NCLEX-PN (Neurology) Questions and answers all correct

NCLEX-PN (Neurology)Cerebrovascular Accident (CVA) ANS: MEDICAL TERM FOR---Stroke: A stroke is when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel Transient ischemic Attack (TIA) ANS: (MINI-STROKE) is a stroke lasts only a few minutes. It happens when the blood supply to part of the brain is briefly blocked. Frontal Craniotomy ANS: craniotomy is the surgical removal of part of the bone from the skull to expose the brain Client went through Frontal Craniotomy, What orders should the nurse expect for the patient? ANS: Administer O2 at 2LPM (prevent hypoxia) Administer Dexamethasone (reduce/prevent Edema) Elevate head of the bed to reduce cerebral edema Nursing intervention in taking care of patient with traumatic brain injury ANS: Elevate Head of the bed Provide relaxing environment such as quiet and darkened room promotes rest and sleep and also helps reduce ICP and seizure episodes What is Subarachnoid Hemorrhage ANS: Subarachnoid hemorrhage, a medical emergency, is usually from a bulging blood vessel that bursts in the brain (aneurysm). If you suspect Spinal Cord injury, How do you administer 2 breaths to a patient? ANS: With a suspected Spinal Cord injury, deliver 2 breath using Jaw-thrust maneuver When should you deliver 2 breaths? ANS: Two breath should be administered every 30 compressions Cerebral Angiogram ANS: is a diagnostic test that can help your doctor find blockages in the blood vessels of your head and neck. These blockages can lead to a stroke or aneurysm. Using the catheter (a long, flexible tube), your doctor will inject a contrast dye into your carotid artery. What happens during the procedure of cerebral Angiogram? ANS: During the procedure, contrast is injected. Afterwards, Radiographic films are taken at various time intervals to visualize the intracranial and extracranial blood vessels. After the procedure, the patient should have fluid forced to help clear the contrast What happens after the procedure (Cerebral Angiogram) ANS: After the procedure the patient is kept on bed rest with the affected extremity kept,immobilized for atleast 4-6 hours to prevent compilation and bleeding at the site. The usual site is the femoral artery. The nurse would assess the site along with the pedal pulse. A weak pulse finding would indicate a complication Patient with Parkinson's Disease ANS: Unless there is difficulty with self feeding, allow the patient independence in self care activities. provide enough time for the patient to eat at his/her own speed What is MYASTHENIA GRAVIS ANS: A weakness and rapid fatigue of muscles under voluntary control. Myasthenia Crisis ANS: A life threatening complication in which the breathing muscle become too weak. Signs are an increase in heart rate, Blood Pressure, respiratory Rate, cyanosis Which cranial nerve deal with movement of the eye? ANS: Cranial Nerve III(3), IV(4), VI(5) Papilledema ANS: Papilledema is a condition in which increased pressure in or around the brain causes the part of the optic nerve inside the eye to swell. Symptoms may be fleeting disturbances in vision, headache, vomiting, or a combination. Assessment finding for a patient with a brain Tumor? ANS: Assessment finding for a patient with a brain tumor Include headache that becomes worse in the morning and with straining and stooping, vomiting, papilledema, seizures, changes in mental status, and altered vision transsphenoidal hypophysectomy ANS: A transsphenoidal hypophysectomy is a surgical procedure most commonly used to remove a tumour of the pituitary gland. Transsphenoidal means through the sphenoid sinus. This is the air sinus (cavity) at the back of your nose. The pituitary tumour is removed through the nose. Hypophysectomy ANS: A hypophysectomy is the surgical removal of the pituitary gland due to a tumor. It is commonly removed transphenoidally, or through the nose. What causes the frequent swallowing after pt underwent transsphenoidal Hypophysectomy ANS: The nasal passage are generally packed after this surgery, and blood draining from the sinuses into the mouth and throat can cause the frequently swallowing Late sign of hemorrhage? ANS: Late sign of HEMORRHAGE is tachycardia(Fast heart beat) Symptoms seen with parkinson's disease and can put a patient at risk of falls ANS: Rigidity(Stiffness), Bradykinesia(slow movement) and small shuffling steps How to assist a post stroke patient? ANS: The chair is placed beside the patient on the strong side, with the nurse on the weaker side to help. What is Guillain Barre Syndrome? ANS: A condition in which the immune system attacks the nerves. An autoimmune disease that demyelination(Destruction) of nerves. The result is Ascending(increase) paralysis that can affect the extremities, respiratory muscles,cranial nerves, and sometimes autonomic function. What is Hemiplegia? ANS: Paralysis on the one side of the body. Depending on the location of the CVA Patient with Right sided CVA? ANS: The effect will be seen on the opposite side of the body. (example: R sided brain damage=Left sided body deficits) Patient w/ Right sided CVA are impulsive and lack judgement. They are unaware of their deficits which put them at high safety risk What is seen on patient with Left Sided CVA? ANS: Impairment of speech and language are seen with Left sided CVA. Damage to Broca's area(frontal Lobe) cause expressive aphasia. Damage to wernicke's area is asssociated with receptive aphasia Glasgow Coma Scale ANS: Glasgow Coma Scale SCORE of 8 or less defines coma. The lowest achievable is 3, which mean deep coma. What is the purpose of snellen chart? ANS: Snellen Chart to assess for visual acuity and to check the function of cranial nerve II, the optic nerve. Another test to check this nerve would be checking the visual field in the four quadrant Decerebrate ANS: Positioning is characterized by rigidity in all four extremities with hyper pronation of the forearms and plantar flexion of the feet(toes pointed). It usually indicates more severe brain damage that decorticate positioning. Patients who are suffering from severe brain trauma may exhibit involuntary responses namely decorticate and decerebrate positioning What is concussion? ANS: Concussion is caused by trauma to the head. It is a transient(lasting for a short time) and reversible neuronal dysfunction marked by instantaneous loss of awareness and responsiveness. The loss of awareness can persist for moments to hours. Patient who has diagnosed with concussion was Discharge from the hospital. What should the nurse include in the discharge instruction? ANS: Vomiting may be a symptoms of increase intracranial pressure and must be reported to the health care provider. Unusual sleepiness,Lethargy, decrease functions, ataxia, slurred speech, or inability to concentrate or foggy thinking should also be reported to the provider Patient with Myasthenia Gravis. What is the priority of the nurse? ANS: Extreme muscle weakness that is increased with activity and reduced with rest is a featured of myasthenia gravis. The nurse must MONITOR THE RESPIRATORY STATUS of the patient frequently as this disease can affect the respiratory What is the first sign of ICP (intracranial Pressure) ANS: A change on LOC is typically the first sign of ICP Sign of ICP ANS: ICP puts pressure on the brainstem. This affects the patient motor function and is indicated by posturing, either decorticate or decerebrate. Decorticate posturing is a stiff body, bent arms, clenched fist and legs straight. Decebrate posturing is a stiff body, arms and legs straight with toes and pointing down, and head and neck arched backwards How to monitory Hypothalamic Function? ANS: It is important to assess urinary Output and temperature. Hypothalamus regulates body temperature, osmolality of body fluids, hunger and satiety Blood Pressure and respirtaroy is controlled by what? ANS: BP and respiratory is controlled by Brainstem What should the nurse perform to decrease ICP? ANS: - Administer Mannitol as ordered -Maintain Neutral Neck Alignment and elevate the head of bed - Space out activities ventriculoperitoneal (VP) shunt ANS: A ventriculoperitoneal (VP) shunt is a medical device that relieves pressure on the brain caused by fluid accumulation Early sign of ICP ANS: Headache Nausea Vomiting Decrease LOC