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level: Level 1 of chapter 14

Questions and Answers List

level questions: Level 1 of chapter 14

QuestionAnswer
increased ICP occurs in patients with acute neurological conditions such asbrain tumor, hemorrhage, anoxic brain injury, and toxic or viral encephalopathies
ICP is most commonly associated withhead injury
subjective data for a diagnosis of ICP include the patients understanding of the condition, andany visual changes such as diploia (double vision)
the earliest sign of ICP ischange in LOC
nursing interventions for ICP to reduce venous volume include:elevate the head of the bed 30-45 degrees to promote venous return & place the neck in a neutral position
types of seizuresgeneralized tonic clinic (grand mal) absence (petit mal) psychomotor (automatisms) jacksonian (focal) miscellaneous (myoclonic and akinetic)
seizures are followed by a rest period of variable length called thepostictal period
aura isa sensation (of light or warmth) or emotion (such as fear) that may precede an attack of migraine or epileptic seizure
types of strokesischemic stroke thrombotic stroke embolic stroke hemorrhagic stroke transient ischemic attack
a TIA should be considered aforerunner of a stroke
central nervous system is made up of thebrain and spinal cord
the peripheral nervous system includesall the nerves that lie outside the CNS
the 2 broad categories of cells within the nervous system are1. neurons 2. neurolglia or glial cells
nerve 1:olfactory
1. olfactory impulses and functionsfrom nose to brain sense of smell
nerve 2:optic
2. optic impulses and functionsfrom eye to brain vision
nerve 3:oculomotor
3. oculomotor impulses and functionsfrom brain to eye muscles eye movements, extraocular muscles, pupillary control
nerve 4:trochlear
4. trochlear impulses and functionfrom brain to external eye muscles down and inward movement of eye
nerve 5:trigeminal
5. trigeminal impulses and functionsfrom skin to mucous membranes of head to brain, from teeth to brain, from brain to facial muscles sensations of face, scalp, teeth, and chewing movements
nerve 6:abducens
6. abducens impulses and functionsfrom brain to external eye muscles outward movement of eye
nerve 7:facial
7. facial impulses and functionsfrom taste buds of tongue to brain, from brain to facial muscles sense of taste, contraction of muscles of facial expression
nerve 8:acoustic
8. acoustic impulses and functionsfrom ear to brain hearing, sense of balance
nerve 9:glassopharyngeal
9. glassopharyngeal impulses and functionsfrom throat and taste buds of tongue to brain, from brain to muscles and salivary glands sensations of throat, taste, swallowing movements, gag reflex, sense of taste, secretion of saliva
nerve 10:vagus
10. vagus impulses and functionsfrom throat, larynx, and organs in thoracic and abdominal cavities to brain from brain to muscles of throat and to organs in thoracic and abdominal cavities secretions of throat, larynx, and thoracic, and abdominal organs, swallowing, voice production, slowing of heartbeat, acceleration of peristalsis
nerve 11:spinal accessory
11 spinal accessory impulses and functionsfrom brain to certain shoulder and neck muscles shoulder movements and turning movements of head
nerve 12:hypoglossal
12. hypoglossal impulses and functionsfrom brain to muscles of the tongue tongue movements
glasgow coma scale eye-opening response4- spontaneous 3- to verbal stimuli 2- to pressure 1- no response
glasgow coma scale verbal response5- oriented 4- confused but able to answer questions 3- words 2- sounds 1- no response
glosgow coma scale motor response6- obeys commands for movement 5- movement to stimulus 4- withdraws in response to pain 3- flexion in response to pain 2- extension in response to pain 1- no response
post procedure for lumbar puncturepatient should lie flat in bed for several hours, assess site for leakage, pain numbness or tingling in extremities
assess for CT scan if use of contrast medium and without use of contrast mediumif use of contrast medium check for allergies to iodine and seafood and without contrast medium pt may be NPO for 4-6 hours before
primary goals for a patient having a seizureprotection from aspiration and injury and observation and recording of the seizure activity
during the demylelination process, the myelin sheath and the sheath cells are destroyed, causingan interruption or distortion of the nerve impulse so that it is slowed or blocked
clinical manifestations for multiple sclerosis have a variety of s/s such asvisual problems, urinary incontinence, fatigue, weakness or in coordination of an extremity, sexual problems such as impotence in men, and swallowing difficulties
stoke is an abnormal condition of the blood vessels of the brain characterized byhemorrhage into the brain or the formation of an embolus or thrombus that occludes an artery, resulting in ischemia of brain tissue
the major importance of TIAs is that theywarn the patient of an underlying pathologic condition
approximately 40% of pts who experience TIAs will have a stroke in2-5 years
most frequently used antiplatelet agentaspirin
hemorrhagic stoke vs ischemic stokehemorrhagic stoke results from bleeding into the brain and an ischemic stoke results from deficient blood flow to the brain from a partial or complete occlusion of an artery
pts with an acute ischemic stoke can benefit from throbolytics such as ______________ that do whattissue plasminogen activator (tPA, alteplase [Activasel]) which digests fibrin and fibrinogen and thus loses the clot
for stoke patient problem insufficient nutrition related to impaired ability to swallow, what are the nursing interventionsthicken liquids with a commercially available thickening agent, do not use a straw
the most frequent long-term disabilities following a stroke arehe i paresis, inability to ambulate, aphasia, depression, and complete or partial dependence on ADLs
with Bell’s palsy clinical manifestations what differentiates it from a strokethe inability to wrinkle the forehead
two abnormal signs that occur with meningitis areKernig’s sign (inability to extend legs without extreme pain) and Brudzinski’s sign (flexion of hip and knee when neck is flexed)
s/s of meningitissevere headache, stiffness of neck, irritability, malaise, and restlessness
autonomic dysreflexia is an abnormal cardiovascular response tostimulation of the sympathetic division of the autonomic nervous system
autonomic dysreflexia s/sbradycardia, hypertension (up to 300mmhg), diaphoresis, “goose flesh”, flushing, dilated pupils, blurred vision, restlessness, nausea, severe headache, and nasal stuffiness