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Complex Exam 2
Complex Exam 2
272
Nursing
10/12/2011

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Cards

Term
number of head injuries per year
Definition
1.5 million
Term
highest incidence group for head injuries
Definition
young adults (15-24)
Term
causes of head injuries
Definition
- accidents
- falls
- assaults and violence
- sports and recreational activities
Term
primary injury occurs when?
Definition
at the time of injury
Term
mechanisms of injury
Definition
- penetrating
- blunt
Term
secondary injuries include...
Definition
- hypoxia
- hypercapnia
- hypotension
- cerebral edema
- hypertension
Term
types of skull fractures
Definition
- open
- closed
- basilar
Term
battle's sign
Definition
- ecchymosis over the mastoid process
- raccoon eyes
- halo sign
Term
with what type of skull fracture does Battle's Sign occur?
Definition
basilar
Term
what can nurses do for basilar skull fractures?
Definition
- place a piece of sterile cotton loosely against the ear and under the nose
- elevate head of bed no more than 30 degrees (to reduce ICP & promote spontaneous closure of leak)
- monitor temp
- monitor for nucheal rigidity
- assess cranial nerves
- rarely, lumbar catheter for continual CSF drainage (most CSF leaks resolve spontaneously within 7-10 days)
Term
concussion (definition)
Definition
temporary loss of neurologic function with no apparent structural damage
Term
concussion symptoms, Grade 1
Definition
- vacant stare
- recovery in <1 min.
Term
concussion symptoms, Grade 2
Definition
- no LOC but retrograde/post-traumatic amnesia
- confusion
- headache
Term
concussion symptoms, Grade 3
Definition
- LOC
- retrograde/post-traumatic amnesia
- confusion
- headache
- loss of judgment
- loss of reaction time
- loss of information processing
Term
postconcussion syndrome (definition)
Definition
- residual effects that occur following orientation or within a few days
Term
postconcussion syndrome symptoms
Definition
- headache
- lethargy
- personality/behavior changes
- attention deficits
- difficulty with memory
Term
cerebral contusions (definition)
Definition
- cerebral bruising associated with blunt/penetrating trauma, depressed skull fracture, or acceleration-deceleration injury
Term
diffuse axonal injury (definition)
Definition
damaged nerve fibers and torn axons caused by shearing forces associated with acceleration-deceleration or rotational injuries
Term
diffuse axonal injury symptoms
Definition
- immediate period of unconsciousness
- longer period of confusion and amnesia
- prolonged recovery
- graded mild to severe based on degree of symptoms and time spent in coma
Term
intracranial hematoma - most common risk factor?
Definition
presence of a skull fracture
Term
intracranial hematoma types
Definition
- epidural
- subdural
- intracerebral
Term
epidural hematoma patho
Definition
1. force/blow to head
2. tearing of middle meningeal artery
3. rapid accumulation of blood in epidural space
4. compression of the motor cortex and brain tissue
5. marked neurologic deficit and increase in ICP
Term
epidural hematoma symptoms
Definition
- brief LOC
- lucidity
- progressive deterioration of LOC and hemiparesis on opposite side
- dilated, fixed pupil on same side of EDH
- headache
- vomiting
- seizures
- sleepiness
Term
subdural hematoma (definition)
Definition
- hemorrhage from small vessels between the dura mater and arachnoid
Term
subdural hematoma cause
Definition
- acceleration/deceleration
- rotational forces
Term
subdural hematoma types
Definition
- acute
- subacute
- chronic
Term
subdural hematoma, acute (definition)
Definition
major contusion or laceration that occurs within 48 hours of injury
Term
subdural hematoma, acute (symptoms)
Definition
- gradually worsening headache, confusion, difficulty thinking, agitation, drowsiness
- ipsilateral pupil dilated and fixed
- contralateral hemiparesis
- profound coma
Term
subdural hematoma, subacute (definition)
Definition
- less severe contusion that occurs within 2 days - 2 weeks of injury
Term
subdural hematoma, chronic (definition)
Definition
minor head injury in which symptoms persist longer than 2 weeks or more after injury
Term
subdural hematoma, chronic (symptoms)
Definition
- headache
- progressive lethargy
- forgetfulness
- possible seizure
- may look like having a TIA, change in pupils, hemiparesis
Term
subdural hematoma, chronic (risk groups)
Definition
- elderly
- persons who have had long term alcohol abuse with impaired blood clotting resulting from deteriorated liver function
- persons on anticoagulant therapy
Term
What can we do for a subdural hematoma?
Definition
- frequent neuro checks & close monitoring
- watch pupils closely
- monitor motor ability
Term
subdural hematoma medical management
Definition
- craniotomy
- burr hole evacuation
- catheter drainage
Term
intracerebral hematoma (definition)
Definition
bleeding within cerebral tissue
Term
intracerebral hematoma causes
Definition
- skull fracture
- penetrating injuries
- contusions
- lacerations
- sudden acceleration/deceleration motion
Term
subarachnoid hemorrhage (definition)
Definition
hemorrhage into the subarachnoid space
Term
subarachnoid hemorrhage cause
Definition
severe head injuries
Term
subarachnoid hemorrhage symptoms
Definition
- nuchal rigidity
- severe headache
- visual disturbances
- ipsilateral dilated pupil
Term
missile injury cause
Definition
object penetrates the skull to produce significant focal damage
Term
missile injury types
Definition
- depressed
- penetrating
- perforating
Term
missile injury, depressed
Definition
- caused by fractures of the skull, with penetration of bone into cerebral tissue
Term
missile injury, penetrating
Definition
- object enters the cranial cavity but does not exit
Term
missile injury, perforating
Definition
- object enters and exits
Term
missile injury symptoms
Definition
- related to velocity/weight of object, structures involved, associated contusions, and hemorrhages
Term
what can we do for a missile injury?
Definition
provide family support?
Term
Glasgow Coma Scale
Definition
13-15 mild injury
9-12 moderate injury
3-8 severe injury
Term
traumatic brain injury priority goals
Definition
- restore circulating volume
- keep BP>90 mmHg
- maintain airway
- decrease ICP
- assess neuro status, including motor movements and pupillary response
- monitor fluid and electrolyte status
- nutrition
Term
diabetes insipidus labs
Definition
serum Na > 145
serum osmolality > 300
urine osmolality < 300
urine specific gravity < 1.005
Term
what can we do for diabetes insipidus?
Definition
- rehydration
- lab tests
Term
diabetes insipidus diagnoses
Definition
- fluid volume deficit
- decreased cardiac output
Term
traumatic brain injury diagnoses
Definition
- risk for aspiration
- impaired gas exchange
- altered nutrition, less than body requirements
- body image disturbance
- self-care deficit syndrome
- ineffective individual/family coping
- anticipatory grieving
Term
factors affecting behavior and personality
Definition
- site of injury
- severity
- personality before injury
- environment
Term
nurse's role in rehabilitation
Definition
- develop plan of care
- determine family needs
- refer to community resources
Term
potential nursing diagnoses in rehab phase
Definition
- caregiver role strain
- chronic confusion
- ineffective family coping
- altered family processes
- impaired home maintenance management
- risk for injury
- self-concept disturbance
Term
neurological assessment history
Definition
- neurological symptoms
- medical history
- familial history
- social profile
- medication profile
Term
neuro assessment physical exam
Definition
- cerebral function
- motor system
- sensory system
- cranial nerves
Term
level of consciousness is controlled by?
Definition
- reticular activating system in the brain stem
- if reticular activating system (RAS) is still functioning, the patient can open his/her eyes spontaneously to voice or pain
Term
higher cognitive functioning components
Definition
- orientation
- fundamental knowledge
- judgment
- calculation
- abstract reasoning
- memory
Term
receptive aphasia (wernicke's)
Definition
- temporal lobe
- inability to comprehend written or spoken words
- hears but can't understand spoken words
- impaired reading and writing skills
- visual aphasia: can see words, can't read them
Term
expressive aphasia (broca's)
Definition
- frontal lobe
- understands questions and/or directions, but words are difficult to initiate and/or responds inappropriately
- unable to combine speech sounds into words or syllables
- can't speak, can't write, mild impaired reading comprehension
Term
normal motor responses
Definition
obeys commands
Term
abnormal motor responses
Definition
- spontaneous
- localizes the pain
- withdraws from pain
- decorticate
- decerebrate
- flaccid
Term
motor system priorities
Definition
- evaluate for equal/symmetrical movements
- evaluate muscle size and tone
- estimate muscle strength
Term
central pain
Definition
- trapezious squeeze
- supraorbital pressure
- mandibular pressure
- sternal rub
Term
peripheral pain
Definition
- nail bed pressure
Term
balance and coordination test
Definition
- touch each of the fingers with the thumb in a consecutive motion; note speed/symmetry
- Romberg test
Term
motor alterations
Definition
- shuffling gait
- flexed posture
- rigidity of movement
Term
deep tendon reflexes
Definition
- achilles
- quadricepts
- biceps
- triceps
Term
deep tendon reflex grading
Definition
0 absent
1+ present but diminished
2+ normal
3+ increased
4+ hyperactive
Term
superficial reflexes
Definition
- corneal
- pharyngeal (gag)
Term
pathological reflexes
Definition
- babinski
- grasp
Term
tactile sensation
Definition
- assessed by lightly touching a cotton wisp on each side of the body and asking the patient to tell you the location
Term
superficial pain perception
Definition
- determining patient's sensitivity to a sharp object
Term
vibration
Definition
- evaluated through use of a tuning fork
Term
proprioception
Definition
- position sense
Term
cranial nerves
Definition
1. olfactory
2. optic
3. oculomotor
4. trochlear
5. trigeminal
6. abducens
7. facial
8. vestibulocochlear
9. glossopharyngeal
10. vagus
11. accessory
12. hypoglossal
Term
olfactory
Definition
- hold an aromatic substance under the nostril
- problems may mean a tumor on olfactory bulb or basilar skull fracture
Term
reactivity to light
Definition
- optic nerve
- oculomotor nerve
Term
eye movements
Definition
- oculomotor
- trochlear
- abducen
Term
pupil priorities
Definition
- estimating pupil size/shape
- evaluating reaction to light
- assessing eye movements
- assessing visual acuity
Term
cataract
Definition
- opacity of the normally clear lens which may develop as a result of aging, metabolic disorders, trauma, or heredity
Term
V, VII: trigeminal and facial
Definition
V trigeminal - assess face for movement and sensation
VII facial - raise eyebrows, close eyes tight, purse the lips, exaggerated smile, frown
Term
VIII, IX, X: vestibulocochlear, glossopharyngeal, vagus
Definition
VIII vestibulocochlear - whisper, Rinne, & Weber test. For vestibular component, question patient on dizziness, vertigo, balance problems
IX glossopharyngeal - assess mouth for taste
IX glossopharyngeal & X vagus - assess for gag reflex
Term
XI, XII: accessory, hypoglossal
Definition
XI accessory - assessed by ability to shrug shoulders against resistance
XII hypoglossal - assessed by ability to move tongue side to side against resistance and protrude outward midline
Term
skull/spine x-rays
Definition
- to identify fractures, anomalies, or possible tumors
- explain positioning during procedure
- spinal precautions must be maintained until integrity of cervical structures is confirmed
Term
CT scan
Definition
- diagnostic study of choice in acute head injury
- if contrast is used, assess renal function and allergy to dye
Term
CT scan normal findings
Definition
- bone appears white
- blood appears off-white
- brain tissue appears shaded gray
- CSF appears off-black
- air appears black
Term
MRI
Definition
- provides excellent images of brain and spinal cord without radiation exposure
- assess for claustrophobia and premedicate if necessary
Term
cerebral angiogram
Definition
- to assess cerebral circulation
- involves placement of a catheter normally in the femoral artery under fluoroscopy. catheter is threaded into the origin of the cerebral circulation
Term
what can we do in anticipation of a cerebral angiogram?
Definition
- informed consent
- assess for allergies to contrast dye
- may have a burning sensation when dye is injected
- provide hydration
- monitor vital signs, and puncture site for hematoma (pressure dressing)
- perform frequent neuro checks secondary to risk of vessel occlusion
Term
cerebral blood flow study example
Definition
carotid duplex
Term
EEG
Definition
- recording of electrical impulses (brain waves)
- often the goal is to elicit a seizure
- informed consent is required with 24 hour videography
Term
what can we do after an EEG?
Definition
- wash hair to remove gel
- resume medications
- test will determine the type of seizure activity
- aids in the diagnosis of brain death criteria
Term
lumbar puncture
Definition
- needle is inserted into subarachnoid space to obtain CSF for analysis
- put anesthetics or medicines into the CSF to treat leukemia and other types of cancer of the CNS
Term
lumbar puncture procedure
Definition
- position patient in fetal position of have patient lean over bedside table
- local anesthetic with strict aseptic technique
- needle inserted at L4, L5, or S1
- CSF placed in three separate test tubes and labeled
Term
lumbar puncture post-procedure
Definition
- lie flat 2-6 hours
- observe puncture site
- monitor VS
- encourage fluids
- pain med for headache
- observe for increased temp, stiff neck, difficulty voiding
Term
lumbar puncture contraindications
Definition
- platelet count <50
- INR >1.2
- known bleeding disorder
- evidence of increased intracranial pressure or definite signs of brain tumor
Term
electromyography (EMG)
Definition
- needle electrodes are inserted into the skeletal muscle to measure the electrical potential of the muscles
- useful in the presence of neuromuscular disorders and myopathies
- fairly painful with electrode insertion
Term
myelogram
Definition
- needle inserted into the subarachnoid space then contrast medium is injected to provide visualization of spinal column under fluoroscopy
- done to check for the cause of arm or leg numbness, weakness, or pain, narrowing of the spinal canal, tumor, infection, or herniated disc
Term
what can we do in anticipation of a myelogram?
Definition
- assess for dye allergy and hydration
Term
what can we do after a myelogram?
Definition
- neuro check and VS
- check for back pain, spasms, neck rigidity
- check for sensation in lower extremities
Term
3 components of intracranial space
Definition
- brain substance 80%
- CSF 10%
- blood 10%
Term
ICP (definition)
Definition
pressure exerted by the total volume within the skull
Term
normal ICP
Definition
<15 mm Hg
Term
Monro-Kellie hypothesis
Definition
- if any one of the components increases in volume, another component must decrease to maintain equilibrium
- body adapts to maintain normal ICP
Term
how the body compensates for increase in components
Definition
- displacement/shifting of CSF from ventricles and cerebral subarachnoid space to the spinal subarachnoid space
- increasing absorption of CSF
- decreasing production of CSF
- vasoconstriction of cerebral vasculature
- compressing the low pressure venous system, especially the dural sinuses
Term
autoregulation
Definition
Refers to the brain's ability to change the diameter of its blood vessels automatically to maintain a constant cerebral blood flow during alterations in systemic blood pressure
Term
compliance
Definition
- the brain's adaptive ability to maintain equilibrium in response to physiological and external changes
Term
what happens when a patient's compliance is exhausted?
Definition
dramatic increase in the pressure/volume curve, leading to a rapid elevation in ICP
Term
cerebral perfusion pressure
Definition
blood pressure gradient across the brain
Term
equation for cerebral perfusion pressure
Definition
CPP = MAP - ICP
Term
cerebral perfusion pressure normal range
Definition
70-100 mm Hg
Term
when is a CPP of 70-80 recommended?
Definition
patients with cerebral injury and intracranial hypertension
Term
equation for MAP
Definition
MAP = [(2xDP) + SP]/3
Term
cerebral blood flow
Definition
regulated to supply the brain with adequate oxygen and substrates to meet its demands
Term
main physiologic influences on cerebral blood flow
Definition
- PaCO2
- arterial oxygenation
- pH
- CPP
- cerebral metabolic rate
Term
how does increased PaCO2 affect cerebral blood flow?
Definition
- results in vasodilation, which will increase cerebral blood flow and potentially increase ICP
Term
how does acidosis and hypoxemia affect cerebral blood flow?
Definition
- results in vasodilation, which will increase cerebral blood flow
Term
how do fever and seizures affect cerebral blood flow?
Definition
- increase cerebral blood flow and cerebral metabolic rate
Term
conditions that increase ICP
Definition
- mass lesions
- head injuries
- brain surgery
- cerebral infections
- vascular insult
- toxic or metabolic encephalopathic conditions
Term
client-related factors that affect ICP
Definition
- restlessness
- straining
- emotional distress
- fever
- hypoxia
- hypercapnia
- seizure activity
Term
environmental factors affecting ICP
Definition
- upsetting conversations
Term
nursing-related factors affecting ICP
Definition
- clustering of activities
- suctioning
- positioning
Term
signs of increased ICP
Definition
- deterioration in LOC
- pupillary dysfunction
- deterioration of motor function
- Cushing's triad
- decreased brain stem reflexes
- projectile vomiting
- altered breathing patterns
- headache
Term
Cushing's triad
Definition
- increased BP
- decreased pulse
- decreased respirations
Term
types of ICP monitoring devices
Definition
- ventriculostomy
- fiberoptic intraparechymal catheter
- subdural monitor
- subarachnoid screw/bolt
- epidural monitor
Term
what can we do for ICP?
Definition
- pupillary evaluation
- cranial nerve evaluation
- motor function
Term
appropriate positioning for ICP
Definition
- keep HOB at least 30 degrees
- keep neck in midline position
- avoid positions that decrease venous return from the head and increase intrathoracic or intra-abdominal pressure
Term
control ventilation for ICP
Definition
maintaining PaCO2 levels on the lower side of normal
Term
medications for ICP
Definition
- sedatives and neuromuscular blocking agents
- benzodiazepines
- narcotics
Term
monitoring with neuromuscular blockers
Definition
- depth of paralysis routinely monitored at bedside using peripheral nerve stimulator and assessment by train of four: pt receives low-voltage electrical stimulation; 1-2 twitches is appropriate
Term
temperature control with ICP
Definition
- with hyperthermia, cerebral metabolic rate increases
- risk of inadequate oxygen supply at the cellular level
Term
control BP for ICP
Definition
desired BP is 140-160 systolic
Term
diuretics for ICP
Definition
- osmotic diuretics
- loop diuretics
Term
ventriculostomy
Definition
- catheter into the lateral ventricle
- document duration, color, and amount of drainage
Term
decompressive craniectomy
Definition
- removal of a variable amount of skull bone to allow a swelling brain room to expand
- a decrease in ICP allows for an increase in cerebral perfusion pressure, aiding blood flow to the ischemic penumbra and optimizing circulation to the damaged area through collateral vessels
Term
what can we do for ICP?
Definition
- monitor fluid/electrolyte balance
- encourage initiation of nutrition
- protect from injury
- provide psychological support for patient and family
Term
herniation syndromes
Definition
- displacement of brain tissue can become an irreversible patho process
- ischemia and edema
- compress brain stem and CNs can be fatal
Term
nursing diagnoses for IICP
Definition
- adaptive capacity, decreased: intracranial
- ineffective airway clearance
- ineffective breathing pattern
- alteration in comfort
- impaired verbal communication
- confusion
- altered family processes
- risk for injury
- sensory perceptual alterations
- alterations in thought processes
- self-care deficit syndrome
Term
clinical brain death criteria
Definition
- no spontaneous respirations
- no motor response
- no cranial nerve activity
- no electrical brain activity
- no brainstem reflexes
Term
apnea test for brain death
Definition
- ventilator is removed but O2 continues to be delivered by tracheal cannula, allow the patient's PCO2 to increase to 60+...this should be enough to stimulate respirations if the brainstem is functioning adequately
- these patients must not be influenced by body temp or narcotics or other depressant drugs
Term
oculocephalic reflex (doll's eyes)
Definition
- normal: eye rotates to left as head is turned to right
- abnormal: eyes remain centered as head is turned to right
Term
oculovestibular reflex (cold caloric test)
Definition
- conjugate eye movement toward stimulation indicate4s brainstem is intact
Term
types of spinal cord injuries
Definition
- concussion
- compression
- contusion or bruising
- laceration
- transection
- hemorrhage
- vascular damage
Term
mechanisms of spinal cord injury
Definition
- acceleration-deceleration
- rotation
- axial loading (falling on head, diving accident)
Term
paraplegia
Definition
- results from complete injury from T-2 - L-1
- variable innervation to intercostal and abdominal muscles
- patients with injuries in this area may have full use of their arms and may need a wheelchair, although some may have limited ability to ambulate short distances with crutches and orthotic devices
Term
central cord injury
Definition
no upper motor
Term
anterior cord injury
Definition
no motor/pain temp below injury
Term
posterior cord injury
Definition
no pressure/vib below injury
Term
lateral cord (brown-sequard) injury
Definition
- side of injury = loss of motor
- opp side = loss pain/temp/sensation
Term
emergency management of spinal cord injury
Definition
- ABCs
- neuro exam
- stabilize neck
- fluid replacement
- vasopressors
Term
methylprednisolone
Definition
- glucocorticosteroids
- directly affects the changes that occur within the spinal cord after injury
- prevents post-traumatic spinal cord ischemia
- improves energy metabolism
- restores extracellular calcium
- improves nerve impulse conduction
- should administer within 8 hours of injury
- bolus followed by cont. infusion
Term
spinal shock
Definition
- occurs within 60 minutes of injury
- recovery takes 4-6 weeks
Term
spinal shock medical management
Definition
- careful fluid resuscitation
- vasopressors
- atropine
- warming measures
Term
spinal shock assessment findings
Definition
- neurogenic shock: hypotension, bradycardia, decreased cardiac output
- flaccid paralysis
- no spinal reflexes
- no sensation of temperature, proprioception, touch, pressure, and pain
- no somatic/visceral sensations
- lack of perspiration secondary to loss of neurologic innervation of the sweat glands
Term
cervical traction: tongs
Definition
- used to provide cervical skeletal traction in order to reduce the cervical fracture and align the cervical spine
Term
cervical traction: halo vest
Definition
- consists of a metal ring secured to the skull with four pins. steel bars anchor screws to the vest to provide cervical immobilization
Term
complications of cervical traction
Definition
- cranial nerve impairment related to pins, screws, traction
- infection related to poor pin site care
- respiratory related to immobility secondary to tong traction
Term
surgical management of spinal cord injury
Definition
- to provide spinal column stability in the presence of disrupted ligaments and tendons, as well as a vertebral column that cannot maintain normal alignment
- particularly important for the patient with minimal neurologic deficit
Term
pulmonary problems with spinal cord injuries
Definition
- respiratory failure
- atelectasis
- pneumonia
- pulmonary embolism
Term
goals for pulmonary issues
Definition
- maintenance of airway and oxygenation
- assess for aspiration
- cough assistance to mobilize secretions
Term
cardiovascular management of SCI
Definition
- hemodynamic invasive monitoring
- hydration
- inotropic or vasopressor support
- monitor/correct temp
- sequential pneumatic compression stockings and/or anticoagulant therapy
Term
bowel/bladder function problems of SCI
Definition
- storing/emptying urine
- spastic or flaccid bowel
Term
goals of bowel/bladder function problems
Definition
- monitor voiding patterns
- indwelling/external urine device
- maintain fluid intake
- assess for bladder distention
- initiate bladder retraining
- monitor for UTI
- digital stimulation/removal of stool
- stool softeners
- suppositories
Term
skin integrity nursing management in SCI
Definition
- reposition Q2h
- lifting devices
- specialty mattresses
- Braden skin scale Q8h
- adequate nutrition
- maximize mobility
Term
pain nursing management in SCI
Definition
- management of pain with non-pharmacological and pharmacological interventions
Term
sexual function nursing management in SCI
Definition
- women: pregnancy in possible, and most can have normal vaginal deliveries; loss of sensation in pelvic area can prevent knowledge that labor has begun
- men: level, type, time elapsed, and site of SCI injury impact sexuality
Term
psychosocial nursing management with SCI
Definition
- grief
- anxiety
- denial
- fear
- anger
- hopelessness
- powerlessness
- altered body image
- provide psych support
- promote coping mechanisms
- identify support systems
- stimulate patient to participate in rehab
- allow patient to make choices and provide input into his/her plan of care
- multidisciplinary team approach
Term
autonomic dysreflexia
Definition
- common in T6 or higher injuries
- occurs when an irritating stimulus is introduced to the body below the level of SCI. the stimulus sends nerve impulses to the spinal cord, travelling upward until they are blocked by the lesion at the level of injury. impulses cannot reach brain, so reflex is activated that increases activity of sympathetic nervous system
Term
causes of autonomic dysreflexia
Definition
- full bladder
- fecal impaction
- pressure ulcer
- fold in bed sheets
- tight clothing
- infected toe nail
- DVT
Term
s/s of autonomic dysreflexia
Definition
- increased BP
- decreased HR
- diaphoresis
- anxiety
- flushing
- spasticity
Term
what can we do for autonomic dysreflexia?
Definition
- sit client upright if supine
- look for causes:
- full bladder? if indwelling catheter, check for kinks. if indwelling catheter not present, catheterize the patient
- check for fecal impaction
- loosen constrictive clothing
- reposition patient and remove folds from linens
- treat BP if >150 mm Hg
Term
diagnoses in acute care setting
Definition
- dysreflexia
- impaired gas exchange
- disuse syndrome
- body image disturbance
- impaired physical mobility
- ineffective individual/family coping
Term
educational needs for SCI
Definition
- prevention of autonomic dysreflexia
- prevention of infections
- skin integrity
- transferring
- bowel/bladder training
- ventilatory support
Term
seizure (definition)
Definition
- a single, finite event resulting in abnormal motor, sensory, autonomic or psychic activity caused by sudden excessive discharge from cerebral neurons
Term
seizure disorder (definition)
Definition
- chronic disorder of abnormal, recurrent, excessive, and self-terminating discharge from cerebral neurons
Term
risk factors for seizures
Definition
- age
- IICP
- cerebral vascular disease
- drugs/alcohol
- electrolyte/vitamin imbalances
- endocrine disorders
Term
precipitating factors for seizures
Definition
- fatigue
- sleep deprivation
- hypoglycemia
- emotional stress
- febrile illness
- alcohol consumption
- certain drugs
- constipation
- menstruation
- hyperventilation
- photo stimuli
- certain types of music
Term
partial seizure
Definition
- part of brain
- simple
- complex
Term
generalized seizure
Definition
- tonic
- clonic
- absence
Term
partial seizure
Definition
- involves epileptic activity in part of the brain rather than affecting the whole brain
Term
simple partial seizure
Definition
- no loss of consciousness
Term
complex partial seizure
Definition
- impaired consciousness
Term
generalized seizures
Definition
- tonic-clonic/grand mal
- loss of consciousness and breathing becomes irregular
- person becomes stiff and limbs jerk
- biting of the tongue and inside of cheek may occur
- pale/diaphoretic
Term
absence seizure
Definition
- onset between 4 and 14 years
- no aura
- sudden vacant facial expression
- no confusion
Term
status epilepticus
Definition
- continuous seizure lasting at least 5 minutes, or 2+ discrete seizures between which there is incomplete recovery of consciousness
- can lead to death because of the interference with respirations
Term
diagnostic tests for seizures
Definition
- H&P
- toxicology screen
- EEG
- CT/MRI
- LP
- sleep study
- continuous videography with EEG
Term
implications with antiseizure drugs
Definition
- monitor therapeutic serum levels
- monitor for signs of toxicity
- monitor protein intake
- decreased bone calcium
Term
dilantin SE
Definition
- visual
- gingival
- hyperplasia
Term
tegretol SE
Definition
- dizziness
- n/v
Term
klonopin SE
Definition
- behavior
- palpitations
Term
keppra SE
Definition
- decreased LOC
Term
luminal SE
Definition
- sedation
Term
depakote SE
Definition
- n/v
- increase weight
- hair loss
Term
seizure precautions
Definition
- side rails up/padded
- suction equipment in room
- artificial airway available
- bed in low position
Term
what can we do during a seizure?
Definition
- prevention of injury
- ease to floor/bed if possible
- remove glasses/loosen clothing
- lay on side if possible
- remain with client
- give O2
Term
what can we do after a seizure?
Definition
- lay on side
- provide adequate ventilation
- allow client to sleep
- reorient as awakens
Term
what can we do for status epilepticus?
Definition
- ABCs
- administer antiseizure drugs
- treat underlying cause
- prevent or treat complications
Term
seizure considerations for women
Definition
- often increase around menses
- antiseizure drugs reduce efficacy of oral contraceptives
- seizure patterns often change during pregnancy
- some antiseizure drugs can cause birth defects
Term
modifiable risk factors for stroke
Definition
- hypertension
- heart disease
- atrial fibrillation
- carotid artery disease
- diabetes
- elevated serum cholesterol/lipids
Term
unmodifiable risk factors for stroke
Definition
- age
- gender
- race
- family history
- personal history of stroke or TIA
Term
5 warning signs of CVA
Definition
- sudden numbness/weakness
- sudden confusion/difficulty speaking/understanding what is being said
- sudden visual changes
- sudden difficulty walking
- sudden severe headache with no known cause
Term
patho of CVA
Definition
- blood clot blocks blood vessel/artery, or blood vessel breaks, interrupting blood flow to an area of the brain
- increases ICP
- results in cellular destruction or loss of function
Term
ischemic stroke
Definition
- most common type
- a clot/thrombus completely occludes a cerebral artery
- can convert to hemorrhagic CVA
Term
hemorrhagic stroke
Definition
- results from a rupture of a cerebral artery
- common in clients with uncontrolled HTN or cerebral aneurysms
- often associated with poorer outcomes
- complains of horrible headache
Term
intracerebral hemorrhagic stroke
Definition
- bleeding within the cerebral tissue caused by a rupture of vessels that lasts from minutes to days
- most often related to poorly controlled HTN
- HTN and atherosclerosis cause degenerative changes in the walls of arteries, resulting in rupture and subsequent hemorrhage
Term
subarachnoid hemorrhagic stroke
Definition
- most often related to ruptured aneurysm or arteriovenous malformation
Term
aneurysm (definition)
Definition
- dilation of bulging of the walls of a cerebral artery that develops as a result of weakness in the arterial wall
Term
causes of aneurysm
Definition
- HTN
- atherosclerosis
- infection
- tumors
- head trauma
- congenital defects
Term
AVM
Definition
- congenital disorder of blood vessels within the brain, characterized by tangles of veins and arteries that disrupt normal blood flow in the brain
Term
National Institutes of Health Stroke Scale (NIHSS)
Definition
- overall level of consciousness
- visual function
- motor skills
- sensation and inattention
- language
- cerebellar integrity
- score ranges from 0-42. The higher the score, the more neurologically impaired the patient
Term
diagnostic tests for CVA
Definition
- CT
- MRI
- EEG
- EKG
- cerebral angiogram
- carotid doppler studies
- ECG
Term
The nurse is working on a surgical floor. The nurse must logroll a client following a:

A. laminectomy
B. thoracotomy
C. hemorrhoidectomy
D. cystectomy
Definition
A. laminectomy

The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight when turning.
Term
The nurse is preparing a female client with tonic-clonic seizure disorder for discharge. Which instructions should the nurse include about phenytoin (Dilantin)? Select all that apply.

1. monitor for skin rash
2. maintain adequate amounts of fluid and fiber in the diet
3. perform good oral hygiene, including daily brushing and flossing
4. receive necessary periodic blood work
5. report to the physician any problems with walking, coordination, slurred speech, or nausea
6. feel safe about taking this drug, even during pregnancy
Definition
1, 3, 4, 5

A rash may occur 10 to 14 days after starting phenytoin. If a rash appears, the client should notify the physician and discontinue the medication. Because phenytoin may cause gingival hyperplasia, the client must practice good oral hygiene and see a dentist regularly. Periodic blood work is necessary to monitor complete blood counts, platelet levels, hepatic function, and drug levels. Signs and symptoms of phenytoin toxicity include problems with walking, coordination, slurred speech, and nausea. Other signs of toxicity include lethargy, diplopia, nystagmus, and disturbances in balance. These symptoms must be reported to the physician immediately.
Term
The nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in ICP?

A. suction the airway every hour and as needed
B. elevate the HOB 15 to 30 degrees
C. turn the client and change his position every 2 hours
D. maintain a well-lit room
Definition
B. elevate the HOB 15 to 30 degrees

To facilitate venous drainage and avoid jugular compression, the nurse should elevate the head of the bed 15 to 30 degrees.
Term
The physician prescribes mannitol (Osmitrol) IV stat for a client who develops increased ICP after a head injury. While preparing to administer mannitol, the nurse notices crystals in the solution. What should the nurse do?

A. administer the solution as is
B. warm the solution in hot water to dissolve the crystals
C. send the crystallized solution back to the pharmacy
D. add a filter to the infusion set and administer the solution
Definition
B. warm the solution in hot water to dissolve the crystals

The nurse must dissolve crystallized mannitol before administering it. This is best done by warming it in hot water and shaking the container vigorously, then allowing the solution to return to room temperature before administering it.
Term
If a client experienced a stroke that damaged the hypothalamus, the nurse would anticipate that the client has problems with:

A. body temperature control
B. balance and equilibrium
C. visual acuity
D. thinking and reasoning
Definition
A. body temperature control

The body's thermostat is located in the hypothalamus; therefore, injury to that area can cause problems of body temperature control.
Term
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?

A. administering zolpidem tartrate (Ambien)
B. assessing laboratory test results as ordered
C. placing the client in Trendelenburg's position
D. monitoring the patency of an indwelling urinary catheter
Definition
D. monitoring the patency of an indwelling urinary catheter

Because a full bladder can precipitate autonomic dysreflexia, the nurse should monitor the patency of an indwelling catheter to prevent its occlusion, which could result in a full bladder
Term
A client with a head injury is being monitored for increased ICP. His blood pressure is 90/60 mm Hg and the ICP is 18 mm Hg; therefore his cerebral perfusion pressure (CPP) is:

A. 52 mm Hg
B. 88 mm Hg
C. 48 mm Hg
D. 68 mm Hg
Definition
A. 52 mm Hg

CPP is derived by subtracting the ICP from the mean arterial pressure (MAP). For adequate cerebral perfusion to take place, the minimum goal is 70 mm Hg. The MAP is derived using the following formula:
MAP = ([diastolic blood pressure x 2] + systolic blood pressure)/3
MAP = ([60 x 2] + 90)/3
MAP = 70 mm Hg
To find the CPP, subtract the client's ICP from the MAP, in this case, 70 mm Hg - 18 mm Hg = 52 mm Hg
Term
A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse expects to administer which neuromuscular blocking agent?

A. succinylcholine (Anectine)
B. vecuronium (norcuron)
C. pancuronium (pavulon)
D. atracurium (tracrium)
Definition
A. succinylcholine (Anectine)

Succinylcholine, a depolarizing blocking agent, is the drug of choice when short-term muscle relaxation is desired - for example, during ECT or intubation.
Term
A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes highest priority in this client's care plan?

A. disturbed sensory perception (visual)
B. dressing or grooming self-care deficit
C. impaired verbal communication
D. risk for injury
Definition
D. risk for injury

Because the client is disoriented and restless, the most important nursing diagnosis is risk for injury.
Term
The nurse is performing a mental status exam on a client diagnosed with subdural hematoma. This test assesses which of the following?

A. cerebellar function
B. intellectual function
C. cerebral function
D. sensory function
Definition
C. cerebral function

The mental status exam assesses functions governed by the cerebrum. Some of these are orientation, attention span, judgment, and abstract reasoning.
Term
Damage to which area of the brain results in receptive aphasia?

A. parietal lobe
B. occipital lobe
C. temporal lobe
D. frontal lobe
Definition
C. temporal lobe

The temporal lobe contains the auditory association area. If the area is damaged in the dominant hemisphere, the client hears words but doesn't know their meaning.
Term
A client is admitted to an acute care facility for treatment of a brain tumor. When reviewing the chart, the nurse notes that the client's extremity muscle strength is rated 1/5. What does this mean?

A. normal, full muscle strength is present
B. muscles move actively against gravity alone
C. muscle contraction is palpable and visible
D. muscle contraction or movement is undetectable
Definition
C. muscle contraction is palpable and visible

Muscle strength is assessed and rated on a five-point scale in all four extremities, comparing one side to the other. A rating of 1/5 indicates palpable, visible muscle contraction on the affected side and normal, full muscle strength on the unaffected side. Normal, full muscle strength on both sides is rated 5/5. Active muscle movement against gravity alone on the affected side with normal, full muscle strength on the unaffected side is rated 3/5. Undetectable muscle contraction or movement on the affected side with normal, full muscle strength on the unaffected side is rated 0/5.
Term
A young man was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's ICP is increasing, the nurse would expect to observe which sign first?

A. pupillary asymmetry
B. irregular breathing pattern
C. involuntary posturing
D. declining level of consciousness
Definition
D. declining level of consciousness

With a brain injury such as an epidural hematoma (a diagnosis that is most likely based on this client's symptoms), the initial sign of increasing ICP is a change in the level of consciousness.
Term
The nurse is assessing the level of consciousness of a client who suffered a head injury. She uses the Glasgow Coma Scale and determines that the client's score is 15. Which responses did the nurse assess in this client? Select all that apply.

1. spontaneous eye opening
2. tachypnea, bradycardia, and hypotension
3. unequal pupil size
4. orientation to person, place, and time
5. motor response to pain localized
6. incomprehensible sounds
Definition
1, 4

The Glasgow Coma Scale assesses level of consciousness by testing and scoring three observations: eye opening, motor response, and verbal stimuli response. Clients are scored on their best responses and these scores are totaled. The highest score is 15. The highest responses in these three categories are spontaneous eye opening, obeying motor commands, and orientation to time, place, and person.
Term
The nurse is monitoring a client for increasing ICP. Early signs of increased ICP include:

A. pupillary changes
B. diminished responsiveness
C. decreasing blood pressure
D. elevated temperature
Definition
B. diminished responsiveness

Usually, diminished responsiveness is the first sign of increasing ICP.
Term
A client is diagnosed with a conductive hearing loss. When performing Weber's test, the nurse expects that this client will hear sound:

A. on the affected side by bone conduction
B. on the unaffected side
C. longer through bone than air conduction
D. by neither air nor bone conduction
Definition
A. on the affected side by bone conduction

During Weber's test, which tests bone conduction, a client with a conductive hearing loss hears sound on the affected side by bone conduction.
Term
The nurse is caring for a client with a complete T5 spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above T5, and a blood pressure of 162/96 mm Hg. The client reports a severe, pounding headache. Which nursing interventions would be appropriate for this client? Select all that apply.

1. elevating the HOB 90 degrees
2. loosening constrictive clothing
3. using a fan to reduce diaphoresis
4. assessing for bladder distention and bowel impaction
5. administering antihypertensive medication
6. placing the client in a supine position with legs elevated
Definition
1, 2, 4, 5

The client is exhibiting signs and symptoms of autonomic dysreflexia. The condition is a potentially life-threatening emergency caused by an uninhibited response from the sympathetic nervous system, resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the head of the bed to 90 degrees and place the extremities in a dependent position to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction - both of which may trigger autonomic dysreflexia - and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, myocardial infarction, or seizure activity. If removing the triggering event doesn't reduce the client's blood pressure, IV antihypertensives should be administered. A fan shouldn't be used because cold drafts may trigger autonomic dysreflexia.
Term
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:

A. raccoon's eyes and Battle's sign
B. nuchal rigidity and Kernig's sign
C. motor loss in the legs that exceeds that in the arms
D. pupillary changes
Definition
A. raccoon's eyes and Battle's sign

A basilar skull fracture commonly causes only periorbital ecchymosis (raccoon's eyes) and postmastoid ecchymosis (Battle's sign); however, it sometimes also causes otorrhea, rhinorrhea, and loss of cranial nerve I (olfactory nerve) function.
Term
nuchal rigidity and Kernig's sign are associated with?
Definition
meningitis
Term
motor loss in the legs that exceeds that in the arms suggests?
Definition
central cord syndrome
Term
Family members would like to bring in birthday cake for a client with nerve damage. What cranial nerve needs to be functioning so the client can chew?

A. CN II
B. CN V
C. CN IX
D. CN X
Definition
B. CN V

Chewing is a function of cranial nerve V.
Term
swallowing is a motor function of which cranial nerves?
Definition
IX and X
Term
A white female client is admitted to an acute care facility with a diagnosis of stroke. Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for stroke?

A. caucasian race
B. female gender
C. obesity
D. bronchial asthma
Definition
C. obesity

Obesity is a risk factor for stroke. Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, hormonal contraceptive use, emotional stress, family history of stroke, and advancing age.
Term
A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:

A. hold the client's arm still to keep him from hitting anything
B. carefully move him to a flat surface and turn him on his side
C. allow him to remain in the chair but move all objects out of his way
D. place an oral airway in his mouth to maintain an open airway
Definition
B. carefully move him to a flat surface and turn him on his side

When caring for a client experiencing a tonic-clonic seizure, the nurse should take steps to ensure that the client can breath and to protect the client from injury. In this situation, the nurse should help the client to a flat nonelevated surface and then position him on his side. These steps help reduce the risk of injury from falling or hitting surrounding objects. They also help establish an open airway.
Term
The nurse is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common?

A. excessive tearing
B. urine retention
C. muscle weakness
D. slurred speech
Definition
C. muscle weakness

The most common adverse reaction to dantrolene is muscle weakness. The drug also may depress liver function or cause idiosyncratic hepatitis.
Term
A client who's receiving phenytoin (Dilantin) to control seizures is admitted to the health care facility for observation. The physician orders measurement of the client's serum phenytoin level. Which serum phenytoin level is therapeutic?

A. a level below 5 mcg/ml
B. 10 to 20 mcg/ml
C. 25 to 35 mcg/ml
D. 40 to 50 mcg/ml
Definition
B. 10 to 20 mcg/ml

Clients require individualized dosages of phenytoin to achieve a therapeutic blood drug level of 10 to 20 mcg/ml
Term
A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic exam, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?

A. diencephalon
B. medulla
C. midbrain
D. cortex
Definition
C. midbrain

Decerebrate posturing, characterized by abnormal extension in response to painful stimuli, indicates damage to the midbrain.
Term
with damage to the dienchephalon or cortex, which type of posturing occurs when a painful stimulus is applied?
Definition
decorticate
Term
damage to the medulla results in?
Definition
flaccidity
Term
a client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eyes) response by:

A. introducing ice water into the external auditory canal
B. touching the cornea with a wisp of cotton
C. turning the client's head suddenly while holding the eyelids open
D. shining a bright light into the pupil
Definition
C. turning the client's head suddenly while holding the eyelids open
Term
A client is receiving an IV infusion of mannitol after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?

A. decreased LOC
B. elevated BP
C. increased output
D. decreased HR
Definition
C. increased output

The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output.
Term
When communicating with a client who has sensory (receptive) aphasia, the nurse should:

A. allow time for the client to respond
B. speak loudly and articulate clearly
C. give the client a writing pad
D. use short, simple sentences
Definition
D. use short, simple sentences

Although receptive aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension.
Term
a writing pad would be helpful for clients with what type of aphasia?
Definition
expressive
Term
true or false: the autonomic nervous system regulates involuntary body functions
Definition
true
Term
functions of the nervous system
Definition
controls all motor, sensory, autonomic, cognitive, and behavioral activities
Term
structures of central nervous system
Definition
- brain
- spinal cord
Term
structures of peripheral nervous system
Definition
- cranial and spinal nerves
- autonomic and somatic systems
Term
basic functional unit of the neurologic system is the...
Definition
neuron
Term
how many cranial nerves does the nurse have to assess?

A. ten
B. eleven
C. twelve
D. thirteen
Definition
C. twelve

There are twelve pairs of cranial nerves that emerge from the lower surface of the brain and pass through the foramina in the skull
Term
true or false: cerebral angiography is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture
Definition
false

myelography is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. Cerebral angiography is an x-ray study of the cerebral circulation with a contrast agent injected into a selected artery
Term
altered level of consciousness (LOC)
Definition
- level of responsiveness and consciousness is the most important indicator of the patient's condition
- is a continuum from normal alertness and full cognition to coma
Term
coma
Definition
unconsciousness, unarousable unresponsiveness
Term
akinetic mutism
Definition
unresponsiveness to the environment, makes no movement or sound but sometimes open eyes
Term
persistent vegetative state
Definition
devoid of cognitive function but has sleep-wake cycles
Term
locked-in syndrome
Definition
inability to move or respond except for eye movements due to a lesion affecting the pons
Term
the body temperature of an unconscious patient is never taken by which route?

a. axillary
b. mouth
c. rectal
d. tympanic
Definition
b. mouth
Term
potential problems related to altered LOC
Definition
- respiratory distress/failure
- pneumonia
- aspiration
- pressure ulcur
- DVT
- contractures
Term
what can we do for altered LOC?
Definition
- frequent monitoring of respiratory status including auscultation of lung sounds
- positioning to promote accumulation of secretions and prevent obstruction of upper airway - HOB elevated 30 degrees, lateral or semiprone position
- suctioning, oral hygiene
Term
The nurse is caring for a client who requires ICP monitoring. The nurse should be alert for what major complication of ICP monitoring?

a. coma
b. infection
c. high blood pressure
d. apnea
Definition
b. infection

the catheter for measuring ICP is inserted through a burr hole into a lateral ventricle of the cerebrum, thereby creating a risk of infection.
Term
coma, high blood pressure, and apnea are late signs of?
Definition
increased ICP
Term
a client recovering from a stroke has right-sided hemiplegia and telegraphic speech and often seems frustrated and agitated, especially when trying to communicate. however, the chart indicates that the client's auditory and reading comprehension are intact. the nurse suspects that the client has:

a. global aphasia
b. nonfluent aphasia
c. fluent aphasia
d. anomic aphasia
Definition
b. nonfluent aphasia

nonfluent aphasia is characterized by telegraphic speech, failure to use conjunctions and pronouns, and impaired repetition and ability to read aloud
Term
type of aphasia where spontaneous speech is absent or limited to a few stereotyped words; comprehension is limited to the client's name or a few words
Definition
global aphasia
Term
type of aphasia where auditory comprehension is disturbed, speech lacks meaningful content, is unrelated to questions, and includes paraphasias
Definition
fluent aphasia
Term
type of aphasia in which client can't name objects, has trouble finding words, and may be unable to read or write
Definition
anomic
Term
the nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. which action should the nurse perform?

a. sit with the client for a few minutes
b. administer an analgesic
c. inform the nurse manager
d. call the physician immediately
Definition
d. call the physician immediately

the headache may be an indication that the aneurysm is leaking. the nurse should notify the physician immediately.
Term
a client who recently experienced a stroke tells the nurse that he has double vision. which nursing intervention is the most appropriate?

a. encourage the client to close his eyes
b. alternatively patch one eye every 2 hours
c. turn out the lights in the room
d. instill artificial tears
Definition
b. alternatively patch one eye every 2 hours

patching one eye at a time relieves diplopia.
Term
the nurse is caring for a client with an acute bleeding cerebral aneurysm. the nurse should do all of the following except:

a. position the client to prevent airway obstruction
b. keep the client in one position to decrease the bleeding
c. administer IV fluid as ordered and monitor the client for signs of fluid volume excess
d. maintain the client in a quiet environment
Definition
b. keep the client in one position to decrease the bleeding

the nurse shouldn't keep the client in one position but rather carefully reposition the client often (at least every hour).
Term
the nurse is assessing a client's extraocular eye movements as part of the neurologic examination. Which cranial nerves are the nurse assessing? select all that apply:

1. II
2. III
3. IV
4. V
5. VI
6. VIII
Definition
2, 3, 5
Term
when caring for a client with head trauma, the nurse notes a small amount of clear, watery fluid oozing from the client's nose. what should the nurse do?
Definition
because CSF contains glucose, testing nasal drainage for glucose helps determine whether it's CSF.