PN1400 Neuro Nclex Flashcards

Standardized Tests
Terms Definitions
Linear skull fractures
blunt trauma
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
Hyperflexion injuries
whiplash - shaken baby
partial seizures are produced (at least initially) by electrical impulses in a relatively small part of the brain.
Clonic Seizure
repetitive, rhythmic jerks that involve both sides of the body at the same time.
Intracranial hemorrhages
dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
deceleration injury
collision between a rapidly moving body part and a stationary object
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?
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.
"Grand Mal" or Generalized tonic-clonic
Unconsciousness, convulsions, muscle rigidity
Artificial tears
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
nsg intervention for spinal injury
vitals/turn freq/call light close/ ROM
Subdural hemorrhage
gap between the dura and the cortical surface of the brain.
Noxious stimuli
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
acceleration injury
head is suddenly forced to stop or start moving, or to turn rapidly.
Encourage the client to hyperventilate
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Epidural hematoma
The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with
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?
4 things that protect the brain
meningies, csf, blood-brain barrier, skull
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?
Activity of the brain
The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions?
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?
"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?
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?
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
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?
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?
Encouraging compliance with drug therapy to prevent loss of vision
A client with history of glaucoma was diagnosed by the community nurse as experiencing Visual Sensory/Perceptual Alterations R/T increased intraocular pressure. The plan of care should focus on:
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
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?
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?
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?
Limiting bladder catherization to once every 12 hours
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?
"Wake him every hour and assess his orientation to person, time, and place
An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions?
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