplasia

These manifestations indicate Cushing's syndrome, a potentially life-threatening increase in intracranial pressure

(ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the

Rapid Response Team. Increasing fluids would increase the ICP . The client does not need a breathing treatment or

painAdmission vital signs for a patient who has a brain injury are blood pressure of 128/68 mm Hg, pulse of 110

beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern

to the nurse?

a. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min Call HCP!

A nurse assesses a client with an injury to the medulla. Which clinical manifestations should the nurse expect to

find? (Select all that apply.)

Cranial nerves IX, X, XI, XII.

Impaired swallowing, inability to shrug shoulders, loss of gag reflex

A nurse obtains a focused health history for a client who is scheduled for magnetic resonance angiography. Which

priority question should the nurse ask before the test?

Do you have any allergies to iodine or shellfish?

A nurse delegates care for an older adult client to the unlicensed assistive personnel (UAP). Which statements

should the nurse include when delegating this clients care? (Select all that apply.)

a. Plan to bathe the client in the evening when the client is most alert. B. Encourage the patient to use a cane when ambulating D. Remind the patient to look at foot placement when walking

A nurse prepares to discharge a client with Alzheimers disease. Which statement should the nurse include in the

discharge teaching for this clients caregiver?

c. Install deadbolt locks on all outside doors.

d. Provide a high-calorie and high-protein diet.

e. Non-skid Mat

A client with myasthenia gravis is malnourished. What actions to improve nutrition may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.

b. Cutting foods up into small bites, thicken liquids prior to drinking, weigh patient daily

A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and

felt like his legs were very heavy. Currently the clients neurologic examination is normal. About what drug should

the nurse plan to teach the client?E

Clopidogrel

A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by

the nurse is most appropriate for this client?E SATA

Rotate patient’s meal tray when they stop eating

A nursing student studying the neurologic system learns which information? (Select all that apply.)

a. An aneurysm is a ballooning in a weakened part of an arterial wall.

c. Intracerebral hemorrhage is bleeding directly into the brain.

d. Reduced perfusion from vasospasm often makes stroke worse.

Several patients have been hospitalized for diagnosis of neurologic problems. Which patient should the nurse assess

first?

b. A patient with a brain tumor who has just arrived on the unit after a cerebral angiogram

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear

drainage from the patient’s nose. Which admission order should the nurse question?

b. Insert nasogastric tube to low suction.

After having a craniectomy and left anterior fossae incision, a 64-yr-old patient has weakness, impaired physical mobility, and a decreased level of consciousness. Which nursing action will be included in the plan of care?

d. Perform range-of-motion (ROM) exercises every 4 hours.

When the patient is weak, clustering nursing activities may lead to more fatigue and weakness.

The public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults.

Which action is most likely to be effective?

b. Encourage immunization for adolescents and college freshmen.

When assessing an adult who has bacterial meningitis, the nurse obtains the following data. Which finding requires

the most immediate intervention?

BP 88/42

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action?

b. Nurse enters with only gloves and gown

After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first?

Ensure neck is in neutral position

Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN)

who has floated from the medical unit?

a. A 45-yr-old patient receiving IV antibiotics for meningococcal meningitis

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding indicates a possible complication that should be reported to the health care provider?

Temperature 101.4 (38.6C)

The charge nurse observes an inexperienced staff nurse caring for a patient who has had a transsphenoidal for

resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?

Nurse suctions patient every 2 hours routinely

While admitting a 42-yr-old patient with a possible brain injury to the emergency department (ED), the nurse obtains

the following information. Which finding is most important to report to the health care provider?

Takes warfarin (Coumadin) daily

Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community?

b. Encourage the use of effective insect repellent during mosquito season

A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse

should consult with the health care provider before giving a prescribed dose of aspirin?

c. The patient reports that symptoms began with a severe headache.

A patient being admitted with a stroke has right-sided facial drooping and right-sided arm and leg paralysis. Which

finding should the nurse expect? E SATA

Impaired comprehension, slow performance, aware of deficit (depression/anxiety)

A female patient who had a stroke 24 hours ago has expressive aphasia. What is an appropriate nursing intervention

to help the patient communicate? E SATA

Ask yes/no questions, give time to answer

A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care?

Apply intermittent compression stockings

The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism. Activities, such as coughing and sitting up, that might increase intracranial pressure or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate. Which intervention should the nurse include in the plan of care for a patient with new right-sided homonymous hemianopsia after a stroke?

Place needed objects left side only

What is the priority nursing assessment for a patient with a traumatic brain injury?

Pupil reaction.

How should the nurse document abnormal posturing in a patient with a neurological deficit?

Decorticate posturing.

What action should the nurse take first for a patient with a suspected spinal cord injury?

Assess level of consciousness and evaluate respiratory status.

Which medication is commonly used for status epilepticus?

Lorazepam (Ativan).

How should the nurse respond to a patient asking why to take deep breaths during an EEG?

Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity.

What should be done for a patient with fixed and dilated pupils?

Indicate a potential brain injury; notify the healthcare provider.

What intervention indicates successful teaching regarding the management of migraines?

Lie down in a dark and quiet place when the headaches begin.