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The priority if one suspects a patient is having a stroke outside of a hospital.
What is call 911 or initiate emergency services?
Emergency medical intervention and transport to a stoke center is crucial-time is brain.
Benztropine is an anticholinergic medication given to patient's with Parkinson's disease to help decrease the rigidity and tremors associated with the disease. Because of this, patient's should be instructed to report these adverse effects.
What are dry mouth, difficulty voiding, constipation, and tachycardia?
Depending on the symptoms of the other adverse effects the urgency of reporting may vary, but urinary retention must be reported sooner than later.
This is the condition where a patient may have a severe headache, elevated temperature, lethargy, vomiting, rash, and photosensitivity and the nurse would monitor the patient's neurologic status and temperature every 2 to 4 hours to ensure there is not an increase in the patient's intracranial pressure.
What is meningitis?
A nurse should help a patient with MS develop this to help maintain muscle strength and coordination.
What is a schedule that includes periods of exercise followed by periods of rest?
This is a common sign of meningitis when the neck is flexed the hips and knees flex.
What is a positive Brudzinski's sign?
Because the greatest risk of to a patient from increased intracranial pressure (because it can lead to herniation of the brain and death); it is important to perform this including evaluation of the cranial nerves at least every 4 hours.
What are neurologic assessments?
Early neurological changes to be monitoring for include a decrease in level of consciousness, the development of Cushing's triad (severe hypertension, widened pulse pressure, and bradycardia), and changes in pupillary reaction. Also changes in cranial nerve function can be seen.
This is expected common manifestation of an epidural hematoma?
What is alternating periods of alertness with unconsciousness?
This could help enhance a patient's ability to comprehend and use language who has aphasia.
What is incorporate nonverbal cues?
A patient who had a stroke and is unable to recognize faces would have this hemisphere involved.
What is the right hemisphere?
The right hemisphere is involved with visual and spatial awareness.
This should be done when communicating with a patient who has global aphasia.
What is speak using sentences that contain on clear thought for better communication and understanding?
This intervention should be done if clear fluid is draining out the nose or ear.
What is allow the drainage to drip onto a sterile gauze pad.
This intervention allows for the collection of data without increasing the risk for further injury.
Because of the weakness of the muscles of the face and throat, this should be evaluated before administering medications to a patient with myasthenia gravis.
What is the ability to swallow?
The weakness of the muscles of the face and throat can increase the risk for aspiration.
This assessment monitors the motor function of C4 to C5.
What is apply downward pressure while the patient shrugs their shoulders upward?
This finding would be found if a Tensilon test is preformed and there was a 4 to 5 min period of improved muscle tone and strength.
What is a positive Tensilon test?
These are the most common triggers for myasthenic crises.
What are respiratory infection, not taking or taking too little of prescribed medication, surgery, and high environmental temperatures?
A nurse's priority is to monitor this when they suspect a patient with myasthenia gravis is experiencing a myasthenic crisis.
What is respiratory status?
A patient experiencing a myasthenic crisis is at risk for loss of adequate respiratory function and the patient may need to be prepared for possible mechanical ventilation.
The cause of Guillain-Barre Syndrome is unknown, but it usually follows this.
What is a viral infection?
This is the reason antihistamines may be helpful in controlling tremors in the early stages of Parkinson's disease.
What are anticholinergic effects?
Patients whose autonomic nerves have been affected by Guillain-Barre syndrome are at risk for developing this because both blood pressure and heart rate are controlled by the autonomic nervous system.
What is neurogenic shock?
Sensitivity to these should be expected with patient's who have had a mild traumatic brain injury, such as a concussion.
What is sensitivity to light and noise?
Because a patient with a spinal cord transection at the level of the fifth cervical vertebrae should have full neck, partial shoulder, back, biceps, and gross elbow movements, this would be a realistic rehabilitation goal.
What is the ability to feed themselves with the use of adaptive equipment?
A halo fixation device is used to stabilize a cervical fracture, and is secured with 4 screws inserted directly into the patient's skull to promote cervical alignment. These are the complications of this device.
What are loose pins, local infection, and scaring?
More serious complications include osteomyelitis, subdural abscesses, and instability. The nurse should monitor and report manifestations of infection such as fever and purulent drainage from pin sites.
When suspecting this, the nurse should prepare the patient for a STAT CT brain and place patient on seizure precautions, while monitoring the patient's blood pressure and PT/INR.
What is a hemorrhagic stroke?
This can help resolve the problem with homonymous hemianopsia.
What is place the food on the opposite side of the tray than the affected side?
By reminding the patient the food is on one side of the tray and to look for it there, will train the patient to scan the tray by moving their head and eyes, which will help to resolve the problem of homonymous hemianopsia.
Although the most common cause of autonomic dysreflexia is a distended bladder, per the safety and risk reduction priority setting, this initial action takes priority.
What is place the patient in a high-Fowler's position?
A high-Fowler's position is to assist in providing immediate reduction in blood pressure and intracranial pressure. A patient in autonomic dysreflexia is at risk for CVA resulting in severe hypertension.