neuro nclex Flashcards

Standardized Tests
Terms Definitions
Tonic Seizure
Muscle stiffness, rigidity
Linear skull fractures
blunt trauma
Hyperflexion injuries
whiplash - shaken baby
Dopamine
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
Assess cranial nerves;

Tongue protrusion
Hypoglossal XII
true
partial seizures are produced (at least initially) by electrical impulses in a relatively small part of the brain.
This drug decreases inflammation within brain tissue:
Coricosteroids:
Dexamethasone (Decadron)

reduces edmea from rain tumors, trauma, abscsses, infarction, and hemorrrhage

take with Zantac as steroids predispose gastric ulcers
Intracranial hemorrhages
dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
This drug does not precipitate with dextrose. Can be given IV push, is an antiseizure med:
Fosphenytoin
Assess cranial nerves;

Salt and sugar discriminations
Facial VII
Myoclonic Seizure
sporadic jerks, usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent, these seizures may result in dropping or involuntarily throwing objects.
Slow, irregular respirations
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
"Grand Mal" or Generalized tonic-clonic
Unconsciousness, convulsions, muscle rigidity
Paralysis of lateral gaze indicates a lesion of cranial nerve:

a. II
b. III
c. IV
d. VI
b. III
Surgery on this tumor is usually the only tx needed. Altho this type of tumor is benign, it tends to reoccur
Miningiomas
Epidural hematoma
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
acceleration injury
head is suddenly forced to stop or start moving, or to turn rapidly.
Parkinson's disease
A gentleman from Peru is brought by his wife to the clinic. He does not speak English and she is translating for him. You learn that he was a manganese miner for over twenty years. This gentleman is at particular risk of developing symptoms of which of the following diseases?
nsg intervention for spinal injury
vitals/turn freq/call light close/ ROM
A patient is suspected of having a cranial tumor. The signs and symptoms include memory deficits, visual disturbances, weakness of right upper and lower extremities, and personality changes. The nurse recognizes that the tumor is most likely located in th
A. frontal lobe.
4 things that protect the brain
meningies, csf, blood-brain barrier, skull
Decrease in LOC
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
CN III
A trauma nurse is caring for a patient that sustained trauma to the head. She notices that the patient has a "blown pupil" (one pupil is fixed a dilated). This is caused by intracranial swelling and brain herniation. A blown pupil is caused by disruption of which cranial nerve?
Vasogenic cerebral edema increases intracranial pressure by

A.shifting fluid in the gray matter.
B.altering the endothelial lining of cerebral capillaries.
C.leaking molecules from the intracellular fluid to the capillaries.
D.altering the osmotic gradie
B.altering the endothelial lining of cerebral capillarie
Damage to cranial nerve I
A 78-year-old client is admitted to the Emergency Department (ED) via emergency medical service (EMS) with complaints of severe diarrhea with resultant weakness and signs of dehydration. Discussion with the significant other reveals that the patient continually eats spoiled foods. Which of the following might be most directly related to this patient's behavior?
Unequal pupil size
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Evaluate urine specific gravity
A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?
A patient with intracranial pressure monitoring has pressure of 12 mm Hg. The nurse understands that this pressure reflects

A. a severe decrease in cerebral perfusion pressure.
B. an alteration in the production of cerebrospinal fluid.
C. the loss of aut
A patient with intracranial pressure monitoring has pressure of 12 mm Hg. The nurse understands that this pressure reflects

A. a severe decrease in cerebral perfusion pressure.
B. an alteration in the production of cerebrospinal fluid.
C. the loss of autoregulatory control of intracranial pressure.
D. a normal balance between brain tissue, blood, and cerebrospinal fluid.
Quadriplegia with gross arm movement and diaphragmic breathing
After falling 20', a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Basilar skull fractures
Caused by a blow to the back of the head, characteristic signs: blood in the sinuses; a clear fluid called cerebrospinal fluid (CSF) leaking from the nose or ears; raccoon eyes
The nurse is alerted to a possible acute subdural hematoma in the patient who
A. has a linear skull fracture crossing a major artery.
B. has focal symptoms of brain damage with no recollection of a head injury.
C. develops decreased level of consciousness
C. develops decreased level of consciousness and a headache within 48 hours of a head
Place a tongue-blade in the patient's mouth to prevent blockage of the airway.
A patient in the hospital for observation after a presumed seizure is found thrashing about in his room. Which of the following would be an improper intervention?
Immobilize the client's head and neck
A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first?
Laceration of the middle meningeal artery
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?
A client with a high cervical spine injury
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
Decorticate
abnormal posturing that involves rigidity, flexion of the arms, clenched fists, and extended legs.
Clonic Seizure
repetitive, rhythmic jerks that involve both sides of the body at the same time.
deceleration injury
collision between a rapidly moving body part and a stationary object
Artificial tears
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Hypogeusia
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
Absence Seizure
short loss of consciousness (just a few seconds) with few or no symptoms. The patient, most often a child, typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are usually not aware that they are having a seizure, except that they may be aware of "losing time."
Atonic Seizure
sudden and general loss of muscle tone, particularly in the arms and legs, which often results in a fall.
Loss of lens elasticity
Which of the following physiologic changes would be expected in a patient with presbyopia?
Depressed skull fractures
high-energy transfer, such as a blow from a baseball bat
Dilated non reactive pupils
A client has been pronounced brain dead. Which findings would the nurse assess?
Rapid dilantin administration can cause cardiac arrhythmias
A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?
Inability to elicit a Babinski's reflex
The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?
Wrap her hands in soft "mitten" restraints
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?
Put the client in the high-Fowler's position
During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions?
CN IX and CN VII
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Back arched; rigid extension of all four extremities.
Which of the following describes decerebrate posturing?
Equal pupillary constriction in response to light
You are the nurse assigned to perform an eye assessment on an 80-year-old client. Which of the following findings during the assessment is considered normal?
"The lens is normally transparent
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
To immobilize the surgical spine
A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons?
The patient should be placed on droplet precautions.
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache, stiff neck, subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit. The lights of the ER triage area seem to bother his eyes. Which of the following is an important part of caring for this patient?
Raise the head of the bed immediately to 90 degrees
A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?
Check the fluid for dextrose with a dipstick
A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?
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