Assessment of Neuro
The Glasgow Coma Scale (GCS) assesses what areas of response to stimuli? Select all that apply:(Required)
A. Auditory response
B. Verbal response
C. Tactile response
D. Eye-opening response
E. Motor response
The answers are B, D, and E. The Glasgow Coma Scale (GCS) assesses THREE areas of a patient’s response to stimuli. This includes eye-opening response (E), verbal response (V), and motor response (M).
Select the main structures below that play a role with altering intracranial pressure:*
The answers are A, C, and D. Inside the skull are three structures that can alter intracranial pressure. They are the brain, cerebrospinal fluid (CSF), and blood.
The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter would the nurse monitor to determine the medication‘s effectiveness?
a. Blood pressure
b. Oxygen saturation
c. Intracranial pressure
d. Hemoglobin and hematocrit
ANS: C Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not parameters for evaluation of the effectiveness of the drug. O2 saturation will not directly improve because of mannitol administration.
Neurons in the brain are tasked with handling and transmitting information. There are different types of neurons, such as excitatory and inhibitory. Excitatory neurons release the neurotransmitter _____________, while inhibitory neurons release the neurotransmitter ________________.*
The answer is C. Excitatory neurons release glutamate and inhibitory neurons release GABA.
Which finding would the nurse expect when assessing a patient who is experiencing a cluster headache?
a. Nuchal rigidity
b. Unilateral ptosis
c. Projectile vomiting
d. Bilateral facial pain
ANS: B Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increased intracranial pressure. Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.
During the Glasgow Coma Scale (GCS) assessment the nurse applies a central painful stimulus to test the best motor response. Which of the following is NOT this type of stimulus?(Required)
A. Trapezius squeeze
B. Fingernail bed pressure
C. Supraorbital pressure
The answer is B. Fingernail bed pressure is a peripheral stimulus and tests the spinal cord’s response to pain. The trapezius squeeze or supraorbital pressure are central stimuli that tests the brain’s response to pain.
A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing?*
The answers are A, B, D, and E. These activities can increase IC
A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. How would the nurse record the patient‘s Glasgow Coma Scale score?
a. 9
b. 11
c. 13
d. 15
ANS: B The patient has scores of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.
A 7-year-old male patient is being evaluated for seizures. While in the child’s room talking with the child’s parents, you notice that the child appears to be daydreaming. You time this event to be 10 seconds. After 10 seconds, the child appropriately responds and doesn’t recall the event. This is known as what type of seizure?*
The answer is D. This is an absence seizure and is most common in children. The hallmark of it is staring that appears to be like a daydreaming state. It is very short and the post ictus stage of this type of seizure is immediate.
The nurse would determine that teaching about migraine headaches has been effective when the patient says which of the following?
a. “I can take the Topiramate (Topamax) as soon as I get a headaches.”
b. “I can drink a glass of wine to help me relax and prevent a headache.”
c. “I will lie down someplace dark and quiet when the headaches begin.”
d. “I will avoid taking aspirin and sumatriptan (Imitrex) at the same time.”
ANS: C It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate (Topamax) is used to prevent migraines. It must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal antiinflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches.
What Glasgow Coma Scale score usually requires intubation because the airway reflexes are affected?(Required)
A. 10 or less
B. 9 or greater
C. 8 or less
D. 10 or greater
The answer is C. If a patient has a GCS of 8 or less the patient is in a coma and usually requires intubation due to the inability of airway reflexes that protect us from aspiration to work
A patient is experiencing hyperventilation and has a PaCO2 level of 52. The patient has an ICP of 20 mmHg. As the nurse you know that the PaCO2 level will?*
The answer is C. An elevated carbon dioxide level in the blood will cause vasodilation (NOT constriction), which will increase ICP (normal ICP 5 to 15 mmHg). Therefore, many patients with severe ICP may need to be mechanical ventilated so PaCO2 levels can be lowered (30-35), which will lead to vasoconstriction and decrease ICP (with constriction there is less blood volume and flow going to the brain and this helps decrease pressure)....remember Monro-Kellie hypothesis.
An unconscious patient is admitted to the emergency department (ED) with a head injury. The patient‘s spouse and teenage children stay at the patient‘s side and ask many questions about the treatment. Which action is best for the nurse to take?
a. Call the family‘s pastor or spiritual advisor to take them to the chapel.
b. Ask the family to stay in the waiting room until the assessment is completed.
c. Allow the family to stay with the patient and briefly explain all procedures to them.
d. Refer the family members to the hospital counseling service to deal with their anxiety.
ANS: C The need for information about the diagnosis and care is very high in family members of acutely injured patients. The nurse would allow the family to observe care and explain the procedures unless they interfere with emergent care needs. A pastor or counseling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety.
Keeping the previous question in mind, the patient is now experiencing characteristics of a tonic-clonic seizure. The seizure started at 1402 and it is now 1408, and the patient is still experiencing a seizure. The nurse should?*
The answer is C. Tonic-clonic seizures should last about 1-3 minutes. If the seizure lasts MORE than 5 minutes, the patient needs medical treatment FAST to stop the seizure….this is known as status epilepticus.
While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action would the nurse take?
a. Insert an oral airway during the seizure to maintain a patent airway.
b. Restrain the patient‘s arms and legs to prevent injury during the seizure.
c. Time and observe and record the details of the seizure and postictal state.
d. Avoid touching the patient to prevent further nervous system stimulation.
ANS: C Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.
A patient with a traumatic brain injury has sustained multiple fractures to the face and eyes. When testing the best motor response, the nurse notes the patient is unable to perform a motor command based on a verbal stimulus. The nurse attempts to use a pressure stimulus to test the motor response. What type of pressure or painful stimuli should the nurse avoid in this patient?(Required)
A. Fingernail bed pressure
B. Trapezius squeeze
C. Supraorbital pressure
D. Toenail bed pressure
The answer is C. This patient has injuries to the face and eyes, therefore, supraorbital pressure (hence pressure applied to the notch of the eye socket under the inner brow) should be avoided. A trapezius squeeze would be more suitable.
External ventricular drains monitor ICP and are inserted where?*
The answer is B. External ventricular drains (also called ventriculostomy) are inserted in the lateral ventricle.
A 20-yr-old is admitted with a head injury after a collision while playing sports. After noting that the patient has developed clear nasal drainage, which action would the nurse take?
a. Have the patient gently blow the nose.
b. Check the drainage for glucose content.
c. Teach the patient that rhinorrhea is expected after a head injury.
d. Obtain a specimen of the fluid to send for culture and sensitivity.
ANS: B Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.
You have a patient who has a brain tumor and is at risk for seizures. In the patient’s plan of care you incorporate seizure precautions. Select below all the proper steps to take in initiating seizure precautions:*
The answers are A, E, F, and G. The bed needs to be in the LOWEST position possible, a pillow should be underneath the patient’s head to protect it from injury, AVOID using restraints (this can cause musculoskeletal damage).
A patient reports feeling numbness and tingling of the left arm before experiencing a seizure. Which type of seizure would the nurse suspect?
a. Focal-onset
b. Atonic
c. Absence
d. Myoclonic
ANS: A The initial symptoms of a focal-onset seizure involve clinical manifestations that are localized to a particular part of the body or brain; patients may have unusual feelings or sensations. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.
You’re assessing a patient's Glasgow Coma Scale at the bedside. What is the patient’s score based on these findings: when you arrive to the patient’s bedside the patient is looking around, the patient tells you they are at a concert hall and the year is 1960 (it is 2022) but they state their correct name, and they are able to open their mouth and stick out their tongue.(Required)
A. GCS 14 (E4 V4 M6)
B. GCS 11 (E3 V3 M5)
C. GCS 15 (E4 V5 M6)
D. GCS 13 (E4 V3 M6)
The answer is A: GCS 14 (E4 V4 M6)
Select all the signs and symptoms that occur with increased ICP:*
The answers are A, D, E, and F. Option B is wrong because bradycardia (not tachycardia) happens in the late stage along with an INCREASE (not decrease) in pulse pressure.
A patient who has a suspected epidural hematoma is admitted to the emergency department. Which action will the nurse expect to take?
a. Administer IV furosemide (Lasix).
b. Prepare the patient for craniotomy.
c. Initiate high-dose barbiturate therapy.
d. Type and crossmatch for blood transfusion.
ANS: B The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary.
The nurse is ordered to administer Lorazepam to a patient experiencing status epilepticus. As a precautionary measure, the nurse will also have what reversal agent on standby?*
The answer is B. Flumazenil is the reversal agent for Lorazepam, which is a benzodiazepine.
Which action would the nurse include in completing a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS)?
a. Assess for the presence of chest pain.
b. Inquire about urinary tract problems.
c. Inspect the skin for rashes or discoloration.
d. Ask the patient about any increase in libido.
ANS: B Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.