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NEUROLOGY - NCLEX
Terms in this set (109)
Phenomenon: After an acute ischemic stroke, the body senses the need for increased pressure to perfuse the penumbra (area of swollen and vulnerable but salvageable brain tissue) to keep the stroke from extending), autocorrects within 24 - 48 hours without treatment
>220/120 mm Hg
Blood pressure that would require treatment after ischemic stroke or hemorrhagic stroke
labetalol [Normodyne], nicardipine [Cardene]
IV antihypertensives that are often used if medication is required for acute stroke treatment; Blood pressure should be lowered cautiously by about 15% within the first 24 hours; Rapid blood pressure reduction may prolong the stroke
Emphasizes the skills necessary for activities of daily living (eg, dressing, bathing, cognitive or perception issues; Above the waist
focuses on mobility, ambulation, ability to transfer, and use of related equipment
Refers to impairment or loss of language comprehension (ie, speech, reading) that is caused by a neurological condition (eg, stroke, traumatic brain injury)
Opioid medications -- the nurse should clarify what medication the client has at home; also avoid alcohols and CNS depressants (e.g. benzo's)
Type of medications that should be avoided following a head injury
a progressive, demyelinating disease of the central nervous system that interrupts nerve impulses, causing a variety of symptoms.
An accumulation of blood between the skull bone and dura mater
Transient time where the client may lose consciousness at the time of impact. The client then regains consciousness quickly and feels well for some time after the injury
An inflammation of the facial nerve (CN VII) in the absence of other disease etiologies
A flaccid extremity and change in verbal ability
symptoms of a stroke, which is considered an emergency.
Medications are used only in ischemic strokes, so the head CT must be completed to confirm the type of stroke (ischemic versus hemorrhagic)
Presents with paroxysms of unilateral excruciating facial pain along the distribution of the trigeminal nerve (CN V) that are often triggered by touch, talking, or hot/cold air or intake.
Drug for trigeminal neuralgia
Steroids, measures to relieve symptoms, and protection of the eye (which may not close tightly),
Treatment for Bell's Palsy
increased drowsiness, difficulty arousing, worsening headache or stiff neck, blurring, difficulty walking, slurred speech, sensory disturbances, seizures, Nausea and vomiting ,bradycardia
Symptoms of ICP
alcohol, muscle relaxants, opioids; and driving, operating heavy machinery
Client should abtain from what when suspecting icp or head injury
Gait abnormality --> go back to ER
7 - 10 mmHG
ICP normal level
refers to the increased confusion experienced by an individual with dementia; it occurs at night, when lighting is inadequate, or when the client is excessively fatigued. Wandering is a common associated behavior
Epileptic medication - don't use with oral contraceptives and it causes gingival hyperplasia (inflammation of gums)
A client with mild-to-moderate dementia may need frequent _____________________
Involves recognizing and exploring the client's feelings and concerns but not reinforcing or arguing with any incorrect perceptions.
an inflammation of the meninges covering the brain and spinal cord
Fever, headache, nuchal rigidity, photophobia, nausea and vomiting
manifestations of bacterial meningitis
head CT scan
Prior to a lumbar puncture (LP), obtain a _____________________ as increased ICP or mass lesions may contraindicate a LP due to the risk of brain herniation
purulent and turbid
CSF is usually _____________________ and _____________________ in clients with bacterial meningitis
is characterized by acute behavior changes and confusion that have an acute onset, and it is usually reversible
infections, medications and hypoxia
Common causes of delirium
mildly elevated temperature, respiratory rate, and hypoxia (O2 sats is low); pleuritic chest pain, productive cough and crackles in the lungs
signs of pulmonary infection
time range for systemic tissue plasminogen activator [tPA] thrombolytic treatment
time range for intra-arterial tPA thrombolytic treatment
muscle weakness, spasticity, incoordination, loss of balance, and fatigue
Symptoms of MS
Walking with the feet apart increases the support base, improving steadiness and gait; use of assistive device like cane or walker
interventions to help with MS
Amyotrophic lateral sclerosis (ALS; Lou Gehrig disease)
It causes progressive degeneration of motor neurons in the brain and spinal cord
fatigue, progressive muscle weakness, twitching and muscle spasms, difficulty swallowing, difficulty speaking, and respiratory failure
symptoms of ALS
Is a loss in half of the visual field on the same side
Poor thiamine intake or absorption
Wernicke's Encelopathy, mostly found in chronic alcohol users d/t poor nutrition
brief loss of consciousness, retrograde amnesia and headache
3 symptoms of concussion
Inability to completely close the eye on the affected side;
Flattening of the nasolabial fold on the side of the paralysis; lteration in tear production (eg, decreased tearing with extreme dryness, excessive tearing) due to lower eyelid muscle weakness
peripheral, unilateral facial paralysis characterized by inflammation of the facial nerve (cranial nerve VII) in the absence of a stroke or other causative agent/disease
prototype of nifedipine and is a potent calcium channel blocking vasodilator. It takes effect within 1 minute of IV administration. It is essential to monitor that the blood pressure is not being lowered too quickly or too slowly as this would extend the stroke.
Occurs when a blood vessel ruptures in the brain and causes bleeding into the brain tissue or subarachnoid space
lobe of the brain registers visual images
lobe controls higher-order processing, such as executive function and personality
lobe integrates visual and auditory input and past experiences
lobe integrates somatic and sensory input
A symptom without nausea can be a sign of increased ICP, especially in the client with a history of increased ICP
affects the vasomotor center in the medulla and causes a disruption in the sympathetic nervous system (SNS)
characteristic manifestation of neurogenic shock, occurs as a result of this alteration in neural activity between the 2 system
a technique that allows them to have voluntary control over closing the vocal cords to protect themselves from aspiration
Cranial Nerve IX (glossopharyngeal)
is involved in the gag reflex, ability to swallow, phonation, and taste.
Arteriovenous malformation (AVM)
tangled vessels do not have a capillary bed, causing them to become weak and dilated
A coup-contrecoup head injury
occurs when the head strikes an object and the brain receives an injury under the area of impact , after which it rebounds to the opposite side of the skull and sustains injury on that side as well
an osmotic diuretic used to treat cerebral edema (increased intracranial pressure) and acute glaucoma
Guillain-Barré syndrome (GBS)
is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle weakness and absent deep-tendon reflexes
Autonomic Dysreflexia (autonomic hyperreflexia)
is a massive, uncompensated cardiovascular reaction by the sympathetic nervous system (SNS) in a spinal injury at T6 or higher.
severe hypertension, throbbing headache, marked diaphoresis above the level of injury, bradycardia, piloerection (goose bumps), and flushing.
Manifestations of autonomic dysreflexia
Distended bladder or rectum
Classic triggers of autonomic dysreflexia
Raise head of the bed and treat the cause
treatment / management of autonomic dysreflexia
Parkinson's disease (PD)
is a chronic, progressive neurodegenerative disorder that involves degeneration of the dopamine-producing neurons. Damage to dopamine neurons makes it difficult to control muscles through smooth movement.
Symptoms of Parkinson's disease
characterized by a delay in initiation of movement (bradykinesia), increased muscle tone (rigidity), resting tremor, and shuffling gait.
Normal muscle strength
3-5 mm in diameter
positive babinki's reflex in adults
indicates an upper motor neuron (brain or spinal cord) lesion
is an autoimmune disease manifesting mainly as muscle weakness and ptosis. The muscle weakness increases with activity, and by the end of the day, ptosis is present
Drug used to stimulate the sinoatrial node in bradycardia with systemic symptoms. An electrocardiogram (ECG) should be obtained prior to administering this drug
bradycardia, increased systolic blood pressure with a widening pulse pressure (difference between systolic and diastolic), and slowed irregular (Cheyne-Stokes)
symptom's of cushing's triad
clear and colorless, and contains a little protein, a little glucose, minimal white blood cells, no red blood cells, and no microorganisms; normal pressure of 60-150 mmH20
normal findings of CSF
Crackles in the lungs
major side effect of mannitol , suggest fluid overload (pulmonary edema) -- life threatening
cerebellum 2 major functions
- coordination of voluntary movements and maintenance of balance and posture
1. Finger tapping - ability to touch each finger of one hand to the hand's thumb (Option 4).
2. Rapid alternating movements - rapid supination and pronation
3. Finger-to-nose testing - clients touch the clinician's finger and then their own nose as the clinician's finger varies in location
4. Heel-to-shin testing - client runs each heel down each shin while in a supine position
assessed with gait testing and includes watching the client's normal gait first and then the gait on heel-to-toe (tandem), on toes, and on heels
coup-contrecoup head injury
type of head injury common in motor vehicle accidents and shaken baby syndrome
rate and dept of respirations are regulated by this part of the brain
inability to express spoken words, occurs after a transient ischemic attack or stroke. This will occur if the frontal lobe (Broca aphasia) or temporal lobe (Wernicke aphasia) is injured
assessment whether need to immobilize spine in suspected injury
N - Neurological examination. Focal deficits include numbness and decreased strength.
S - Significant traumatic mechanism of injury
A - Alertness. The client may be disoriented or have an altered level of consciousness (Option 2).
I - Intoxication. The client could have impaired decision-making ability or lack awareness of pain (Option 1).
D - Distracting injury. Another significant injury could distract the client from spinal pain.
S - Spinal examination. Point tenderness over the spine or neck pain on movement (if there is no midline tenderness) may be presen
is an autoimmune disease involving a decreased number of acetylcholine receptors at the neuromuscular junction.
most often presented as ptosis/diplopia, bulbar signs(difficulty speaking or swallowing), and difficulty breathing. Muscles are stronger in the morning and become weaker with the day's activity as the supply of available acetylcholine is depleted
symptoms of Myasthenia Gravis
Anticholinesterase drugs -
Common treatment for Myasthenia Gravis; give before meals
involves removing a sample of cerebrospinal fluid through a needle inserted between vertebrae.
Elevated intracranial pressure
Contraindicated for lumbar puncture
Fetal position or sitting and leaning over a table
Position for LP
Continued leaking in the puncture site after LP
indicates that the site did not seal off and a blood patch (autologous blood into the epidural space) is required.
Coughing, straining and blowing the nose
Contraindicated for clients with ICP
1. Daydreaming episodes or brief (<10 seconds) staring spells
2. Absence of warning and postictal phases
3. Absence of other forms of epileptic activity (no myoclonus or tonic-clonic activity)
4. Unresponsiveness during the seizure
5. No memory of the seizure
Symptoms of Absence Seizures
Good oral and eye care
Care needed for Bell's palsy patients
is the period with warning signs that precede the seizure (before the aural phase)
is the period before the seizure when the client may experience visual or other sensory changes. Not all clients experience or can recognize a prodromal or aural phase before the seizure
The period of active seizure activity.
the client may experience confusion while recovering from the seizure. The client may also experience a headache.
there will be only a brief loss of consciousness without prolonged post-event confusion.
ruptured cerebral aneurysm
is a surgical emergency with a high mortality rate; abrupt onset of "the worst headache of my life" that is different from previous headaches (including migraines).
Cranial Nerve I
Is the olfactory sensory nerve. This nerve is tested by having the client identify a readily recognized odor
Cranial Nerve III
is a motor nerve of the eye, which is tested by having the client track an object, such as a finger, through the fields of vision
is the optic nerve and is a sensory nerve. It is assessed by testing the fields of vision for the client's ability to see objects in the field
The nurse should speak clearly, ask simple "yes" or "no" questions, and use gestures and pictures to increase understanding.
refers to impaired comprehension of speech and writing;
Refers to loss of the ability to perform a learned movement (eg, whistling, clapping, dressing) due to neurological impairment
is weakness of the muscles used for speech. Pronunciation and articulation are affected. Comprehension and the meaning of words are intact, but speech is difficult to understand (eg, mumble, lisp)
refers to difficulty swallowing. The term dysphagia is often confused with dysphasia. Clients with motor deficits after a stroke may have dysphagia, which requires swallowing precautions to prevent aspiration
occurs when the lower limbs are completely paralyzed and there is complete or partial paralysis of the upper limbs. This is usually due to injury of the cervical spinal cord.
Airway and oxygenation assessment - assess breath sounds, accessory muscle use, vital capacity, tidal volume, and arterial blood gas values (if prescribed
Priority assessment for a client who is tetraplegic
Droplet Precaution Isolation
The client with suspected bacterial meningitis should be placed on _____________
The oculomotor (cranial nerve III), trochlear (cranial nerve IV), and abducens (cranial nerve VI
are motor nerves of the eye that are tested by having the client track an object, such as a finger, through the fields of vision; also tested by checking for pupillary constriction and accommodation (constriction with near vision).
Deficits in cranial nerves III, IV, and VI
include disconjugate gaze (eyes do not move together), nystagmus (fine, rapid jerking eye movements), or ptosis (drooping of the eyelid).
Cranial nerve II
This nerve is assessed by testing the fields of vision for the client's ability to see objects in the field.
Cranial nerve V
The sensory portion of this nerve is assessed by testing sensation at the ophthalmic (forehead), maxillary (cheekbone), and mandibular (jaw line) branches by light touch. Corneal sensation is also a portion of the trigeminal nerve, but this is typically not tested by the nurse.
Serial neurologic assessments
1. Glasgow Coma Scale (GCS)—best eye, verbal, and motor responses. Best verbal response assesses orientation to person, place, and time (time is the most sensitive).
2. Pupils—equal, round, response to light, and accommodate (PERRLA)
3. Motor—strength and movement in all four extremities
Vital signs—especially any signs of Cushing's triad of bradycardia, bradypnea/abnormal breathing pattern and widening pulse pressure (the difference between systolic and diastolic blood pressure readings). The nurse is assessing for signs of increased intracranial pressure (ICP).
Range from 3 - 15
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