neurological diseases
this issue involves inflammation of the protective membrane around the brain and spinal cord. patients may complain of a stiff neck and severe headache.
meningitis
assessing LOC assesses what topics?
person, place, time, situation
when testing CN I, what is a consideration for the patient to do prior to the assessment?
blow nose, if there is mucus, it may block scent.
olfactory nerve
recognize symptoms immediately, determine last-known-well time, activate the stroke response, and assess airway and swallowing. what is this issue?
CVA/ stroke
what is a spinal cord injury? what can result from it?
SCI is from traumatic disruption of the spinal cord, commonly from fractures, dislocations, or significant impact. it can result in numbness, loss of sensation, paralysis, and loss of bowel or bladder control.
identify the difference between dementia and delirium
Dementia: Usually gradual. Progressive decline in memory and cognition. Over months to years.
Delirium: Acute onset. Sudden change in attention and awareness. Develops over hours or days w/ fluctuating symptoms. Often associated with an underlying medical cause, (like infection)
A nurse evaluates a patient's ability to hear whispered words. Which cranial nerve is being assessed?
A. CN V – Trigeminal
B. CN VII – Facial
C. CN VIII – Vestibulocochlear
D. CN X – Vagus
c
GCS, define, what is a perfect score, what is the worst score?
glasgow coma scale assesses loc, 15 is perfect, 3 is the worst
mask like facial expression, forward-flexed posture, shuffling gait. from degeneration dopamine producing neurons in the brain.
parkinsons disease
an older adult suffered a spinal cord injury from a fall. they are partially immobilized, what are nursing considerations for this patient?
name 3
Fall prevention
Spinal immobilization and alignment
Respiratory and hemodynamic monitoring
Skin integrity and pressure injury prevention/DVT prevention
progressive mobility in later stages of healing
Bladder and bowel management
name 1 sensory nerve
name 1 motor nerve
name 1 mixed
Olfactory Sensory
Optic Sensory
Oculomotor Motor
Trochlear Motor
Trigeminal Both
Abducens Motor
Facial Both
Vestibulocochlear Sensory
Glossopharyngeal Both
Vagus Both
Spinal Accessory Motor
Hypoglossal Motor
define bradykinesia
slow movement
what is considered the early classic sign of myasthenia gravis
ocular muscle weakness, this results in diplopia and ptosis
Confusion and disorientation, inattention, memory issues, altered awareness and behavior, changes in sleep, hallucinations, fluctuating symptoms
Bells Palsy is a dysfunction ________ (cranial nerve and number) and results in sudden weakness or paralysis unilaterally of the face.
CN VII facial
define double vison
diplopia
Which nursing intervention is a priority for a client immobilized during the acute ascending paralysis phase of Guillain-Barre Syndrome?
A. Encouraging high-intensity active resistance training in bed
B. Repositioning the client every two hours and performing passive range-of-motion exercises
B
An older adult with peripheral neuropathy reports "pins and needles" sensation in both feet. Which instruction is most important for the nurse to emphasize regarding injury prevention?
A. Apply a heating pad to your feet for 20 minutes every evening to improve circulation.
B. Walk barefoot inside your home on carpeted surfaces to maintain foot muscle strength.
C. Soak your feet in warm water twice a day to soothe the nerve pain.
D. Inspect your feet daily using a mirror and always check bath water temperature with your hand or a thermometer.
d
what are the three cranial nerves that would be affected with myasthenia gravis (think early stages and its assessment)?
Oculomotor, Trochlear, and Abducens Nerves (CN III, IV, and VI)
DOUBLE POINTS
Define BEFAST, explain what you look for in each assessment of BEFAST, and what is it used for?
The BEFAST acronym for identifying a stroke.