Neuro assessment
This initial clinical assessment must be established immediately upon admission so the nurse can identify subtle changes in a patient's neurological status over time.
"What is a baseline assessment (or baseline neurological status)?"
This diagnostic test must be performed immediately upon an acute stroke patient's arrival to rule out a hemorrhage.
What is a non-contrast head CT scan?
Immediately following an acute spinal cord injury, a patient enters a temporary state characterized by a complete loss of all sensory, motor, and reflex activity below the level of the injury, resulting in flaccid paralysis.
What is spinal shock?
When evaluating a patient's cognitive awareness, the LPN assesses for orientation to these four distinct spheres: person, place, time, and situation.
What is Orientation x 4?
alert and oriented to person, place, time, and situation
This chronic, severe neurodevelopmental disorder is characterized by a major disruption in a patient's perception of reality, presenting with positive symptoms like auditory hallucinations and delusions, as well as negative symptoms like social withdrawal and a flat affect. Usually occurs in early adult years.
What is schizophrenia?
What standard clinical tool is most commonly used by the care team to objectively score and track this neurological baseline?
What is the Glasgow Coma Scale (GCS)? (Measuring eye, verbal, and motor responses).
Normal values are 15, below or equal to 7 NOT GOOD
This neurological term describes a patient's inability to perform coordinated, purposeful movements or motor tasks (such as tieing their shoes or using a fork), even though their muscles are perfectly strong enough to do so.
What is dyspraxia?
A patient with a T6 spinal cord injury suddenly complains of a pounding headache, has a flushed face, and a BP of 180/100 mmHg. What is this problem called?
When evaluating a psychiatric patient's physical appearance, the LPN documents objective observations regarding these three specific markers of self-care and posture.
What are hygiene (or grooming), style of dress, and body language (or posture/eye contact)?
When a patient taking a first-generation antipsychotic (like haloperidol) develops a shuffling gait, pill-rolling tremors, and muscle rigidity, the LPN recognizes these extrapyramidal side effects collectively by this clinical name.
What is parkinsonian syndrome?
These three clinical signs make up Cushing's Triad, indicating dangerously high increased intracranial pressure (ICP).
What are bradycardia, irregular respirations, and a widening pulse pressure?
Tissue plasminogen activator (tPA) can only be administered to a patient experiencing ______ stroke, and it must be initiated within this strict time frame from when the patient was last seen normal. This time frame is ____?
What is ischemic stroke?
Within 3 hours
An acute spinal cord injury occurring at or above the C4 level can cause immediate death at the scene of an accident because it severs communication to this specific nerve, completely paralyzing the diaphragm.
What is the phrenic nerve?
A patient who is highly anxious and furious about being admitted to the psychiatric unit slams their fist on the table and screams at the nurse, "Why are you being so hostile and aggressive toward me?!"—utilizing this specific defense mechanism.
What is projection?
Projection is like a movie projector. You take an ugly feeling inside yourself, and you project it onto the screen of someone else.
This severe, potentially irreversible extrapyramidal side effect occurs after long-term use of antipsychotic medications and is characterized by involuntary, repetitive movements of the face, tongue, and limbs, such as lip-smacking and tongue-thrusting.
What is tardive dyskinesia?
When performing serial neurological checks on a patient following a head injury from a motor vehicle accident (MVA), the LPN monitors for restlessness, confusion, or increased lethargy, because this clinical finding is the earliest and most sensitive indicator of a worsening brain bleed or increased intracranial pressure.
What is an altered level of consciousness (or change in LOC)?
An LPN administers daily low-dose Aspirin and Clopidogrel (Plavix) to a patient recovering from a transient ischemic attack (TIA), explaining to the patient that the primary therapeutic goal of these long-term medications is to accomplish this specific outcome.
What is to prevent a future (or recurrent) stroke?
Once someone has had a TIA or a stroke, their risk of having another one shoots up drastically. These medications don't fix the damage that already happened; they act as an insurance policy to stop platelets from sticking together and creating a brand-new clot tomorrow.
This specific surgical procedure involves removing the bony posterior arch of a vertebra to decompress the spinal canal and relieve pressure on a crushed or swollen spinal cord following an injury.
What is a laminectomy?
When a patient has a severe spinal injury, herniated disc, or massive swelling, that hard bony roof begins crushing the soft spinal cord underneath. By performing a laminectomy, the surgeon essentially cuts away the roof of the bone. This gives the swollen spinal cord room to breathe, restores blood flow, and protects the nerve pathways from permanent, irreversible damage.
In a mental health assessment, the nurse identifies this specific nursing diagnosis when a patient's emotional response is triggered by a clear, identifiable, and real external danger—such as a physically abusive partner standing in the room.
What is fear?
Fear is the response to a specific threat and anxiety is response to a NON specific threat. If a patient is panicking because they are looking directly at a needle and they have a phobia of injections, that is Fear. If they are panicking while sitting in the waiting room just thinking about a potential diagnosis they might get next week, that is Anxiety.
Patients on MAOIs must strictly avoid foods containing this amino acid derivative to prevent a hypertensive crisis.
What is tyramine?
Following a lumbar puncture, the LPN instructs the patient to remain completely _____ in bed for 4 to 6 hours and push oral fluids primarily to prevent this severe, throbbing post-procedural complication caused by a leakage of cerebrospinal fluid (CSF).
What is laying flat?
Spinal headache
When the provider inserts the needle into the subarachnoid space to gather CSF, it leaves a tiny hole in the dura mater. If that hole doesn't seal up quickly, CSF leaks out. This drop in fluid volume reduces the "cushion" around the brain, causing the brain to sag slightly when the patient sits up, pulling on sensitive meninges and causing an excruciating, throbbing headache.
This specific clinical term describes a cerebrovascular accident (CVA) where the patient's neurological deficits—such as worsening paralysis or spreading numbness—continue to actively deteriorate or expand over a period of hours while under the nurse's care.
What is a stroke in evolution (or progressing stroke)?
A completed stroke means that the neurological damage has reached its maximum peak and has stabilized. For the carotid artery system (the most common type), a stroke is considered "completed" once the patient shows no further worsening or changes in their neurological deficits for a solid 18 to 24 hours.
This is the immediate, mechanical nursing action for a T6 spinal cord injury patient experiencing Autonomic Dysreflexia.
What is finding the cause and fixing it?
When evaluating a patient's coping mechanisms, the LPN assesses these specific factors, which encompass a person's shared heritage, traditional family roles, dietary customs, and generational beliefs regarding how to physically express pain or illness.
What are cultural beliefs (or cultural factors)?
What is the therapeutic range for Lithium, and what common electrolyte imbalance can cause Lithium levels to skyrocket?
What is 0.5 to 1.5 mEq/L. A drop in Sodium (Hyponatremia) causes the kidneys to hold onto Lithium, triggering toxicity. If a bipolar patient gets the stomach flu or sweats heavily out in the July heat, their sodium drops and their Lithium levels become toxic fast. Drink fluids with electrolytes.