Neurological Disorders
A Glasgow Coma Scale score of 8 indicates this condition, requiring total nursing care.
What is a coma?
A fasting blood glucose level of less than this amount is considered a normal reference range for a client without diabetes.
What is 100 mg/dL?
A client with a vascular occlusion of the right lower extremity who reports cold feet should be given these to promote comfort.
What are slipper socks?
Incorrect or Correct? A client who extends their body part towards a painful stimulus is exhibiting a normal response.
What is an incorrect statement? A normal response to painful stimuli is pushing the stimulus away.
This sign of meningitis is present when a patient's hips and knees involuntarily flex upon passive flexion of the neck.
What is Brudzinski's sign?
This condition results in excessive urine output, hypovolemia, and hypotension due to a deficiency of antidiuretic hormone (ADH).
What is diabetes insipidus?
For a client with severe chest pain and shortness of breath, the nurse's first action should be this.
What is initiating oxygen therapy?
The nurse should immediately report this finding in a client with a recent closed head injury, as it is an early manifestation of increased intracranial pressure.
What is difficulty speaking?
This type of seizure is characterized by a loss of consciousness lasting 5 to 10 seconds, a blank stare, and minimal change in behavior
What is an absence seizure?
The nurse should expect this finding in a client with a capillary blood glucose of 48 mg/dL.
What are tremors, irritability, and anxiety?
This condition places a client at risk for an ischemic embolic stroke because a small thrombus might dislodge and travel to the brain.
What is chronic atrial fibrillation?
A client with a GCS score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response would have this expected finding.
What is opening his eyes when spoken to?
This age-related change to the nervous system can affect the speed and efficiency of nerve signal transmission.
What is decreased myelin sheath thickness?
A client with hyperthyroidism (Graves' disease) would be expected to have a TSH level that is below this reference range.
What is the expected reference range for a normal TSH level?
This is the earliest indicator of a client's cerebral status.
What is level of consciousness?
A client who has a spinal cord injury at T-4 is at risk for this condition, which can be prevented by preventing bladder distention
What is autonomic dysreflexia?
A common complication of brain tumors is this due to abnormal electrical activity in the brain.
What are seizures?
A nurse should provide high-fiber food and apply warm blankets to a client with this condition to address constipation and cold intolerance.
What is hypothyroidism with myxedema?
Following a stroke, a nurse should instruct a client with dysphagia and left-sided weakness to perform this action to prevent aspiration.
What is tilting her head forward when she swallows?
This type of posturing is indicated by plantar flexion of the legs and internal rotation of the lower extremities, and is a result of lesions of the corticospinal tracts.
What is decorticate posturing?