Neurological Assessment
The nurse assesses a patient’s Glasgow Coma Scale (GCS) score as Eye 3, Verbal 4, Motor 5. Which action is most important?
Continue frequent neuro checks and report any decrease in GCS; the current score (12) indicates moderate injury.
A patient with a head injury becomes restless and disoriented. What is the priority nursing action?
Assess for increasing ICP — restlessness is an early sign of neurological deterioration.
Which finding most strongly differentiates a hemorrhagic stroke from an ischemic stroke?
Sudden severe headache (“worst headache of my life”) with nausea and vomiting.
Which statement by a patient taking phenytoin indicates the need for further teaching?
“I can stop taking my seizure medication once I feel better.”
(Correct education: never stop abruptly; may cause status epilepticus.)
Which patient condition is a contraindication for a lumbar puncture?
Signs of increased ICP — may cause brain herniation.
When testing cranial nerve IX and X, which finding would indicate an abnormal response?
Absence of gag reflex or hoarse/absent cough response.
Which of the following should the nurse avoid in a patient with elevated ICP?
Suctioning frequently or allowing neck flexion — both increase intracranial pressure.
A client who experienced a left hemispheric stroke may require which specific nursing intervention?
Use of communication aids — due to aphasia and impaired language comprehension.
A patient has repeated tonic-clonic seizures without regaining consciousness. What’s the first action?
Maintain airway and administer IV lorazepam or diazepam.
After a lumbar puncture, the patient complains of severe headache when upright but relief when lying flat. What is the cause?
CSF leakage at puncture site — treat with fluids, bed rest, or blood patch if needed.
During a neuro exam, the patient demonstrates pronator drift when extending both arms. What does this finding indicate?
Possible motor weakness or upper motor neuron lesion (often seen with stroke).
The nurse notes irregular respirations and bradycardia in a TBI patient. Which intervention has highest priority?
Maintain airway, and notify provider immediately — indicates Cushing’s triad and impending herniation.
The nurse is preparing to administer IV alteplase (tPA). Which assessment finding requires immediate clarification before giving the drug?
History of GI bleed within the past 3 months or current anticoagulant use (↑ bleeding risk).
Which lab result would require immediate intervention for a patient taking valproic acid?
Elevated liver enzymes — indicates hepatotoxicity risk.
Before an EEG, which nursing instruction should be given?
Avoid caffeine, wash hair (no oils), and hold sedatives or antiseizure meds if ordered.
The nurse assesses a patient who opens eyes to pain, utters incomprehensible sounds, and withdraws from painful stimulus. What is the GCS score?
8 (E2 + V2 + M4) — indicates severe brain injury; prepare for possible airway management.
A patient with suspected increased ICP has orders for mannitol IV. What assessment finding best indicates this medication is effective?
Improved LOC and decreased ICP reading due to osmotic diuresis reducing cerebral edema.
During acute stroke care, what position should the nurse place the patient in?
Head of bed 30° with head midline — promotes venous drainage and reduces ICP.
The nurse prepares to discharge a patient with a seizure disorder. Which home safety instruction is most important?
Avoid swimming or bathing alone — risk of drowning during a seizure.
The EEG technician reports abnormal electrical discharges in the temporal lobe. Which type of seizure is most likely?
Focal (partial) seizure — originates from one hemisphere, often the temporal lobe.
A patient is unable to perform rapid alternating movements. Which lobe or structure is most likely affected?
The cerebellum — responsible for coordination and balance.
A client with a basilar skull fracture develops clear drainage from the nose. Which action is appropriate?
Test the fluid for glucose or halo sign — indicates CSF leak; do not insert NG tube or pack the nose.
The nurse notes a patient with a right-sided stroke ignores the left side of the body. What is this condition called and how should it be managed?
Left-sided neglect; place objects within the patient’s visual field and encourage scanning to affected side.
During a seizure, the patient suddenly stops convulsing but does not regain consciousness and begins shallow breathing. What is the priority nursing action?
Assess airway and respirations; prepare for suction or possible ventilation support.
A patient post-lumbar puncture develops clear drainage at puncture site and neck stiffness. What complication should the nurse suspect?
Meningitis — requires immediate provider notification and antibiotics.