Neuro Assessment
What are the three major components of a neurological assessment?
Mental status, cranial nerves, and motor/sensory function?
What are two early signs of increased ICP?
- LOC changes (restlessness, confusion, lethargy)
- Headache
- Visual disturbances
- Unequal pupils
What does “BE FAST” stand for?
- Balance
- Eyes
- Face drooping
- Arm weakness
- Speech difficulty
- Time to call 911
What should the nurse do first when a patient is having a seizure?
Turn the patient on their side and protect the airway?
What is the purpose of a lumbar puncture?
What is to collect CSF for analysis (infection, bleeding, ICP)?
What does a total Glasgow Coma Scale score of 15 indicate?
Full responsiveness?
What is Cushing’s Triad?
- Hypertension with widened pulse pressure
- Bradycardia
- Bradypnea (w/ Cheyne-Stokes)
What is the difference between ischemic and hemorrhagic stroke?
- Ischemic = blockage
- Hemorrhagic = bleeding
What is status epilepticus?
Continuous seizure activity without recovery between episodes
What position should the patient be in for a lumbar puncture?
What is side-lying with knees drawn to chest (fetal position)?
Which cranial nerve controls hearing and balance?
Cranial nerve VIII (Vestibulocochlear)?
What is the most common cause of an epidural hematoma?
Rupture of an arterial vessel between the skull and dura?
What is the most common risk factor for a stroke?
- Hypertension
- Atherosclerosis related
Name two medications used to control acute seizure activity.
Lorazepam and Diazepam
After a lumbar puncture, what should the nurse encourage the patient to do?
Drink fluids and lie flat to prevent headache?
How do you assess fine motor coordination?
Performing finger-to-nose or rapid alternating movements?
Name one nursing intervention to help lower ICP.
- Elevate HOB 30–45°
- Keep head midline & neutral
- Avoid coughing, suctioning, or straining
- Maintain airway & oxygenation (hyperoxygenation)
- Monitor: I&O, neuro function, electrolytes
- Decrease environmental stimuli
Which type of stroke often causes speech/language impairment?
Left-sided stroke
What are seizure precautions in the hospital setting?
- Padded side rails
- Bed low position
- Airway & suction available
- Turn side-lying after seizure
What should the patient avoid before an EEG?
Caffeine or sedatives
What is the earliest and most sensitive indicator of a change in neurological status?
Change in level of consciousness (LOC)?
What are two signs of a basilar skull fracture?
- Raccoon eyes (periorbital bruising)
- Battle’s sign (mastoid bruising)
- CSF leak from ears/nose → test drainage for glucose (“halo sign”)
What medication is used for an ischemic stroke if given within 4.5 hours of onset
Tissue plasminogen activator (tPA) A.K.A Alteplase
Why are grand mal (tonic-clonic) seizures dangerous?
Risk for:
- Hypoxia
- Aspiration
- Brain injury
What is the main purpose of an EEG test?
To assess electrical brain activity to diagnose seizure disorders