MED-SURG (NR325) ADULT HEALTH II FINAL | FROM
QUESTION TO PERFECTION| STUDY WITH
CONFIDENCE!
Neurological Diagnostic Procedures - Answer: -Cerebral angiography
-cerebral computed tomography (CT) scan
-Electroencephalography (EEG)
-Glasgow coma Scale (GCS)
-ICP monitoring
-spinal tap
-MRI
-Positron emission tomography (PET)
-single-photon emission computed tomography (SPECT)
-radiography (x-ray)
Cerebral angiography - Answer: *indications*: assesses bloodflow to/within brain,
identifies aneurysms, defines tumor vascularity, can be used to inject medications
*intraprocedure*
-catheter placed into artery (groin/neck), dye injected, x-rays taken
-catheter removed once pics are finished, closure device/pressure held over artery to
control bleeding by forming a thrombus and sealing the artery off.
Nursing considerations pre-cerebral angiography - Answer: -weigh benefits before allowing
preg patient to continue
-instruct client: NPO 4-6 hrs before and void right before
-assess for allergies
APPHIA – Crafted with Care and Precision for Academic Excellence.
1
,-obtain hx of bleeding/anticoags
-assess BUN/creatinine to determine ability to excrete dye
-ensure they're wearing 0 jewelry
-mild relaxing sedative sometimes administered, vitals monitored during.
-client will feel warmth through face and taste something metallic as dye is injected
Nursing considerations post-cerebral angiography - Answer: -closely monitor area to
ensure proper clotting
-restrict client's movements depending on procedure used to seal artery
-place ice pack on insertion site
*complications*
-risk for bleeding/hematoma @ site so
--check frequently
--if bleeding occurs, apply pressure & call HCP
-check extremity distal to puncture site for adequate circulation
Intracranial pressure - Answer: -normal is 10-15 mmhg, elevation minimizes cerebral
circulation and can lead to brain death
-monitoring is done for ID/treatment of > ICP.
-patients with GCS scores 8 or lower are candidates
-*s/s increased ICP:*
-severe headache
-irritability
-dilated pupils
-slowness
-breathing alterations
APPHIA – Crafted with Care and Precision for Academic Excellence.
2
,-motor fxn deterioriateion
-abnormal posturing
Lumbar puncture (spinal tap) - Answer: -small amount of CSF withdrawn from spinal canal
and analyzed for constituents
-used to detect presence of diseases (MS, syphilis, meningitis), reduce CSF pressure,
administer meds/chemo, instill medium/air for diagnostics
*possible complications*: brain herniation, bleeding that compresses spinal cord if PT on
anticoags.
Nursing considerations pre-lumbar tap - Answer: -ensure all PT jewelry gone
-instruct PT to void before
-instruct PT to get in "cannonball" position to stretch spinal canal
-local anesthetic injected into area, needle is inserted to withdraw CSF, then removed
Nursing considerations post-lumbar tap procedure - Answer: -monitor puncture site (client
should remain lying for several hrs to ensure site clots/decrease risk of post-lumbar
headache caused by CSF leakage)
-normal activities may be resumed after bedrest if stable
*complications*
-if clotting doesn't occur, CSF can leak, resulting in headache/infection
-prepare client for epidural blood patch to seal hole in dura if headache continues
Confusion Assessment Method - Answer: 1) acute onset and fluctuating course
2) inattention
3) disorganized thinking
4) altered level of consciousness
APPHIA – Crafted with Care and Precision for Academic Excellence.
3
, -used to assess for delirium and confusion
Seizures - Answer: -abrupt, abnormal electrical discharge of neurons in brain causing
alteration in LOC/motor/sensory ability and behavior
-most likely to occur 24 hrs after stroke due to increased ICP
Patient safety during seizure - Answer: -protect client's privacy, keep head off floor and
away from furniture
-provide patent airway, be prepared to suction oral secretions
-turn to side to decrease aspiration risk
-loosen restrictive clothing
-don't try to insert anything in mouth
-document onset/duration of seizure & findings (LOC, apnea, cyanosis, etc) before, during,
after seizure
Patient safety after seizure - Answer: -"postictal" phase
-maintain side position to prevent aspiration
-check vitals
-assess for injuries
-perform neuro checks
-allow PT to rest
-reorient/calm client
-determine if client experienced aura (can indicate seizure origin)
-try to determine possible trigger (fatigue maybe)
Seizure medication - Answer: -antiepileptic drugs (AED'S) like *phenytoin*
APPHIA – Crafted with Care and Precision for Academic Excellence.
4
QUESTION TO PERFECTION| STUDY WITH
CONFIDENCE!
Neurological Diagnostic Procedures - Answer: -Cerebral angiography
-cerebral computed tomography (CT) scan
-Electroencephalography (EEG)
-Glasgow coma Scale (GCS)
-ICP monitoring
-spinal tap
-MRI
-Positron emission tomography (PET)
-single-photon emission computed tomography (SPECT)
-radiography (x-ray)
Cerebral angiography - Answer: *indications*: assesses bloodflow to/within brain,
identifies aneurysms, defines tumor vascularity, can be used to inject medications
*intraprocedure*
-catheter placed into artery (groin/neck), dye injected, x-rays taken
-catheter removed once pics are finished, closure device/pressure held over artery to
control bleeding by forming a thrombus and sealing the artery off.
Nursing considerations pre-cerebral angiography - Answer: -weigh benefits before allowing
preg patient to continue
-instruct client: NPO 4-6 hrs before and void right before
-assess for allergies
APPHIA – Crafted with Care and Precision for Academic Excellence.
1
,-obtain hx of bleeding/anticoags
-assess BUN/creatinine to determine ability to excrete dye
-ensure they're wearing 0 jewelry
-mild relaxing sedative sometimes administered, vitals monitored during.
-client will feel warmth through face and taste something metallic as dye is injected
Nursing considerations post-cerebral angiography - Answer: -closely monitor area to
ensure proper clotting
-restrict client's movements depending on procedure used to seal artery
-place ice pack on insertion site
*complications*
-risk for bleeding/hematoma @ site so
--check frequently
--if bleeding occurs, apply pressure & call HCP
-check extremity distal to puncture site for adequate circulation
Intracranial pressure - Answer: -normal is 10-15 mmhg, elevation minimizes cerebral
circulation and can lead to brain death
-monitoring is done for ID/treatment of > ICP.
-patients with GCS scores 8 or lower are candidates
-*s/s increased ICP:*
-severe headache
-irritability
-dilated pupils
-slowness
-breathing alterations
APPHIA – Crafted with Care and Precision for Academic Excellence.
2
,-motor fxn deterioriateion
-abnormal posturing
Lumbar puncture (spinal tap) - Answer: -small amount of CSF withdrawn from spinal canal
and analyzed for constituents
-used to detect presence of diseases (MS, syphilis, meningitis), reduce CSF pressure,
administer meds/chemo, instill medium/air for diagnostics
*possible complications*: brain herniation, bleeding that compresses spinal cord if PT on
anticoags.
Nursing considerations pre-lumbar tap - Answer: -ensure all PT jewelry gone
-instruct PT to void before
-instruct PT to get in "cannonball" position to stretch spinal canal
-local anesthetic injected into area, needle is inserted to withdraw CSF, then removed
Nursing considerations post-lumbar tap procedure - Answer: -monitor puncture site (client
should remain lying for several hrs to ensure site clots/decrease risk of post-lumbar
headache caused by CSF leakage)
-normal activities may be resumed after bedrest if stable
*complications*
-if clotting doesn't occur, CSF can leak, resulting in headache/infection
-prepare client for epidural blood patch to seal hole in dura if headache continues
Confusion Assessment Method - Answer: 1) acute onset and fluctuating course
2) inattention
3) disorganized thinking
4) altered level of consciousness
APPHIA – Crafted with Care and Precision for Academic Excellence.
3
, -used to assess for delirium and confusion
Seizures - Answer: -abrupt, abnormal electrical discharge of neurons in brain causing
alteration in LOC/motor/sensory ability and behavior
-most likely to occur 24 hrs after stroke due to increased ICP
Patient safety during seizure - Answer: -protect client's privacy, keep head off floor and
away from furniture
-provide patent airway, be prepared to suction oral secretions
-turn to side to decrease aspiration risk
-loosen restrictive clothing
-don't try to insert anything in mouth
-document onset/duration of seizure & findings (LOC, apnea, cyanosis, etc) before, during,
after seizure
Patient safety after seizure - Answer: -"postictal" phase
-maintain side position to prevent aspiration
-check vitals
-assess for injuries
-perform neuro checks
-allow PT to rest
-reorient/calm client
-determine if client experienced aura (can indicate seizure origin)
-try to determine possible trigger (fatigue maybe)
Seizure medication - Answer: -antiepileptic drugs (AED'S) like *phenytoin*
APPHIA – Crafted with Care and Precision for Academic Excellence.
4
