Intracranial Pressure & Neuro Assessment
Stroke & Communication
Neurodegenerative & Seizure Disorders
Spinal Cord & Autonomic Dysreflexia
Neuro I know
100
What is the earliest indicator of increased ICP?
Change in LOC
100
A nurse is caring for a client with the following visual field deficit.
What is the most important information for the nurse to teach this client?
1. Scan the environment on the affected side
2. Use memory aids such as pictures
3. Plan for adequate rest
4. Make simple, non-risky decisions
1. 1. Scanning the environment can help a client with homonymous hemianopia overcome a loss in visual perception and prevent injury. Clients with other types of perceptual or memory loss may benefit from the interventions, nonspecific for a visual field loss, in the remaining answer choices.
CN: Physiological integrity; CNS: Physiological adaptation; CL: Apply
100
Deficient neurotransmitter in Parkinson’s?
Dopamine
100
Level of injury where dysreflexia occurs?
T6 or above
100
What is carbadopa/levodopa
200
Name the three parts of the Glasgow Coma Scale.
Eye / Verbal / Motor responses
200
Why must the “last known well” time be identified?
Determines eligibility for tPA within 3–4.5 hrs
200
What triad defines Parkinson’s?
Tremor, Rigidity, Bradykinesia
200
Two common triggers?
Bladder distension & fecal impaction
200
The nurse anticipates that stool softeners will be given to a client prior to repair of a cerebral aneurysm. Why would stool softeners be given to this client?
1. To stimulate the bowel due to loss of nerve innervation
2. To prevent straining, which increases intracranial pressure (ICP)
3. To prevent the Valsalva maneuver that can result in a reflex bradycardia
4. To prevent constipation due to osmotic diuretics
2. Straining when having a bowel movement, sneezing, coughing, and suctioning may lead to increased ICP and should be avoided when the potential for increased ICP exists. Stool softeners don't stimulate the bowel and aren't used in combination with osmotic diuretics. Although the Valsalva maneuver may lead to an increase in ICP, it does not prevent reflex bradycardia.
CN: Physiological integrity; CNS: Reduction of risk potential; CL: Apply
300
Which posture indicates brainstem injury?
Decerebrate posturing
300
Which type of aphasia prevents speaking but not understanding?
Expressive (Broca’s)
300
Medication to avoid with urinary retention?
Benztropine (Anticholinergic)
300
Early sign of autonomic dysreflexia?
Severe headache & sudden HTN
300
1. Elevate the head of the bed to reduce intraocular pressure
2. Preventing secondary acute tubular necrosis
3. Preparing to administer hypertonic saline or mannitol per provider order
4. Lower the head of the bed to improve cerebral perfusion
3. Hypertonic saline and mannitol promote osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Therefore these agents are often used as first-line agents to decrease ICP while preparing the client for surgery. Elevating the head of the bed can also help facilitate venous return, targeting a decrease in ICP, not intraocular pressure. Although it is important to closely monitor fluid and electrolytes, preventing acute kidney injury is secondary.
CN: Physiological integrity; CNS: Pharmacological and parenteral therapies; CL: Apply
400
State two interventions that lower ICP.
Elevate HOB 30° & keep neck neutral
400
BP 190/110 while on tPA — what’s your action?
Stop tPA, notify HCP → bleeding risk
400
Priority action during a seizure?
Turn patient on side & protect airway
400
First action when dysreflexia occurs?
Sit the patient upright
400
A client with a large cerebral intracranial hemorrhage was given mannitol to decrease intracranial pressure (ICP). What therapeutic effect should the nurse anticipate from mannitol?
1. Increased urine output
2. Pupils that are bilaterally 7 mm and nonreactive
3. Evidence of rebound cerebral hypertension
4. Normal blood urea nitrogen (BUN) and creatinine levels
1. Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubules, thus increasing urine output. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage, seen in herniation associated with a deteriorating cerebellar hemorrhage. No information is given about abnormal BUN and creatinine levels, or that mannitol is being given for renal dysfunction. Rebound cerebral hypertension is an adverse and undesired complication from ongoing mannitol use.
CN: Physiological integrity; CNS: Physiological adaptation; CL: Apply
500
What vital-sign pattern defines Cushing’s Triad?
↑ BP (widened pulse pressure), ↓ HR, irregular RR
500
Give two communication strategies for aphasia.
Yes/No questions & use picture boards
500
Dark urine on carbamazepine means what?
Possible liver toxicity → hold med & notify HCP
500
Untreated autonomic dysreflexia can lead to what?
Stroke or seizure from severe HTN
500
The nurse is preparing to administer vasopressin to a client who has undergone a hypophysectomy. What is the purpose of the medication?
1. To treat growth failure
2. To prevent syndrome of inappropriate antidiuretic hormone (SIADH)
3. To reduce cerebral edema and lower intracranial pressure
4. To replace antidiuretic hormone (ADH) normally secreted from the pituitary
4. After hypophysectomy, or removal of the pituitary gland, the body can't synthesize ADH; therefore, vasopressin is administered. Somatropin or growth hormone is used to treat growth failure. SIADH results from excessive ADH secretion. Vasopressin is not used to treat cerebral edema.
CN: Physiological integrity; CNS: Pharmacological and parenteral therapies; CL: Apply
600
A client has recently experienced an embolic stroke, and is now stable. The client has been started on dabigatran. What information should the nurse provide to this client?
1. Dabigatran is the standard of care for preventing recurrent ischemic stroke.
2. Dabigatran is more effective than antiplatelet therapy in the presence of a thrombus.
3. Dabagitran is inexpensive and readily available, with few side effects.
4. Dabigatran helps prevent blood clots from forming in the presence of atrial fibrillation.
4. Atrial fibrillation is the most common cause of embolic stroke. It is a newer anticoagulant medication approved for secondary stroke prevention in clients with atrial fibrillation of non heart valve origin. It helps prevent blood clots. Although anticoagulation is the standard of care for a client with stroke due to atrial fibrillation, antiplatelet medication remains the standard of care for non-cardiac thromboembolic stroke. Because of the increased risk of life-threatening bleeding, careful consideration is needed when ordering dabigatran.
CN: Physiological integrity; CNS: Pharmacological and parenteral therapies; CL: Apply
600
3. A 65-year-old client, who is experiencing a stroke, has been ordered alteplase. The order is for 0.9 mg/kg over one hour. The client weighs 110 lb (50 kg). What is the total dose in milligrams (mg) that the client will receive? Record your answer using a whole number.
________mg
45.
Multiply 0.9 mg by 50 kg to obtain a dose of 45 mg. The total dose the client will receive is 45 mg.
CN: Physiological integrity; CNS: Pharmacological and parenteral therapies; CL: Apply
600
A client who experienced head trauma three hours ago now has clear fluid draining from her nose and mouth. What would the nurse suspect?
1. Basilar skull fracture
2. Cerebral concussion
3. Subdural hematoma
4. Sinus infection
1. Clear fluid draining from the ear or nose of a client may indicate a cerebrospinal fluid leak, which is common in basilar skull fractures. Concussion is associated with a brief loss of consciousness. Subdural hematoma occurs when there is bleeding between the dura and the arachnoid layers of the brain, and sinus infection is associated with facial pain and pressure with or without nasal drainage.
600
When offered acetaminophen, the client's mother tells the nurse that she would like her son to have something stronger. What is the nurse's best response?
1. “Acetaminophen is strong enough for your son's mild concussion.”
2. “We avoid giving aspirin to children and young adults because of the danger of Reye's syndrome.”
3. “Opioids are avoided following a head injury because they may hide a deteriorating condition.”
4. “Stronger medications may lead to vomiting, which increases the intracranial pressure (ICP).”
3. Opioids may mask changes in the level of consciousness (LOC) that indicate increased ICP, and shouldn't be given as a first-line drug. Stating that acetaminophen is strong enough ignores the mother's question and isn't appropriate. Aspirin is contraindicated in conditions that include bleeding, and for children or young adults with viral illnesses due to the danger of Reye's syndrome. Stronger medications may not necessarily lead to vomiting, but will sedate the client, thereby masking changes in his LOC.
CN: Physiological integrity; CNS: Reduction of risk potential; CL: Apply
600
The nurse is assessing a client with head trauma. The client has urine output of 300 ml/hr, dry skin, dry mucous membranes and high serum sodium. What is the nurse's most important intervention for this client?
1. Evaluate urine specific gravity
2. Anticipate treatment for renal failure
3. Provide emollients to the skin to prevent breakdown
4. Slow the IV fluids and notify the provider
1. Urine output of 300 ml/hr in the presence of high serum sodium may indicate diabetes insipidus (DI). Sodium disturbances are common in clients with brain injury because of the major role that the central nervous system plays in the regulation of sodium and water homeostasis. Other related conditions include cerebral salt wasting and syndrome of inappropriate antidiuretic hormone (SIADH). DI may occur with increased intracranial pressure and head trauma. The nurse should evaluate for low urine specific gravity, increased serum osmolarity, and dehydration. There is no evidence that the client is experiencing renal failure. Providing emollients to prevent skin breakdown is important but not the priority. Slowing the rate of IV fluid would contribute to dehydration when polyuria is present.
CN: Physiological integrity; CNS: Physiological adaptation; CL: Analyze