1
Q
changes in LOC can represent
A
ICP
recdued blood flow
2
Q
myasthenia gravis what is it
A
autoimmune disease
involves a decreased number of atch recports
3
Q
myasthenia gravis signs
A
weakness of skeletal muscles (ptsosis, diplopia)
bulbar signs (diff speaking and swallowing)
siff breathing
-BLADDER NOT AFFECTED BC SKELTAL MUSCLES ARE THE ONES THAT ARE INVOLVED
4
Q
myasthenia gravis atch levels
A
muscles are stronge r in the morning and weaker with the days activity as the supply of atch is depled
5
Q
treatment of myasthenia gravis
A
anticholingeic drugs are adm before meals so that the client can swllow strong
6
Q
myasthenia gravis education and food
A
semi solid foods (easiily chewed) are preferred over solid to avoid stressing muscles in chewing or swllowing and liquids are not preferred bc of aspiration risks
-annual flu and pnuemonia
7
Q
NUCHAL rigidity
A
menegitis
inability to flex the neck forward due to rigidity of the neck muscles.
8
Q
normal pupils are what in diameter
A
3-5mm
9
Q
oculocephalic reflex (dolls eye)
A
intact brainstem
- rotate the head and watch the eyes move in opposite direction
- dont do this test if spinal trauma is suspected
10
Q
babinski reflex
A
normal finding is absent babinski (toes point townward with stimulus to the sole)
=presence of babinski (toes fan outward and upward) is expected in infants up to 1 age but in adults it indicates brain or spinal cord lesions.
11
Q
abrnoaml neuorlogical assessment
A
nuchal ridigity
- pupils less than 3 or greater than 5
- absent oculucephalic reflex, presence of babinski
12
Q
multiple sclerosis
A
progressive disease
-affects cns by interupting the nerve impulses
13
Q
MS symtoms
A
muscle weakness
- spasicity
- incoordination
- loss of balance
- fatigue
14
Q
MS treatment
A
walk with feet aprt
- cane or walker when it gets worse
- rom excerrcises to help with spasicity
- balance excercises with rest
- excecise in cool weather and stay hydrated
- dehdyration and extremes in temp causes exacerbation
- wheelchair only when independcne no longer possible
15
Q
botulism
A
blacks ATCH resulting in muscle paralysi
16
Q
botulism is found in
A
soil and food
17
Q
manesifications of botulism
A
descending flaccid paralysis (starting from the face)
- dysphagia
- constripation
18
Q
main source of botulism is
A
improperly canner or stored food
-metal can swollen or bulging end can cause from the gases and should be discarded
19
Q
in children botulism can occur
A
if they eat honey under one age
20
Q
giardia
A
contimated water
21
Q
huntington disease
A
incurable
autosomal dominant
progressive nerve degernation
22
Q
signs of hunting ton disease
A
impaired movment swollowing specech cog abilities chlorea
23
Q
hallmark sign if huntington disase
A
chorea-involvuntary tic like movement
24
Q
complications of huntington disease
A
neuromusclar
resp complications
25
HD vonfirmed by
genetic testing
| and if client has a parent with HD and want to have children do genetic cousenling
26
transspehnoidal hypophysectomy
surgical removal of the pituatry gland
27
clients who undergo hypophysectomies are at risk for developing
DI
28
DI signs
low ADH
- decresed sp
- increased osmoilaity
- hypernatremia
- hypovoemia
- hypotension
- polydipsia
- polyuria
29
alzehmiers clients and food
give something when they say they are hungry
small meals throughout the day
-low calorie snakcs
-
30
bell palsy
unilateral facial paralysis
| -facial neve (VII)
31
bell palsy signs
inability to close the eye on the affected side
- alteration in tear production
- flateening of the nasobial fold
- inability to smile and frown symerical
32
trigeminal
cranial nerve V
| -electric shock like pain in the lips and gums and severe pain along the cheekbones
33
hemorrhahic stroke
blood vessels ruptures in the brain and causes bleeding into the brain tissue
34
hemmoragic stroke inteventeion
seziure due to ICP
=disphagia so remian NPO until swallow function
- neuro assessments
-
35
stroke interventions
```
reduce stimulation
quiet and dim lit env
-limit vistors
-adm stool softners
-reduce exertion
-maintain BED REST
-assist with daily living
-maintain head in midline poistion
-comrpession shocks
```
36
what is contraindicated in pts with hemmophagic stroke
anticogulants
37
late onset AD
advancing age
38
risk factors of AD
gentic
truma to the brain(wear seat belts, sports helmets, prevent falls)
-lifestyle choices (not eccersiing, drinking, smoking, not particpating in mentally challenging actv)
39
glasgow scale
eye opening, verbal, motor
40
eye opening grading (max 4)
4-spontanoues
3-speech
2-pain
1-none
41
verbal response (max 5)
```
5-oriented
4-confused
3-inapp words
2-incomprehensible (sounds no words)
1- none
```
42
motor
```
6-obeys commands
5-localizes to pain
4-withdraws to pain
3-flexion in resp to pain (decoricate)
2- extension (decerbate
1- none
```
43
glascoma scale used to deermine
LOC
44
complication of GBS
respiratory failure (priority)
dvt (not as priotiryt)
paralytic ilues
45
signs of resp failure
inability to cough
shallow resp
dyspnea and hypoxia
inabilty to lift the head or eye brows
46
gold standard for assessing ventilation
forced vital capity (FVC)
47
mannitol SE
can cause fluid overload causing LIFE THERANTING PULMOARY EDEMA
-hyponatermia
48
mannitol complication
pulmoary edema so look for crackles
49
preventing mannitol complication
mointor serum osmolarity
I&O
electryoltes
kidney function
50
mannitol treats
acute glucoma
| cerbral edema
51
what is important when giving mannitol
normal kidney function
| UOP
52
contrindiation of doing lumbar puncture
ICP
53
poistion for lumbar puncture
fetal postion or sitting and leaning over the table
54
what is enouraged to replace CSF
fluids
55
education for lumbar puncture post op
lie flat for 4 hours atleast
| prone or supine is recommended to prevent headache
56
what is expected after lumbar puncture
headahce
57
ischemic stroke
loss of brain tissue perfusion due tot bloackage of blood flow
58
permissive HTN and ischemic stroke
the HTN rsolves by itself within 24-48 hours unless (systolic blood pressure >220 mm Hg or diastolic blood pressure >120 mm Hg)
59
expected finding of ischemic stroke
ELEVATED BPPP
60
cranial nerve
18,34,45,49,53,65
61
parkison appearlance
```
stopped posture
masked facoial expression
ridigity
forward tilt of trunk
reduced arm swinging
fflexed elbows and writist
slightly flexed highs and kees
-trembling of ext
-shuffling short stepped gait
```
62
parkinson degeneration of
dopamine
63
damage to dopamine in PD causes
diff to control muscles
- delay inition of movement (bradykinesia)
- increase muscle tone (rigitiy)
- resting tremor
- shuffling gait
64
poor thiamine intake or abstoption can lead to
Wernicke encephalophy
65
wernicke encephalopahy meanifestations
- altered mental status
- oculomotor dyfunction
- ataxia
66
elevated blood lvels treatmened
no antidote for etoh gotta wait
67
alcholl abusers suffer from
poor nutrtion and improper diet such as thiamine
68
seizure phases
prodromal- warning signs before aural
aural- might exp cisual or sensory changes before seizure
ictal- seziure
postictal- confusion, reocvering from seizure, headahce,
69
epilepsy
chronic seizure actv
70
epilepsy clients require
life long anticonvulsanrs
71
seizure triggers
etoh excessively
- sleep dep
- stress
72
epilpesy education
- wear med idenfitication bracelet
- use non hormonal bith control if using phentoyin
- dont stop anticonvusants abriptylu bc it increases risk for seizure
73
coup- countrecoup head injury
head strikes an object and the brain receives an injury under the area of impact (coup), after which it rebounds to the opposite side of the skull and sustains injury on that side as well (contrecoup).
74
coup-contrecoup head injury common in
MVA
| shaken baby synrdrome
75
expressive aphasia
inabilty to express sporken words
| -can happen after TIA or stroke
76
autnomic dysreflexia
above t6 and unable to feel
77
signs of autnomic dsyreflexia
- HTN
- SWEATING
- NEAUSEA
- BRADYCARDIA
- HEADCHE
78
stimuli that causes autnomic
bladder distention (obstructed urinary cathter)
-fecal impaction
-tight clothing (shoelaces and waistbands)
REMOVE STIMULI TO PREVENT STROKE
79
how to lower bp
elevate the bed
80
decrease risk of aspiration pneumonia
left side/lateral side because the emesis will drain out of the
mouth
-turning q 2 hours helps prevent stasis BUT DOES NOT PREVENT ASPIRATION
-listening to breath sounds DONT PREVENT ASPIRATION
81
carotid endarectcomy
remove plague from the carotid artery to improve cerebral perfusion
82
FAST
facial dropping
arm weakness
speech diff
time of onset
83
do not make clients who have uncreases icp
TO COUGHHHHHH and deep breatheeee
84
skipped
28
85
broca (expressive )aphsia
can comprehend sppech but demonstrate sppech diff
- speech is hsort, limited prases that make sense but require great effort and freeq omission of smaller words such as "and" "is"' "the"
- FRONTAL LBE
- they are aware of their deficits and can become dustrated eaisly
- nonfluent speech
86
wenicke (receptive) aphsia
unwarre of their speech impairment
- termpral
- cant comprehend spoekn or wirtten word
- exhibit long but meaningless psech pattern
- flient and vloluminous but lacks meaning
- comprehension is dimished by the client
87
global aphsia
inability to read, write, or understand speech. This is the most severe form of aphasia.
88
stroke and permissive HTN
HTN is required for the first 24-48 hours to allow perfusion but no more than 220?120
we want the bp to be around 170 mmhg and not below that
89
prior to lumbar
empty the bladder
-sitting upright or recumbent postion
(sitting poistion or left side with ke=nees drawn up like fetal position)
-sterile needle inserted into L3/4 or L 4/5
-pain may be felt radiating down the leg and is temporary
90
after lumbar procedure
lie flat WITH NO PILLOW for 4 hours to reduce spinal leak and headahce
2) increase fluid intake for at least 24 hours to prevent dehydration
91
bel pasly teaching
Eye care: Use glasses during the day; wear a patch (or tape the eyelids) at night to protect the exposed eye. Use artificial tears during the day as needed to prevent excess drying of the cornea (Option 1).
Oral care: Chew on the unaffected side to prevent food trapping; a soft diet is recommended. Maintain good oral hygiene after every meal to prevent problems from accumulated residual food (eg, parotitis, dental caries) (Options 3 and 4).
(Options 2 and 5) Vision, balance, consciousness, and extremity motor function are not impaired with Bell's palsy. SO THEY CAN DRIVE and dont need cane
92
amyotrophic lateral scleoris ALS signs
```
muscle weakness
twiching
muscle spasms
diff swallowing
diff speaking
RESP FIALUREEE
```
93
survival of ALS
3-5 years after dignosis NO CURE
94
treatent of ALS
symtom management
-resp support (BIPAP OR VENT)
-eeding tube with enteral nutrition
-mobility assistive decides such as walker and wheechair
-consnitpation NOT diarhrea BC OF DECREASE MOBILITY
-communication assitive devices (alphabet boards and computers)
-
95
resting tremor
parkinsons
96
alzhmiers disease injury prevention
arrange furniture to alow free movmenet
-locks or stairwells and outside doors
-label doors
-provide night light in sleeping area to prevent falls and aid in orientaion and decreased ilusions
-Medical identification/location devices (eg, bracelets, shoe inserts) in case the client wanders outside the designated area (Option 2)
-LOCK ALL MEICATIONS AND DONT DO TEH WEEKLY PILL CONTAINER
Decreased water heater temperature and "hot" and "cold" labels on faucets to prevent burns
Household hazards (eg, gas appliances, rugs, toxic chemicals) removed to prevent injury
97
arteriovenous maformation (AVM)
tangle of veins and srteries
98
arteriovenous malformation (AVM) treatment
bp control
99
arteriovenous malformation (AVM) complciation
inctrecranial bleeding as the veins are weak and dilated so they can eaisly rupture
100
first signs of hemm
nueorloic changes
severe sudden headache
NV
101
arteriovenous malformation (AVM) education
avoid heavy excercises bc this increases bp
| -
102
hemm and ischemic stroke
Ischemic stroke occurs when circulation to parts of the brain is interrupted by occlusion of cerebral blood vessels by a thrombosis or embolus. Hemorrhagic stroke occurs when a cerebral blood vessel ruptures and bleeds into the cranial vault. Both types of stroke result in brain tissue death without prompt treatment.
103
tpa
ishcmic stroke unless contrindicatied (active bleeding, uncontrolled HTN, anueysm)
-must adm within .5 hours from onset of he symtoms
104
conussion signs
- A brief disruption in level of consciousness
- Amnesia regarding the event (retrograde amnesia)
- Headache
105
concussion education
fam membes should observe them
- dont particpate in atelctic or strenous actv for 1-2 days
- rest and light diet
106
serious brain injury that are not expected with simple concussion
worsening of headache and vomiting (ICP)
- sleepiness or confusion (ICP)
- visual changes
- weakness ot nombess of part of the body
107
what should be avoided following head injury
opiod meds because the SE of opoiods might be misitnerpreted as symtoms of worsening of head injury
- avoid etoh and other cns depressants
- avoid driving, using heay machinerym contact sports, taking hot baths for 1-2 days
- use nsaids or non narcotics instead
108
quadriplegia
lower limbs are paralyzed and partial paralyis or complete paalysis of the upper ext
109
piority of quadripligia
airway and o2 so assess breath sounds
| -vital capicity and tidal volume and abg
110
risk factors for stroke
```
DM
high chloesterol
HTN
smoking
obesity
older age
geentic
```
111
signle most modifiable risk factors in stroke
HTNNNN
112
stroke can be reduced 50% by
app treatment for HTNNN
113
epidural hematoma bleeding
arterial
114
epidural hematoma charactersitc
lose consciounsess at time of impact and then regains the consicouness quick and feels well for some time (lucid interval)
it is then followed by a quick decline in mental function and can progress into coma and death
115
emergnecy dgnosis and treatment needed for epiural hematoma to prevent
brain stem hernimation
116
cushing traiad signs
loc is the earliest sign
late: bradycardia, increases sbp with widening pulse pressure
- slowed irrgular resp (cheyne stokes)
117
cushing triad
later sign and does not appear until ICP is icnreased for some time
118
cushing traid indicates
brain stem compression
119
Homonymous hemianopsia
loss of one half of the field of vision on the same side in both eyes.
120
parietal
sensory input
| sensation
121
frontal
order processing
personality
-beh changes if damaged
122
temportal
visual and audiroty and past expericnes
| -if injured clients cannot understand verbal or written language
123
occiptal
vision
124
spinal immbolization procedure
N - Neurological examination. Focal deficits include numbness and decreased strength.
S - Significant traumatic mechanism of injury
A - Alertness. The client may be disoriented or have an altered level of consciousness (Option 2).
I - Intoxication. The client could have impaired decision-making ability or lack awareness of pain (Option 1).
D - Distracting injury. Another significant injury could distract the client from spinal pain.
S - Spinal examination. Point tenderness over the spine or neck pain on movement (if there is no midline tenderness) may be present (Option 5).
125
aphasia
aka dysphasia
126
receptive aphasia
impaired comprehension of speech and writing. A client with receptive aphasia may speak full sentences, but the words do not make sense. The nurse should speak clearly, ask simple "yes" or "no" questions, and use gestures and pictures to increase understanding.
127
expressuve aphsia
impaired speech and writing. A client with expressive aphasia may be able to speak short phrases but will have difficulty with word choice (Option 1). The nurse should listen without interrupting and give the client time to form words. A client may have one type of aphasia or a combination of both, and the severity will vary with the individual.
128
apraxia
loss of the ability to perform a learned movement (eg, whistling, clapping, dressing) due to neurological impairment.
129
Dysarthria is
s weakness of the muscles used for speech. Pronunciation and articulation are affected. Comprehension and the meaning of words are intact, but speech is difficult to understand (eg, mumble, lisp).
130
cerebellum major functiosn
coordination of voluntary mmovmenets
| maintence of balance and posture
131
how maintence of balance is tested
first watch their normal gait and then gait on heel to toe, on toes, and on heels
132
coordination testing
Finger tapping – ability to touch each finger of one hand to the hand's thumb (Option 4).
Rapid alternating movements – rapid supination and pronation
Finger-to-nose testing – clients touch the clinician's finger and then their own nose as the clinician's finger varies in location
Heel-to-shin testing – client runs each heel down each shin while in a supine position
133
neuro assessment
Glasgow Coma Scale (GCS)—best eye, verbal, and motor responses. Best verbal response assesses orientation to person, place, and time (time is the most sensitive).
Pupils—equal, round, response to light, and accommodate (PERRLA)
Motor—strength and movement in all four extremities
Vital signs—especially any signs of Cushing's triad of bradycardia, bradypnea/abnormal breathing pattern and widening pulse pressure (the difference between systolic and diastolic blood pressure readings). The nurse is assessing for signs of increased intracranial pressure (ICP).
134
absence seziures
Daydreaming episodes or brief (<10 seconds) staring spells
Absence of warning and postictal phases
Absence of other forms of epileptic activity (no myoclonus or tonic-clonic activity)
Unresponsiveness during the seizure
No memory of the seizure
135
menegitis signs
```
fever
headache
n/v
nuchal rigifity
icp
phtophobia
alterned MS
```
136
For bacterial meningitis with sepsis
fluid resuscitation is the priority to increase BP
137
, interventions and prescriptions for a client with sepsis and meningitis may include:
Administer vasopressors.
Obtain relevant labs and blood cultures prior to administering antibiotics.
Administer empiric antibiotics, preferably within 30 minutes of admission (Option 1). This client will continue to decline without antibiotic therapy.
Prior to a lumbar puncture (LP), obtain a head CT scan as increased ICP or mass lesions may contraindicate a LP due to the risk of brain herniation (Option 4).
Assist with a LP for cerebrospinal fluid (CSF) examination and cultures (Option 3). CSF is usually purulent and turbid in clients with bacterial meningitis. CSF cultures will allow for targeted antibiotic therapy.
138
essential part of discharging client with head injury is
ensuring that a respobile adult will check their LOC
139
return back to ER if you have the following after head injury
Change in level of consciousness (eg, increased drowsiness, difficulty arousing, confusion)
Worsening headache or stiff neck, especially if unrelieved by over-the-counter analgesics
Visual changes (eg, blurring)
Motor problems (eg, difficulty walking, slurred speech) (Option 3)
Sensory disturbances
Seizures
Nausea/vomiting or bradycardia (indicates IIC
140
neuro examination should be done by a
clinician not fam or anyone else
141
Interventions to help decrease aspiration
swllowing 2 times before thaking another bite of the food
- thicekning liquids
- avoiding OTC cold meds bc they have antichloingeic properties which causes drowniess and derreased salvia and dry mouth and salivia helps with swllowing
- sit upright for 30-40 mins after meals
- brushing teeth and mouth wash before and after meals
- chin tuck
- smoking cessation
- smoking cessaition
142
status epulepticus
serious, life therening ermgency which a client has been seizuing fofr 5 mins or longer
143
2 common signs of STATUS epil
grunity
| dazed appearance
144
clients with what are at higher risk for seizures
hydropcephalus and ventriculoperitoneal shunt
145
number one proioty in SE
stopping the seizure act as long as theres airway and breathing so give IV benzo such as diapezma or lorazepam but rectal can be given too
146
aspiration prevention methods include
thicken liquids
ensure lcient is fully awake before eating so be careful the timing of meds
-elevate head of bed 90 degree and for 30 mins after meals and never place bed lower than 30
-ecnourage ti swllow by flexing the neck (chin to chest)
- monitored for coughing, gagging, and pocketing food.
147
When transferring a client from bed to chair the following are recommended for client safety:
Clients should wear nonskid shoes (first step)
Make sure the bed and chair (wheelchair) brakes are locked
Use a transfer belt. A transfer belt worn around the client's waist allows the nurse to assist the client while maintaining proper body mechanics and safety.
Transfer the client toward the stronger (not the weaker) side. If the client is weak on the left side, ask the client to pivot on the right side.
148
never bend where
at waist bc you are using your back to lift
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