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This manifestation is commonly associated with the aura phase of a migraine
What is Tunnel vision?
This is the most frequently used diagnostic test to diagnose brain tumors.
What is Computerized tomography (CT) scan?
Cloudy lens found with ____________ alter the passage of light through the eye lens, which might cause painless, blurred vision or glare.
What is cataracts?
_____________, __________ and ______________ helps prevent falls and allows the Alzheimer's client to move around safely.
What is adequate lighting, limiting throw rugs, and installing handrails in multiple areas of the home?
_______________ is a risk factor for both tension and cluster headaches
What is stress?
This manifestation is caused by an excessive accumulation of endolymph fluid in Mèniére's disease.
What is vertigo?
This past medical history finding makes the client most at risk for developing Guillain-Barre Syndrome.
What is Respiratory or gastrointestinal infection during the previous month?
Removing all ___________ is crucial before a CT scan to prevent interference with the magnets used during the imaging process.
What is metallic objects?
Teaching for minimizing episodes of pain for a client with trigeminal neuralgia should include to chew food on unaffected side, wash face with cotton pads, rinse mouth if tooth brushing is painful and _____.
What is avoid hot or cold food and fluids?
__________ is a hallmark manifestation of meningitis due to inflammation of the meninges.
What is severe headache?
Hypertensive clients who maintain BP less than _________ have a 42% lower incidence of strokes
What is 130 mm Hg?
Open-angle glaucoma develops slowly over time but progressively causes _____________ against the optic nerve due to a _________ in the amount of ______________
What is increased ocular pressure; decrease aqueous humor?
Assessing ________ function is crucial in determining any deficits that may be directly related to the stroke, such as _____________ or ________.
What is cranial nerve; facial weakness or visual changes?
When dealing with an agitated client the nurse should use this intervention first, since it is the least restrictive method.
What is place a seat alarm in the client's chair?
These complications should be monitored for these complications. {there are 3 of them}.
What is hypotension, absence of bowel sounds, and weakened gag reflex?
This activity can prevent elevations in intracranial pressure.
What is exhaling during repositioning?
A person with a concussion may experience this manifestation.
What is sensitivity to light?
The Glasgow Coma Scale (GCS) is used to assess the extent of _________ and ________ the client's responsiveness to treatment.
What is impaired consciousness and monitor?
This is an intervention for surgical treatment for a supratentorial brain tumor.
What is elevate the HOB to 30*?
What assessment finding would indicate that the client is developing meningitis.
What is a positive Brudzinski's sign?
These are the signs of increased ICP
What is restlessness, irritability, confusion, decrease in LOC or change in speech?
This type of seizure is noted that the episode only lasts for several seconds and there is brief jerking of the extremities.
What is myoclonic?
This intervention should be implemented for a client with a cerebral aneurysm.
What is encourage to exhale through mouth during defecation?
_______________ are a key symptom of stroke and should prompt the FAST assessment
What is speech difficulties?
What is sit to put on pants and shoes, try to exercise everyday and rest when tired, remove all loos rugs from the house, use walker at all times?
This technique is used to test the client's peripheral response to pain in an unconscious patient to assess the motor and sensory function after a head injury.
What is Nailbed Pressure?
Cerebral edema is caused by ______ ______ flowing from the _________ space to the _______ area of the brain.
What is cerebrospinal fluid; intraventricular; interstitial?
The nurse can help the client with Guillain-Barre syndrome with ascending paralysis cope with being intubated by providing information, giving __________, and encourage _______.
A patient with homonymous hemianopsia should be reminded of this to help overcome the deficit.
What is turn his head to scan the lost visual field?
Creating _________________ is a well-known strategy to help alleviate discomfort during a migraine.
What is a quiet, dark environment?
Clients who have spinal cord injuries at the fifth cervical vertebrae and above might be able to use a _____ - ______ _______ for mobility.
What is sip-and-puff device
The client with Guillain-Barre syndrome is at risk for ____________ because of ___________. Intubation tray should be available at bedside. The client is also at risk for ________, with necessitates the use of electrocardiographic monitoring.
What is respiratory failure; ascending paralysis; cardiac dysrhythmias?
These vital signs are an indication that the intracranial pressure is rising in a patient with a head inury.
What is increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure?
The __________nervous system regulates the body's response to _________stimulus.
What is peripheral; external?
When caring for a client who has dementia the nurse should provide a calm environment with minimal stimulation, keep a constant caregiver, avoid confrontation and __________.
What is limit the client's choices for daily activites?
Cushing's Triad consists of _______, ___________ and __________ as a response to increased intracranial pressure.
What is hypertension, bradycardia, and irregular respirations?
This environmental modification is most effecting to reduce agitation in an Alzheimer's client.
What is reducing stimuli, like noise and clutter?
This is an expected finding with a brain tumor.
What is hyporeflexia?
neurological deficit involving the limbic system assessment findings will include ___________.
What is affect is flat, with period of emotional lability?
This finding is an indication that cerebrospinal fluid is present.
What is the fluid separates into concentric rings and test positive for glucose?
Transection is a complete severing of the spinal cord. A complete SCI is severe and causes ____ _____ ____ & the ____ _______ ____ ______ below the level of the damage.
What is loss of all sensation & ability to control movement?
These measures can minimize occurrence of autonomic dysreflexia. {There are 3}
What is: keep linen wrinkle-free; prevent unnecessary pressure on lower limbs and turn and reposition Q2hr?
A client who has a halo device after a cervical spinal cord injury should be educated to use a straw for drinking, be careful with ambulation as the device alters balance, complete pin care every _________ hours and restricted _________.
What is every 8-12 hours; restricted driving (they are not aloud to drive d/t impairment in range of vision?
Retinal detachment occurs when retinal tissue, in the posterior of the eye, __________________ that provide oxygen and nourishment to the retina.
What is pulls away or detaches from the blood vessels ?
The nurse should recognize that _________is a risk factor for stroke that is modifiable through diet, management of blood glucose levels, and exercise.
What is hypertension?
This finding could indicate that spinal shock persists following a spinal cord injury.
What is flaccid paralysis?
_____________ can lower intercranial pressure (ICP) by decreasing partial pressure of carbon dioxide (PCO2), thus causing vasoconstriction which decreases ICP.
What is Hyperventilation?
These steps should be taken when a client experiences a seizure. {there are 3}
What is: loosen restrictive clothing; remove pill and raise padded side rail, and position client on side with head flexed forward?
Cushing's Triad includes ________of pulse pressure, bradycardia, and irregular breathing patterns as intracranial pressure increases. This stimulates a sympathetic response that allows for an increase in blood pressure and heart rate, thus helping with brain perfusion, preventing __________ ________.
What is widening; brainstem ischemia?
This activity helps to prevent myasthenic and cholinergic crises in a patient with myasthenia gravis.
What is taking medications as scheduled?
In a TBI the mechanical force damages blood vessels and ______ _______ ________, leading to a series of chemical reactions that causes ______ ______ _____, ischemia, blood-brain barrier breakdown, and edema.
What is disrupts cellular function; blood vessel damage?
The client with __________ glucose, as evidence by an __________ ___________ is more prone to metabolic cerebral edema.
What is uncontrolled; increased hemoglobin A1C?
this observation would indicate that a patient is adapting most successfully after a stroke.
What is consistently using adaptive equipment in dressing themselves?
A client who has complete right-sided hemiparesis from a stroke will have these conditions. {there are 3}
What is aphasia, weakness on the right side of the body and weakness on the right side on the face and tongue?
These actions should be taken for a client being admitted for seizure and has seizure precautions ordered. {there are 4}
What is: pad the side rails, place an airway at bedside, place oxygen & suction equipment at the bedside, and flush the IV to ensure it's patent?
These findings would be expected in a client with a herniated cervical intervertebral disc. {there are 3}
What is tingling in the arms, shoulder pain and a stiff neck?
These assessment findings would be expected in a client who has meningitis. {there are 4}
What is headache, nuchal rigidity, seizures and photophobia?
These questions should be included in an assessment in a client with a throbbing headache. {there are 4}
What is: any nausea and vomiting, bothered by lights, any strange smells, weakness before the headache or now?
These instructions should be included in discharge teaching for a client with Parkinson's disease. {there are 3}
What is: encourage to walk regularly, provide fresh fruits and vegetables, and teach how to use a walker?
These instructions should be included in discharge teaching for a client with epilepsy. {there are 4}
What is refrain from climbing ladders, do not go swimming alone, avoid using power tools, place client on the floor if having a seizure and refrain from driving for at least 6 months?
These could trigger autonomic dysreflexia in a client with a spinal cord injury at the first thoracic level.
What is sexual intercourse, surgery below level of injury and urinary tract infections?
These cues may be seen in a client with increased intracranial pressure and a worsening neurologic condition. {there are 3}
What is decreasing Glasgow Coma scores, changes to pupil size and shape and swelling of the optic nerve?
These instructions should be including in discharge teaching for a client with a head injury. {there are 3?}
What is avoid activities that could lead to head trauma, seek emergency care for sudden loss of consciousness, and use both verbal & written information for better understanding?
What is: worsening headache, increased confusion, sudden loss of consciousness, inability to awaken, slurred speech and restlessness and agitation?