Nursing Assessment
Periorbital ecchymosis
What is raccoon's eyes?
Left-sided paralysis, Impulsive behavior, Impaired judgment.
What is a right brain CVA/Stroke?
Most common method to obtain cerebral spinal fluid for analysis
What is a lumbar puncture?
Characteristic plaque formation scattered throughout regions of the CNS
What is multiple sclerosis?
Administered to decrease inflammation?
What are corticosteroids?
Nursing care after a seizure.
What is making sure the airway is patent and reorient the patient?
This is what the Glasgow Coma Scale is based on
What are patient responses: eye opening, motor responses, and verbal responses?
An individual presents With tremor, muscle rigidity, and bradykinesia.
What is Parkinson's Disease?
Therapeutic phenytoin level
What is 10 to 20 mg/L?
Abnormal firing of neurons within parts of the brain.
What are seizures?
An osmotic medication for increased intracranial pressure.
What is mannitol?
Arrange the client’s environment so that items needed can be seen in their visual field.
What is homonymous hemianopsia?
When passively flexing the patient's neck there is an involuntary flexion of both legs.
What is Brudzinski's sign?
Raise the person to a sitting position. Remove the noxious stimulus (i.e. fecal impaction, kinked urinary catheter)
What is autonomic dysreflexia?
This test is quickly done to detect the presence of hemorrhage which will preclude treatment with antithrombotics.
What is a computed tomography (CT) scan?
Absence of brainstem reflexes, apnea, and coma or unresponsiveness
What is brain death?
ICP is monitored with an intraventricular catheter (ventriculostomy) using what reference range.
What is a normal ICP reference range of 5 to 15 mm Hg?
Patient teaching when discharged with a concussion.
What are observing for difficulty in awakening, difficulty speaking, confusion, seizures, severe headache, and vomiting?
Hypertension with a widening pulse pressure, bradycardia, and respiratory depression.
What is increased intracranial pressure?
The thumb and forefinger moving in a rotary fashion.
What is pill-rolling?
IV injection of an anticholinesterase agent that improves muscle contractility.
What is a Tensilon Test?
Cell-mediated and humoral immune attack on peripheral nerve myelin causing inflammatory demyelination.
What is Guillain-Barre Syndrome?
This gamma-aminobutyric acid (GABA) agonist is the first choice to treat spasticity.
What is Baclofen (Lioresal)?
The nurse observes for the following when administering Phenytoin (Dilantin) IV.
What is administering phenytoin slowly, observe for phlebitis, and flush line with normal saline?
Severe damage to the lower midbrain and upper pons.
What is decerebrate posturing?
A complete severing of a spinal cord lesion at C2.
What is tetraplegia?
Gold standard for a definitive diagnosis of meningitis.
What are bacterial culture and gram staining of CSF and blood?
Unilateral inflammation of the 7th cranial nerve is caused
What are inflamed, edematous, compressed nerves causing ischemic necrosis?
Prophylactic treatment of this problem because of side effects caused by long term use of steroids.
What is osteoporosis?
For a stroke patient this is completed on admission, at 24 hours, and at discharge.
What is the NIHSS (National Institutes of Health Stroke Scale) scale?