Neuromuscular Disorders
What information does the nurse include in an explanation of the disease process for Myasthenia Gravis?
“Your body has a disorder that destroys receptor sites at the neuromuscular junction, leading to decreased nerve conduction.”
What action is taken for a Glasgow Coma Scale (GCS) score of 15?
Record the finding; it is normal
Which factor places a patient at the greatest risk for an embolic stroke?
Carotid plaque
What fluid is anticipated for a patient with 36% TBSA burns?
Lactated Ringers
Which sign indicates ototoxicity from gentamicin?
Tinnitus/ringing in ears
After a lumbar puncture, a patient has an 8/10 headache. What is indicated?
Increase oral fluids
A patient is suspected of having Guillain-Barré syndrome (GBS) after a viral infection. What is the nurse’s priority?
Monitoring breathing pattern (due to risk of ascending paralysis affecting the diaphragm).
Which age-related change is expected in an older patient’s neuro status?
Slower reaction time
What is the concern for a patient with unilateral pupillary dilation who is unresponsive?
Cerebral herniation
Which electrolyte is a major indicator of massive cell destruction after a burn?
Hyperkalemia
What is the priority nursing action for a client with vertigo?
Protect from injury
For a patient with MG on corticosteroid therapy this finding would require immediate notification of the healthcare provider
Weight gain
Before beginning a Tensilon test for MG, the nurse ensures which medication is available as an antidote?
Atropine sulfate
A left pupil larger than the right in a patient with high ICP correlates to which nerve?
Left oculomotor nerve
In neurogenic shock, what reduces the risk of orthostatic hypotension?
Raising the head of the bed slowly
After airway/hemodynamics are stable, what is the next step in a secondary survey?
The AMPLE Mnemonic Breakdown: Allergies, Medications, Past Medical History, Last Oral Intake, Events/Environment
How do you administer ear drops to a 2-year-old child?
Pull pinna down and back
What should the nurse do first before suctioning a patient with increased ICP who is in a barbiturate coma?
Administer 100% oxygen.
What is the priority nursing action when administering pyridostigmine (Mestinon)?
Administering the medication 30 to 60 minutes before each meal (to maximize muscle strength for chewing and swallowing).
Which test is used to evaluate a patient's ataxia and gait?
Romberg test
These factors would contraindicate the use of rt-PA for a patient with an ischemic stroke
Using the Rule of Nines, what is the total body surface area (TBSA) percentage of the burns to the following areas: entire anterior chest & abdomen, the entire left arm, the perineum?
The most appropriate instruction for a patient with Meniere's disease to prevent a fall?
Sitting down at the first sign of feeling dizzy
A nurse's immediate priority action for an unconscious patient in the ER with a GCS of 8
Prepare for intubation / Airway management
Which neurotransmitter is primarily affected in MG?
Acetylcholine
A positive Babinski response in an adult is seen in which disorders?
MS or Traumatic Brain Injury
What is the action of verapamil (Calan) for a stroke patient?
Decreases blood pressure
How should the nurse treat a flash burn?
Apply cool towels intermittently
This condition causes abnormal blood vessel growth behind the retina
Wet Macular Degeneration
This form of Multiple Sclerosis involves a continuous increase in disability from onset without the "ups and downs" of attacks and recoveries
Primary progressive