Document this finding
1. Patient admitted for slurred speech at home, resolved by the time she came in the ER. Admitted for stroke rule out. You go in to do your scheduled neuro assessment and you notice that she has a left sided facial droop, left sided weakness, and expressive aphasia. What do you do?
Sensory function
Face
dull, sharp, and soft with paperclip and cotton ball or q - tip
Patient scores CIWA of 14, what orders do we anticipate?
You get a call from the EEG technician. She says that your patient under observation for seizures is having a grand mal seizure. What do you do?
Motor function
Balance: Romberg or walking heel to toe
Strength: push/pull, resistance, holding extremities off bed
Patient scores NIH of 8, previous was 4, what orders do we anticipate?
Diminished sensation of light touch on left side of face
You are assessing your patient who was admitted to the hospital with shortness of breath and is now being treated for pneumonia with IV antibiotics. He has been in the hospital for 24 hours. You notice during your assessment that he has tremors. You ask him about his tremors and he says that he gets tremors when he stops drinking his whiskey. What do you want to know and what do you do?
ask orientation questions: person, place, time
notice speech as questions are asked (clear or slurred)
Complete COMA scale when necessary
Patient has a seizure that is lasting 5 minutes, what orders do we anticipate?
Should also be on seizure medications (such as keppra)
You are the nurse getting a direct admit from a small hospital for congestive heart failure. What neuro assessment would be included upon admission?
LOC, movement, sensation, vital signs
Your patient care technician comes to you saying your patient is leaning to his right side in the chair and is unable to stand (previously up with stand by assistance). You have your medications ready for you patient who has been asking for them all morning and complaining about how long it is taking you. What do you do first?
Right lower extremity: no effort against gravity
You have a patient who is 2 days into his withdrawal from alcohol in the hospital. His last 3 CIWA assessments have been above 20. You have been giving him ordered Lorazepam 4 mg every hour with no improvement. What is your next step?
May need more critical care to manage symptoms to prevent complications
You are on your way to break because you have not eaten breakfast this morning yet. Another nurse is covering for you, but your patient care technician runs to you because your alcohol withdrawal patient is agitated, saying there are bugs crawling all over him, and won’t stay in bed. What do you do?
Could assess your patient and administer appropriate medications.