Comprehensive NCLEX Nursing Review - Neurology, Psychiatric, and Med-Surg Highlights

Intracranial Pressure (ICP) and GCS Scoring

• Intracranial Pressure Regulation:

  • Lower levels of $CO2$ result in lower Intracranial Pressure (ICP).

  • Carbon dioxide acts as a vasodilator; therefore, an increase in $PaCO2$ leads to increased ICP.

  • Nursing interventions to decrease ICP include increasing the respiratory rate on a ventilator to promote a decrease in carbon dioxide levels.

  • Valsalva maneuvers must be avoided to prevent spikes in pressure.

• Mobility and Positioning:

  • Patients should be turned as "one unit" to maintain alignment.

  • The head must be immobilized (C-Spine precautions).

  • Avoid deep breathing exercises that might cause straining.

• Pharmacology for ICP:

  • Phenytoin: Used to prevent seizures.

  • Steroids (Dexamethasone): Used to reduce swelling.

  • Phenobarbital: A barbiturate used to decrease brain activity.

  • Mannitol: An osmotic diuretic; noted as the number one drug to know for this condition.

• Glasgow Coma Scale (GCS) Scores:

  • $15$: Represents the highest/best possible score.

  • $8$: The threshold at which intubation is typically required.

  • $3$: Indicates a state of coma or severe neurological impairment.

• Questions & Discussion:

  • HESI Question: If a nurse notes an increased $PaCO2$, what should be done? Answer: Increase the respiratory rate on the ventilator to decrease ICP by lowering carbon dioxide.

  • HESI Question: A patient is alert and oriented to person and place but provides the incorrect year and date. How should the nurse document this? Answer: Alert and oriented to person and place.

  • HESI Question: A patient recovering from head trauma shows fixed pupils that remain $8\,mm$ when assessed with a pen light, and the toes fan out when the sole of the foot is stroked. These are priority findings indicating increased ICP.

Parkinson’s Disease

• Pathophysiology:

  • Parkinson’s is a movement disorder characterized by the progressive death of neurons in the brain.

  • It results in low levels of dopamine and high levels of acetylcholine.

  • Memory Trick: Think "NO dope in the park" (low DOPamine in PARK-insons) and "HIGH acetylCCCholine" which leads to "seCCCretions" like drooling.

• Three Key Signs:

  1. Resting tremors: Specifically tremors at rest.

  2. Pill rolling: A specific type of hand tremor.

  3. Bradykinesia: A delay or slowness in the initiation of movement.

• Nursing Care and Safety:

  • Airway is the primary priority.

  • Suction equipment should be kept at the bedside.

  • During eating, patients should have tissues readily available due to drooling and monitor for dysphagia (swallowing difficulties).

  • The head of the bed (HOB) should be elevated ($HOB\,up$).

• Pharmacology:

  • Levodopa/Carbidopa: Increases dopamine levels to improve movement. Carbidopa helps conserve more dopamine.

  • Selegiline: An MAOI antidepressant that increases dopamine availability.

  • Memory Trick: "LEAVE the protein with LEVOdopa" because protein can block the absorption of the medication.

Overview of Neurological Diseases

• Multiple Sclerosis (MS):

  • Pathophysiology: Autoimmune destruction of the myelin sheath.

  • Key Phrase: "Mellow out and Stay cool" because heat (sun, hot tubs) triggers flare-ups.

  • Signs: Muscle spasms and stiffness.

  • Intervention: Balance exercise and rest; use gait training before moving to assistive devices like canes or walkers.

  • The 4 S’s (Triggers): Stress (exercise, surgery, injury), Sickness (sepsis), Smoking, and Sun/Extreme heat (saunas, hot tubs).

• Myasthenia Gravis (MG):

  • Pathophysiology: Autoimmune attack on acetylcholine receptors resulting in low acetylcholine.

  • Signs: Ptosis (droopy eyes), diplopia (double vision), dysphagia, and dyspnea.

  • Intervention: Give Pyridostigmine before meals to assist with swallowing. Use semi-solid foods.

  • Crisis: Myasthenic crisis can lead to respiratory arrest; intubation equipment must be at the bedside.

• Amyotrophic Lateral Sclerosis (ALS):

  • Pathophysiology: Deterioration of motor neurons leading to total body paralysis.

  • Survival: Death usually occurs within $3 - 5$ years, typically from respiratory failure.

  • Memory Trick: Think of ALS as "Advanced Life Support" because patients eventually require a ventilator.

• Huntington Disease:

  • Pathophysiology: Genetic disorder passed from a single parent (One parent needed).

  • Signs: Dysphagia and respiratory secretion issues.

  • Memory Trick: "HuntingTON" refers to "one" parent needed.

• Guillain-Barr–Barr Syndrome (GB):

  • Pathophysiology: Rapid ascending paralysis moving from the legs upward.

  • Primary Risk: Respiratory failure once paralysis reaches the diaphragm.

  • Early Signs: Inability to cough, lift the head, or lift eyebrows.

  • Memory Trick: "Ground up barees" (paralysis from the ground up).

Meningitis

• Signs and Symptoms:

  • Agitation and altered level of consciousness (LOC) are often the first signs.

  • Infant Signs: High-pitched cry and bulging fontanels.

  • Kernig Sign: Physical pain when the hip and knee are flexed and then the knee is extended.

  • Brudzinski Sign: When the neck is flexed, the hip and knee also flex.

• Diagnostics:

  • Lumbar puncture (LP) is used to test cerebrospinal fluid (CSF).

  • CT scans are often performed first.

• Interventions:

  • Droplet Precautions: Required for Pertussis, Meningitis, and Pneumonia. Maintain a private room or keep the door closed and wear a mask.

  • Airborne Precautions: Required for Measles, TB, and Varicella (shingles/chickenpox). Use an $N95$ mask.

  • Donning PPE (GMGG): Gown, Mask, Goggles, Gloves.

  • Doffing PPE (GGGM): Gloves, Goggles, Gown, Mask.

Traumatic Brain Injury (TBI) and Cranial Anatomy

• Causes: Motor vehicle accidents, falls greater than $20\,ft$, and shaken baby syndrome.

• Basilar Skull Fracture: Characterized by CSF leakage from the eyes, ears, or nose. Check drainage for glucose to confirm it is CSF.

• Concussion: A minor TBI; "Coup-Contrecoup" refers to the brain hitting the front and back of the skull.

• Brain Lobe Functions:

  • Frontal Lobe: "Front Office" - controls speech, memory, and movement.

  • Occipital Lobe: "Ocular Sight" - controls visual perception.

  • Temporal Lobe: "Tempo" - controls hearing.

  • Parietal Lobe: "Purr-ietal" (like a cat) - controls sensory and touch.

  • Cerebellum: "Cere-balance" - controls balance.

  • Brain Stem: Controls heart rate ($HR$) and respiratory rate ($RR$).

Dementia vs. Delirium

• Dementia:

  • Permanent, irreversible damage to the brain (Alzeimer's, Parkinson's, TBI).

  • In end-stage, patients cannot understand reality; interventions focus on distraction and redirection.

• Delirium:

  • Limited, short-term confusion that is easily reversible.

  • Causes: Infection (Sepsis, Temp over $100.3\,^{\circ}F$), Hypoxia (Low $SpO2$), opioid medications, low sodium (Normal: $135 - 145\,mEq/L$), and low blood glucose (Normal: $70 - 110\,mg/dL$).

Bell’s Palsy vs. Trigeminal Neuralgia

• Bell’s Palsy:

  • Affects the $7^{th}$ cranial nerve.

  • Sudden weakness on one side of the face.

  • Intervention: Use warm, moist heat; protect the affected eye with a patch.

• Trigeminal Neuralgia:

  • Affects the $5^{th}$ cranial nerve.

  • Characterized by severe, electric-shock-like pain in the face.

  • Intervention: Avoid triggers such as cold wind or high-stimulation activities.

Seizures and Epilepsy

• Phases of a Seizure:

  • Prodromal: Warning signs.

  • Aura: A visual or auditory clue prior to a major seizure.

  • Ictal: The period of active seizure.

  • Postictal: The period of confusion, exhaustion, and headache following the seizure.

• Status Epilepticus:

  • A medical emergency where a seizure lasts $5\,minutes$ or longer, or repeated activity occurs over $30\,minutes$.

  • Priority: Stop the seizure using IV or rectal benzodiazepines (Lorazepam/Ativan or Diazepam/Valium).

• Seizure Precautions:

  • Turn the client to the side, loosen restrictive clothing, and stay with the client.

  • Clear the area of objects and pad the side rails. Never insert anything into the mouth.

• Electroencephalogram (EEG):

  • Wash hair before and after. No caffeine or stimulants $12 - 24\,hours$ prior.

  • The patient should be sleep-deprived for the best results. Not necessary to be NPO; they should eat before the test.

Stroke (CVA)

• Types:

  • Ischemic CVA: Caused by a clot (embolic or thrombotic).

  • Hemorrhagic CVA: Caused by a bleed (aneurysm); manifests as the "worst headache of my life."

  • TIA (Transient Ischemic Attack): Short-term lack of oxygen that resolves.

• Symptoms by Hemisphere:

  • Right-Side Stroke: Results in reckless behavior, lack of impulse control, and left-sided neglect. Educate families to scan surroundings.

  • Left-Side Stroke: Results in language and logic deficits.

• Feeding and Care:

  • NPO until a swallow screen is performed. Use a pureed diet.

  • Flex the neck while swallowing and avoid straws.

  • Always transfer patients toward their stronger side using a transfer belt.

• Questions & Discussion:

  • NCLEX Question: For a suspected embolic stroke, what is the priority action? Answer: STAT CT of the head to rule out hemorrhage, followed by alteplase ($tPA$) within $4.5\,hours$ of symptom onset.

Spinal Cord Injury (SCI) and Autonomic Dysreflexia

• Injury Levels:

  • Cervical (C1-C8): Quadriplegia; breathing is impaired.

  • Thoracic (T1-T12): Paraplegia (legs and trunk).

  • Lumbar (L1-L5): Legs and leaky bladder.

• Autonomic Dysreflexia:

  • Occurs with injuries above $T-6$. It is a miscommunication between the SNS and PNS.

  • Signs: Severe hypertension (up to $300\,systolic$), throbbing headache, and bradycardia (HR < 60\,bpm).

  • First Action: Sitting the client up (High Fowler's). Then address the cause (usually a distended bladder or bowel).

Mental Health Interventions

• Therapeutic Communication:

  • Avoid personal opinions, advice, or false reassurance. Never ask "Why?"

  • Use open-ended questions like "Tell me what concerns you have."

  • Acknowledge feelings: "I understand you are worried."

• Somatic System Disorder:

  • Unexplained physical symptoms with no medical cause. Symptoms are real to the client and caused by stress. Do not dispute the symptoms OR advocate for more medical tests.

• PTSD:

  • Persistent anger, flashbacks, and avoidance of trauma reminders. Priority is assessing for self-harm.

• Phobias:

  • Intervened with systematic desensitization (gradual exposure).

• Personality Disorders:

  • Narcissistic: Believes they are perfect.

  • Histrionic: Needs to be the center of attention.

  • Borderline: Fear of being abandoned; use of manipulative "splitting" behavior.

  • Antisocial: No guilt or remorse for hurting others.

• Eating Disorders:

  • Anorexia Nervosa: Fear of gaining weight, excessive exercise. Physical signs include Lanugo (thin hair) and cold intolerance. Hospitalize if weight is < 75\% of ideal.

  • Bulimia: Binge and purge cycles. Signs include tooth decay and dental erosion from vomiting. Monitor for hypokalemia (Potassium < 3.5\,mEq/L).

• Questions & Discussion:

  • Kaplan Question: A client with a phobic disorder says, "I am so scared, but I know it sounds ridiculous." Best response: "You feel like your fear does not make sense, but it is very real to you."

  • ATI Question: How to help a child with Autism who displays repetitive behavior? Answer: Provide a structured routine or schedule.

Pharmacology and Lab Values

• Therapeutic Ranges:

  • Digoxin: $0.5 - 2.0\,mg/ml$.

  • Lithium: $0.8 - 1.5\,mEq/L$ (Levels over $1.5$ are toxic).

  • Phenytoin: $10 - 20\,mcg/dL$.

  • Theophylline: $10 - 20\,mcg/dL$.

  • Vancomycin (Peak): $20 - 40\,mcg/ml$.

  • Warfarin (INR): $2.5 - 3.5$ for valve replacements.

• Tuberculosis Drugs:

  • Meds last $6 - 12\,months$. All are liver toxic.

  • Rifampin: Causes red/orange tears, urine, and sweat. Wear glasses instead of contacts.

  • Isoniazid (INH): Can cause peripheral neuropathy; take Vitamin $B6$ ($25 - 50\,mg/day$) to prevent it.

  • Pyrazinamide: Liver toxic.

  • Ethambutol: Can cause vision changes; report blurred vision.

Cardiac Disorders

• Myocardial Infarction (MI):

  • Signs: Crushing chest pain, radiation to jaw/back, diaphoresis (sweating).

  • Diagnostic: Troponin over $0.5\,ng/mL$ is the only specific indicator.

  • Treatment (OANM): Oxygen, Aspirin, Nitro, Morphine.

  • Fibrinolytics (t-PA): Must be given within a specific window and not to those with active bleeds or uncontrolled hypertension (BP > 180/110).

• Heart Failure:

  • Right-Sided: Peripheral edema, JVD, weight gain (water gain).

  • Left-Sided: Pulmonary edema, crackles (rales), pink frothy sputum.

  • Treatment: Diuretics (Furosemide). Limit sodium to $2\,g$ and fluids to $2\,L$ per day. Report rapid weight gain (water gain).

• EKG Interpretation:

  • PR Interval: $0.12 - 0.20\,seconds$.

  • QRS Complex: < 0.12\,seconds.

  • V-Tach: Wide, bizarre QRS complexes.

  • V-Fib: Chaotic rhythm; no QRS complexes. Priority: Defibrillate.

  • Atrial Flutter: Sawtooth pattern.

  • Asystole: Flatline. Do not shock; perform CPR and give Epinephrine.

Endocrine Disorders

• Diabetes Insipidus (DI):

  • "Dry Inside" - lack of ADH.

  • Symptoms: High urine output, low specific gravity (< 1.005), hypernatremia (Na+ > 145), and extreme thirst.

  • Treatment: Desmopressin.

• SIADH:

  • "Soaked Inside" - too much ADH.

  • Symptoms: Low urine output, high specific gravity (> 1.030), hyponatremia (Na+ < 135), and high blood pressure.

• Diabetes Mellitus (DM):

  • Insulin Types: Rapid (Aspart/Lispro - Peak $30 - 90\,min$), Regular (Ready to go IV - Peak $2 - 4\,hr$), NPH (Intermediate - Peak $4 - 12\,hr$), Long-acting (Glargine/Detemir - No peak, do not mix).

  • DKA (Type 1): Key signs are Ketones, Kussmaul respirations, and fruity breath. Blood sugar $250 - 500+$.

  • HHNS (Type 2): Highest sugars ($600+$), severe dehydration, and altered state of consciousness. No ketones.

• Thyroid Disorders:

  • Hyperthyroid (Graves): High metabolism, heat intolerance, exophthalmos (grape eyes). Treat with PTU or Radioactive Iodine.

  • Hypothyroid (Hashimoto): Low metabolism, cold intolerance, weight gain, constipation. Treatment: Lifelong Levothyroxine taken on an empty stomach in the morning.

Gastrointestinal Disorders

• Peptic Ulcer Disease (PUD):

  • Gastric Ulcers: Pain increases with food; leads to weight loss.

  • Duodenal Ulcers: Pain decreases with food; pain is worse at night; leads to weight gain.

  • Danger Sign: Rigid, board-like abdomen indicates perforation/peritonitis.

• Appendicitis:

  • Pain starts at the umbilicus and moves to the Right Lower Quadrant (RLQ). Rebound tenderness at McBurney's point.

• Celiac Disease:

  • Immune reaction to gluten (wheat, barley, rye). Symptoms include steatorrhea (fatty stools). Malabsorption of fat-soluble vitamins ($A, D, E, K$) is common.

• Small Bowel Obstruction (SBO):

  • High-pitched bowel sounds above the obstruction, followed by absent sounds. Signs include abdominal distension and colicky pain.