Neuro Assessment
This rapid assessment method uses four categories: Alert, Voice, Pain, and Unresponsive.
AVPU
Tremor, rigidity, bradykinesia, and postural instability are the four cardinal manifestations of this neurologic disorder.
Parkinson Disease
During a tonic-clonic seizure, the nurse should position the patient this way to maintain the airway and decrease aspiration risk.
On their side
Photophobia, decreased LOC, and nuchal rigidity can be associated with this CNS infection.
Meningitis
Balance, Eyes, Face, Arm, Speech, and Time make up this stroke-recognition mnemonic.
BE FAST
Headaches associated with a brain tumor are often most severe during this time of day.
Awakening in the morning
A patient is drowsy but awakens easily when the nurse calls their name. The nurse should document this level of consciousness using this term.
Lethargic
Loss of this neurotransmitter contributes to the movement problems associated with Parkinson disease.
Dopamine
These two pieces of emergency equipment should typically be available at the bedside for a patient on seizure precautions.
Oxygen and suction
This diagnostic procedure obtains cerebrospinal fluid and plays a major role in diagnosing meningitis.
Lumbar puncture
The nurse should obtain this information as quickly as possible because it strongly affects treatment options for an acute stroke.
LKW time / symptom onset time
This corticosteroid may be administered to a patient with a brain tumor to decrease cerebral edema.
Dexamethasone (Decadron)
A patient opens their eyes only after vigorous painful stimulation. This describes the patient's level of consciousness.
Stuporous
A patient with Parkinson disease takes levodopa/carbidopa. The nurse should teach the patient to take this medication at this time to increase absorption.
Before meals
A patient suddenly loses muscle tone and falls to the floor. Afterward, the patient experiences confusion. This type of seizure is suspected.
Atonic seizure
A patient is suspected of having meningitis but demonstrates manifestations of severely increased ICP. The nurse knows this commonly performed diagnostic procedure may initially be unsafe.
Lumbar puncture
A patient arrives with sudden weakness and aphasia. Before assuming that the neurologic changes are caused by a stroke, the nurse should quickly assess for these two reversible conditions that can mimic neurologic emergencies.
Hypoglycemia & hypoxia
Following supratentorial surgery, the head of the bed may be elevated approximately this many degrees to promote venous drainage.
30 degrees
A patient's neurologic assessment reveals extension of the arms and legs, pronation of the arms, and plantar flexion. This abnormal posturing is typically associated with brainstem dysfunction.
Decerebrate posturing
A patient taking an MAO-B inhibitor for Parkinson disease should avoid aged cheese, cured meats, red wine, and beer because they contain this substance.
Tyramine
A patient taking phenytoin develops overgrowth of gum tissue. This adverse effect should prompt the nurse to emphasize frequent oral care and regular dental assessment.
Gingival hyperplasia
A patient with multiple sclerosis reports that weakness and blurred vision become worse after taking a hot bath. The nurse explains that what environmental factor can exacerbate MS symptoms.
Increased body temperature or heat
A patient suddenly develops the “worst headache of my life,” nausea, vomiting, photophobia, and neck stiffness. The nurse should suspect this type of stroke.
Subarachnoid hemorrhage (SAH)
Following a craniotomy, the nurse closely monitors this electrolyte because an abnormally low level can precipitate seizures.
Sodium
A neurologic patient's blood pressure rises to 182/68 mm Hg, heart rate decreases to 48/min, and respirations become irregular. The nurse recognizes this group of findings as a late indication of increasing ICP.
Cushing reflex, or Cushing response
A patient with progressive Parkinson disease coughs during meals, has difficulty swallowing, and has experienced weight loss. This member of the interprofessional team should be consulted to perform an extensive swallowing evaluation.
Speech Language Pathologist (SLP)
A hospitalized patient has experienced continuous seizure activity for more than 5 minutes. The nurse recognizes this life-threatening neurologic emergency.
Status epilepticus
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What IV medications may be used to stop the seizure?
A patient with MS experiences diplopia. The nurse anticipates using this intervention, switching sides periodically, to help manage the visual disturbance.
Eye patch alternated from eye to eye every few hours
A patient with an acute stroke has not yet undergone a swallowing evaluation. The family asks for water. This is the nurse's priority response.
Keep the patient NPO until swallowing ability has been assessed
The nurse caring for a patient with increased ICP avoids extreme neck flexion, extreme hip flexion, and clustering nursing activities because all three may contribute to this problem.
Further elevation of intracranial pressure