NCLEX
A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How would the nurse document this activity?
A. Atonic seizure
B. Tonic-clonic seizure
C. Myoclonic seizure
D. Absence seizure
B. Tonic-clonic seizure Correct
What is the difference between embolic stroke and thrombotic Stroke?
Embolic stroke is caused by a clot that travels from somewhere else in the body, usually the heart.
What lab value must be obtained before calling a code stroke?
blood glucose level
Why would you want to use validation therapy rather than reality orientation for a patient with dementia??
recognizes and acknowledges the patients feelings and concerns.
For example: patient is looking for their mother-ask them what they look like, what they are wearing..
What is the national benchmark for door to CT result time for a stroke?
60 mins or less
A nurse is teaching a client who experiences migraine headaches and is prescribed a beta-blocker. Which statement would the nurse include in this client’s teaching?
A. “Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache.”
B. “This drug will relieve the pain during the aura phase soon after a headache has started.”
C. “Take this drug as prescribed, even when feeling well, to prevent vascular changes associated with migraine headaches.”
D. “This medication will have no effect on your heart rate or blood pressure because you are taking it for migraines.”
C. “Take this drug as prescribed, even when feeling well, to prevent vascular changes associated with migraine headaches.”
Difference between generalized seizures and partial seizures?
generalized seizures, such as the tonic-clonic seizure, involve both cerebral hemispheres. Partial seizures, also called focal or local seizures, usually involve only one hemisphere.
Signs that a patient is having a stroke
Face drooping
Arm weakness
Speech or language difficulty
Time to call 9-1-1
What are the nurses priorities for a patient having a seizure?
observation, timing, turning the patient on the side to prevent aspiration and allow secretions to drain, and removing any objects that might injure the patient.
What are important medications to give a patient with Status epilepticus?
Lorazepam and diazepam are the major drugs used for this emergency (benzodiazepines)
A patient with a stroke is being evaluated for fibrinolytic therapy. What information from the patient or family is most important for the nurse to obtain?
A. Loss of bladder control
B. Other medical conditions
C. Progression of symptoms
D. Time of symptom onset
D. Time of symptom onset
What is the classic triad associated with meningitis?
Nuchal rigidity, fever, and altered mental status
The most important nursing interventions for patients with meningitis
monitoring and documenting of their neurologic status, including vital signs and neurovascular checks. Observe for early signs and symptoms of ICP.
What are signs and symptoms of increased cranial pressure?
How often will you assess neurological and vital signs after a craniotomy?
15-30 mins for the first 4-6 hours and then every hour
A nurse is caring for four patients in the neurologic intensive care unit. After receiving the hand-off report, which patient does the nurse see first?
A. Patient with a Glasgow Coma Scale score that was 10 and is now 7
B. Patient with a Glasgow Coma Scale score that was 8 and is now 12
C. Patient with a moderate brain injury who is amnesic for the event
D. Patient who has a temperature of 102°F (38.9°C)
A. Patient with a Glasgow Coma Scale score that was 10 and is now 7
Which is the disease with the following cardinal signs: tremor, muscle rigidity, bradykinesia, and postural instability
Parkinson Disease
When would you notify the HCP of a stroke patients blood pressure?
when systolic is 180 or above
Explain why you would check PaC02 levels in a patient with a traumatic brain injury (TBI)?
Hypercarbia (PaCO2 greater than 40-45mmhg)-can cause cerebral vasodilation and contribute to increased ICP
Hypcocarbia (PaCO2 less than 40-45mmhg)- caused by hyperventilation and can lead to vasoconstriction and ischemia
Name 2 contraindications for t-Pa therapy
- Symptom onset is unknown, > 4.5 hours, or if patient awoke with stroke
-Acute or previous intracranial hemorrhage
-Prior ischemic stroke, severe head trauma, or intracranial/intraspinal surgery within 3 months
-Active bleeding
-Coagulopathy: (Platelets < 100, 000/mm³, INR > 1.7, aPTT > 40 s, PT > 15 s)
The student learning about neurological disorders remembers that key features of increased intracranial pressure include which of the following? (Select all that apply.)
A. Projectile vomiting
B. Hyperactivity
C. Narrowed pulse pressure
D. Aphasia
E. Decerebrate posturing
A. Projectile vomiting
D. Aphasia
E. Decerebrate posturing
Describe the 3 types of dementia
Stage 1 (mild)
Stage 2 (moderate)
Stage 3 (severe)
what are seizure precautions?
oxygen and suctioning emergency equipment available, starting an IV access, and keeping the siderails up at all times and padded (or a mattress on the floor)
Do not use padded tongue blades!
The priority of care for the patient having migraines
pain management
explain left and right hemispheric strokes
right-more involved with visual and spacial awareness, poor impulse control, poor judgement and proprioception (sense of body position)
left-center for language, math skills, and analytic thinking