Don't be Nervous System
This part of the brain is the belle of the ball
What is...Cerebellum, the ballerina :)
List 4 warning signs of a stroke.
What is...FAST
Facial drooping
Arms drifting
Speech difficulty
Time to call 911
A patient with Parkinson's Disease received their dinner. YOU, the nurse caring for this patient opens the patient's meal tray and finds chicken breast, meatball soup, broccoli, and rice. WHAT ARE YOU GONNA DO ABOUT IT?
Send the meal tray BACK to the kitchen and let them know this patient should be avoiding protein while on Sinemet.
A patient is rushed into the emergency department. A CT scan was done and evidence of Increased Intracranial Pressure was found. Which two medications should the nurse anticipate for the care of this patient
What is...Mannitol and Lasix
A patient with Parkinson's Disease is frustrated and tired of having tremors at a rapid frequency. The nurse knows this symptom will improve during
What is...SLEEP
The nurse is caring for a hospitalized patient with a history of seizures who is receiving oral phenytoin sodium. Which would be included in the plan of care for this patient?
A. Monitoring intake and output
B. Providing oral hygiene, especially care of the gums
C. Administering medications 1 hour before food intake
D. Checking the heart rate before administering the phenytoin
B. Providing oral hygiene, especially care of the gums
Gingival hyperplasia is a normal finding when taking phenytoin sodium. Careful with oral care using soft-bristled toothbrush and follow-up visits to the dentist.
A nurse assess the patient in the intensive care unit and found a blood pressure of 300/60, a heart rate of 52, and a respiratory rate of 9
What is...Cushing's Triad
đ” stop takin' stop takin' i don't want to take pheny-more, I left my head and my heart on the dance floor stop takin', stop takin' I don't want to take pheny-more
I got my head and my heart on the dance floor. Eh, eh, eh, eh, eh, eh, eh, eh, eh, eh stop telephonin' me đ”
What is...drug holiday
A patient with receptive aphasia is frustrated because she is having difficulty conveying her needs.
WHAT ARE YOU GONNA DO ABOUT IT?
What is...White board and marker
A patient was admitted to the definitive observation unit 1 week after a stroke. The patient has been evaluated by a Speech Language Pathologist and is placed on a mechanical soft diet with thick liquids. How can the nurse prevent aspiration when the patient is eating
What is...chin tuck
A patient reports to the clinic of having ptosis, diplopia, dysarthria, and dysphagia
What is...Myasthenia Gravis
A client with a history of seizures is taking phenytoin for seizure control. The client arrives at the health care clinic, and a serum phenytoin drug level is drawn. The laboratory calls the nurse and reports a result of 10 mcg/mL. Which interpretation would the nurse make of this value?
A. The laboratory value represents a toxic level.
B. The laboratory value represents an inadequate drug level
C. The laboratory value is at the low end of therapeutic range
D. The laboratory value is at the high end of therapeutic range.
C. The laboratory value is at the low end of therapeutic range
The therapeutic serum drug level range for phenytoin is 10 to 20 mcg/L. A laboratory result of 10 mcg/mL is at the low end of therapeutic range.
A patient Glasgow Coma Scale recovering from head trauma went from 14 four hours ago, but now the patient's GCS score is 7
What is...INTUBATE!
The nurse explains the pathophysiology of which disorder involving which cranial nerve that involve unilateral facial flaccidity
What is...Bell's Palsy; CN VII
A patient who is on Levetiracetam reports to YOU, the nurse that she is having sudden paresthesias, visual field defects, and disorientation.
WHAT ARE YOU GONNA DO ABOUT IT?
What is...Seizure precautions
A patient is prescribed phenytoin (Dilantin) and had a loading dose. The patient's blood was drawn and his phenytoin level is 16. Upon discharge, what should the nurse anticipate for this patient before leaving the unit
What is...ensuring that the patient has someone to drive them home
A patient's MRI results present multiple lesions in the brain. Upon assessment, the patient presents nystagmus, ataxic gait, and dysphagia
What is...Multiple Sclerosis
The nurse is caring for a client following craniotomy who has a supratentorial incision. The nurse reviews the client's plan of care, expecting to note that the client would be maintained in which position?
A. Prone position
B. Supine position
C. Semi-Fowler's position
D. Dorsal recumbent position
C. Semi-Fowler's position
The client's head usually is elevated 30 degrees to promote venous outflow through the jugular veins.
What is...fiber, fluids, and stool softeners
This treatment is contraindicated for patients with hypertension, history of angina pectoris, and a history of a myocardial infarction
What is...Sumatriptan
A patient is rushed into the emergency department after a motor vehicle collision. There is evidence of minor scrapes and bruises. The patient was found to have a stroke before the accident. YOU, the nurse assess facial drooping of the left side of the face and arm weakness.
WHAT ARE YOU GONNA DO ABOUT IT?
What is...CT scan
Tyramine, nitrates, and MSG are contraindicated for which patient
What is...Headache and Migraines
A patient is admitted to the emergency department for having signs and symptoms of chorea, gait deterioration, emotional lability, and psychotic behavior
What is...Huntington's Disease
The nurse is caring for a 35-year-old client following a motor vehicle accident (MVA). The client has a complete transection of the cervical spine. Which interventions should the nurse anticipate to implement? (Select all that apply.)
A. Assist the client with repositioning every 2 hours.
B. Insert an indwelling urinary catheter.
C. Apply moisture chamber around each eye.
D. Prepare for immediate intubation.
E. Administer Enoxaparin (Lovenox) 40 mg SC once daily.
A, B, D, E
Choice A is correct because clients with a C7 transection are at increased risk of developing pressure ulcers due to immobility, sensory deficits, and nutritional deficits. Therefore, repositioning the client every two hours and implementing pressure relieving devices are priority interventions that the nurse would most likely implement as part of the client's care plan.
Choice B is correct because an indwelling urinary catheter is necessary to prevent urinary retention and monitor urine output. In addition, bladder distention can lead to autonomic dysreflexia in clients with spinal cord injuries.
Choice D is correct because clients with complete cervical transections require intubation to maintain airway and facilitate breathing in the setting of paralysis of the respiratory muscles.
Choice E is correct because the client with a spinal cord injury is at increased risk of venous thromboembolism (VTE) due to immobility and resulting venous stasis. Enoxaparin is a low molecular weight heparin anticoagulant given via subcutaneous injection to prevent deep vein thrombosis (DVT). The nurse should also expect to implement additional interventions to prevent DVT, including sequential compression devices or compression stockings.
Choice C is incorrect because a moisture chamber is required for clients with facial nerve (cranial nerve 7) injury. The facial nerve exits the base of the skull at the stylomastoid foramen and would not be affected by a cervical cord transection. The facial nerve is responsible for eye closure. When the facial nerve is transected, the client is unable to close the eye on the affected site and requires interventions such as a moisture chamber to prevent exposure keratopathy.
A patient is found to have arterial bleeding and blood collecting rapidly between the dura mater and the skull
What is...Epidural Hematoma
The nurse uses the Glasgow Coma Scale to assess a client with a head injury. The Glasgow Coma Scale score that indicates the client is in a coma is a score of?
What is...a GCS score of 3 to 8
A patient suspected to have Guillain-BarreÌ Syndrome. YOU, the nurse admit this patient immediately and according to YOUR assessment findings, the patient is unable to move his upper extremities.
WHAT ARE YOU GONNA DO ABOUT IT?
What is...assess for airway, lung sounds, and anticipate mechanical ventilation
A patient has been recently diagnosed with Myasthenia Gravis and has been prescribed anticholinesterase drugs (neostigmine and pyridostigmine). What other medication order does the nurse anticipate being in the MAR
What is...Atropine
A patient with Trigeminal Neuralgia was found to have an artery bulging and compressing on the patient's cranial number what and is to have a what procedure where the surgeon places an object between the offending artery and the cranial nerve to decrease the pain.
What is...CN V; Microvascular decompression
Mid conversation with the nurse, an 84-year-old long term resident of a skilled nursing facility suddenly falls silent, then stares across the room and says âIâm not sure when my wife and daughter will be home, but it shouldnât be too long. Why donât you wait for them?â The nurse knows the client is widowed and their daughter lives across the country. What action should the nurse take? (Select all that apply).
A. Measure oxygen saturation.
B. Prepare for a STAT CT scan.
C. Complete a full neurological assessment.
D. Contact the client's daughter to see if a visit is scheduled.
E. Obtain order for blood and urine tests.
A, C, E
Choice A âMeasure oxygen saturationâ is correct because hypoxia is a major cause of acute onset of confusion, especially in the elderly. If the client is hypoxic, the nurse should apply supplemental oxygen and notify the healthcare provider.
Choice C âComplete a full neurological assessmentâ is correct because a number of neurological causes (delirium, stroke, TIA, bleed) should be investigated as a potential cause of the clientâs change in mental status.
Choice E âObtain order for blood and urine testsâ is correct because the clientâs symptoms could be signs of an infection (e.g. a UTI and subsequent delirium) or electrolyte imbalances (e.g. hyponatremia). Obtaining blood and urine samples will aid in determining a cause (and subsequent treatment) of the clientâs acute onset of confusion.
Choice B âPrepare for a STAT CT scanâ is incorrect because while the clientâs symptoms could be a sign of a CVA, TIA, or intracranial hemorrhage, the nurse should complete a full neurological exam first. If the client was confused, and additionally displayed other symptoms on the neurological exam (e.g. facial drooping, slurring of speech, one-sided paralysis), then a STAT CT would be appropriate.
Choice D âContact clientâs daughter by telephone to see if a visit is scheduledâ is incorrect because the nurse should recognize that client is experiencing a change in mental status and prioritize interventions focused on assessment and subsequent treatment.