NEURO EXAM #1-MED SURG
QUESTIONS WITH CORRECT ANSWERS
Pt.kiskgointktokhavekmyeologram,kwhatkthe knursekneedsktokdoktokgetkthekpatientkreadykforkthekprocedure?k-
kCORRECTkANSWER--Obtain kankinformed kconsent
-Have kthe kclientkemptykthe kbladder-Verifykallergies-
especiallykthosektokiodinekandkshellfishkandkanykpreviouskreactionsktokcontrast
-explainkthatkprocedure kwillktakekaboutk2khourskandkpuncturekwill kbe kmaidkinkthe klumbarkarea.
-Assesskbaseline klower-extremitieskstrengthskandksensation
-Procedure kinvolveskslightkdiscomfortkandkheadachekiskverykcommonkpost-
procedure.kNauseakandkvomitingkarekpossiblekaskwell.
-postkprocedure kpatientkneedsktokremainkflatkforkakseveralkhours.
tokwithholdkMetforminkifkiodinatdkdye kiskgoingktokbekused,kbecausekof kthe kriskkofkMetformin-
inducedklactickacidosis.
Pt.khaskICP,kwhatkiskthe kbestkpositionktokputkthemkinto?k-kCORRECTkANSWER--
Elevate kthe kheadkof kthe kbedktok30ktok45kdegreesktokpromotekvenouskreturn
-Place kthe kneckkinkakneutralkpositionk(tokflexedkorkextendedk) ktokpromotekvenouskreturn
-
Positionkthekpatientktokavoidkflexionkofkthekhips,kthekwaist,kthekneckkandkrotationkofkthekhead,kespeciallykt
okthe kright.
-
Avoidkextremekhipkflexionkbecausekthiskpositionkcauseskincreasedkintraabdominalkandkintrathoracickpress
ure,kwhichkcankcausekrisekinkICP.
Whatkare kthe ks/skof kICP?k-kCORRECTkANSWER-Clinicalkmanifestations:
-
Askthe kpressurekincreaseskwithinkthekcranial kcavity,kitkiskfirstkcompensatedkforkbykvenouskreturnkandkCSFkdi
splacement.
-
Askthe kpressurekcontinuesktokrise,kthekcerebralkbloodkflowkdecreaseskandkinadequate kperfusionkof kthe kbrai
nkoccurs.
,-Thiskcycle kcauseskPco2ktokincrease kandkthe kPo2kandkPhktokdecrease.
-
These kchangeskcausekvasodilationkandkcerebral kedemakwhichkleadsktokincreasedkcompressionkofkneuralktis
sue kandkincreasedkICP
-
Whenkthe kpressurekbuildupkiskgreaterkthankthekbrain'skabilityktokcompensate,kpressure kiskexertedkonksurro
undingkstructureskwhere kthe kpressurekisklower
-Thiskmovementkof kpressure kiskcalledkSupratentorialkshiftkandkcankresultkinkherniation
-Thiskcankleadktokalterationkinktheklife-
sustainingkmechanismsksuchkaskBloodkpressure,krespirations,ktempeerature,kpulse
-
Late ksigns:Therekiskakrisekinksystolickpressure kwithkunchangedkdiastolickcausingkakwideningkpulsekpressure,k
bradycardia,kabnormal krespirationskwhichkindicate kthatkthere kiskherniationkinkthekbrain.
Subjectivekdata:
-Visual kchangesksuchkaskDiplopia-doublekvision
-Changeskinkpersonalitykandkabilityktokthink
-
Nausea,kpain,kheadachekthatkincreaseskinkintensitykwithkcoughing,kstraining,kstooping.kUsuallykpresentkinkt
he kearlykmorningkandkmaykawakenkthekpt.kfromksleep.
Objective kdata:
-Earliestksign:kChangeskinkLOCk(disorientation, krestlessness,klethargy)
-Pupillaryksigns,ksluggishkreaction,kthekoculomotorknervek(III)kiskcompressed
-Fixedkandkdilatedkpupil-calledkblownkpupil-OminousksignkthatkmustkbekreportedktokthekphysiciankASAP.
-Ipsilateralkpupilkthatkiskunable ktokconstrictkandkremainskdilated
-ChangeskinkBPkandkpulse.kRisingksystolickandkwideningkpulsekpressure
-Cushing'skresponse-wideningkpulse kpressure,kincreasedksystolickBPkandkbradycardiaktogether.
-Respiratorykproblemsk(Cheyne-Stokeskorkdeepkandkstertorus).kAtaxic
Ataxia?k- kCORRECTkANSWER-Impairedkabilityktokcoordinatekmovement.
,Aphasia?k-kCORRECTkANSWER-
Aphasiakiskankabnormalkneurologickconditionkinkwhichkthe klanguage kfunctionkiskdefectivekorkabsentkbecaus
e kbecause kofkankinjuryktokcertainkareaskofkthekcerebralkcortex-
Broca'skareakinkthe kfrontalklobekandkWernicke'skareakinkthekposteriorkpartkofkthe ktemporal klobe.
Aphasiakincludeskallkarekofklanguagge,kincludingkspeech,kreading,kwritingkandkunderstanding. kAphasiakhask
beenksubdividedkaskfollows:
-
Sensorykorkreceptive kaphasia:kInabilityktokcomprehendkthekspokenkwordkorkwrittenkword.kWernicke'skarea
kinkthe ktemporal klobekiskassociated kwithklanguage kcomprehension.
-
Motorkorkexpressive kaphasia:kInabilityktokuseksymbolskofkspeech.kBroca'skareakinkthe kfrontalklobekmediate k
motorkspeech.
-Global kaphasia:kInabilityktokunderstandkthe kspokenkwordkorktoksspeak-
PathologickconditionskinkbothkBroca'skandkWernicke'skareas.
Anomiakiskakformkof kAphasiakcharacterizedkbykinabilitykytokname kobjects.
Dysarthriakiskdifficult,kpoorlykarticulatedkspeechkgenerallykcausedkbykinterference kinkcontrol koverkthe kmusc
leskof kspeechkandkdamagektokcentralkorkperipheral knerve.
Agnosia?k-kCORRECTkANSWER-
Agnosiakiskthektotalkorkpartial klosskofkthekabilityktokrecognizekfamiliarkobjectskbyksight,ktouchkorkhearing,kork
tokrecognize kfamiliarkpeople kthroughksensorkstimulikaskakresultkof korganickbrainkdamage.
Whatkare kthe kLate ksymptomskof kICP?k-kCORRECTkANSWER-Late ksigns:
-Cushing'skressponse-widenedkpulsekpressurekwithkincreasedksystolickBP,kbradycardia
-DilatedkPupils
-Abnormal krespirations
-Hyperthermia
-PositivekBabinski'skreflex
-Posturingk(Decorticate korkDecerebrate)
-Changeskinkmotorkfunctionkfromkweaknessktokhemipledgia.
, Whatkpositionkthe kpatientkshouldkbe kinkforklumbarkpuncture korkspinal ktap?k-kCORRECTkANSWER-
The kpatientkiskusuallykpositionedkonkthe kside kwithkthee kknee kandkheadkflexedkatkankacutekangle.kThiskallow
skforkmaximumklumbarkflexionkandkseparationkofkthekinterspinouskspace.kCSFktapkiskdone kbetweenkthekL4-
L5korkL5-S1kinterspace.
Afterkthe kprocedurekthekpatientkliekflatkforkseveral khours.
Whatknursingkpost-procedure kactionkwouldkbe kappropriatekrightkafterkthekpatientkhadkmyelogram?k-
kCORRECTkANSWER--MonitorkpunctureksitekforkbleedingkandkleakingkofkCSF
-applykpressure ktokthekpuncture ksite
-Positionkpatientkflatkforkseveralkhours
-Assesskthekstrengthkandksensationkof kthe klowerkextremities
-Headache,knauseakandkvomitingkarekcommon
-Prepare kpt.kforkCTkscan,kusuallykdonek4-6khourskpost-myelogram
-Encourage kfluids
-MonitorkVS,kI&O's
Pt.kiskpost-
lumbarkpuncture, kwhatkfinding/observationkwouldkbekofkconcernkandkwouldkrequirektokcallkthekMD?k-
kCORRECTkANSWER--LeakagekofkCSF
-ChangeskinkLOC
-Decreasedkstrengthkandksensationkinklowerkextremities
-bleedingkfromkpunctureksite
Whatknursingkinstructionskare kgivenktokpt.kwhokiskgoingktokhavekCTkofkthekhead?k-kCORRECTkANSWER--
Obtainkankinformedkconsentkifkakdyekiskgoingktokbekused
-AssesskforkallergiesktokIodine,kshellfish,kcontrastkdyes
-Instructkclientkonkthekneedktoklie kstillkandkflatkduringkprocedure
-instructkthe kclientktokremove kanykmetalkobjectsksuchkaskjewlery,khairpins,kwigs
-Instructktokholdkbreathkwhenkindicated
-Initiate kankIV kline
QUESTIONS WITH CORRECT ANSWERS
Pt.kiskgointktokhavekmyeologram,kwhatkthe knursekneedsktokdoktokgetkthekpatientkreadykforkthekprocedure?k-
kCORRECTkANSWER--Obtain kankinformed kconsent
-Have kthe kclientkemptykthe kbladder-Verifykallergies-
especiallykthosektokiodinekandkshellfishkandkanykpreviouskreactionsktokcontrast
-explainkthatkprocedure kwillktakekaboutk2khourskandkpuncturekwill kbe kmaidkinkthe klumbarkarea.
-Assesskbaseline klower-extremitieskstrengthskandksensation
-Procedure kinvolveskslightkdiscomfortkandkheadachekiskverykcommonkpost-
procedure.kNauseakandkvomitingkarekpossiblekaskwell.
-postkprocedure kpatientkneedsktokremainkflatkforkakseveralkhours.
tokwithholdkMetforminkifkiodinatdkdye kiskgoingktokbekused,kbecausekof kthe kriskkofkMetformin-
inducedklactickacidosis.
Pt.khaskICP,kwhatkiskthe kbestkpositionktokputkthemkinto?k-kCORRECTkANSWER--
Elevate kthe kheadkof kthe kbedktok30ktok45kdegreesktokpromotekvenouskreturn
-Place kthe kneckkinkakneutralkpositionk(tokflexedkorkextendedk) ktokpromotekvenouskreturn
-
Positionkthekpatientktokavoidkflexionkofkthekhips,kthekwaist,kthekneckkandkrotationkofkthekhead,kespeciallykt
okthe kright.
-
Avoidkextremekhipkflexionkbecausekthiskpositionkcauseskincreasedkintraabdominalkandkintrathoracickpress
ure,kwhichkcankcausekrisekinkICP.
Whatkare kthe ks/skof kICP?k-kCORRECTkANSWER-Clinicalkmanifestations:
-
Askthe kpressurekincreaseskwithinkthekcranial kcavity,kitkiskfirstkcompensatedkforkbykvenouskreturnkandkCSFkdi
splacement.
-
Askthe kpressurekcontinuesktokrise,kthekcerebralkbloodkflowkdecreaseskandkinadequate kperfusionkof kthe kbrai
nkoccurs.
,-Thiskcycle kcauseskPco2ktokincrease kandkthe kPo2kandkPhktokdecrease.
-
These kchangeskcausekvasodilationkandkcerebral kedemakwhichkleadsktokincreasedkcompressionkofkneuralktis
sue kandkincreasedkICP
-
Whenkthe kpressurekbuildupkiskgreaterkthankthekbrain'skabilityktokcompensate,kpressure kiskexertedkonksurro
undingkstructureskwhere kthe kpressurekisklower
-Thiskmovementkof kpressure kiskcalledkSupratentorialkshiftkandkcankresultkinkherniation
-Thiskcankleadktokalterationkinktheklife-
sustainingkmechanismsksuchkaskBloodkpressure,krespirations,ktempeerature,kpulse
-
Late ksigns:Therekiskakrisekinksystolickpressure kwithkunchangedkdiastolickcausingkakwideningkpulsekpressure,k
bradycardia,kabnormal krespirationskwhichkindicate kthatkthere kiskherniationkinkthekbrain.
Subjectivekdata:
-Visual kchangesksuchkaskDiplopia-doublekvision
-Changeskinkpersonalitykandkabilityktokthink
-
Nausea,kpain,kheadachekthatkincreaseskinkintensitykwithkcoughing,kstraining,kstooping.kUsuallykpresentkinkt
he kearlykmorningkandkmaykawakenkthekpt.kfromksleep.
Objective kdata:
-Earliestksign:kChangeskinkLOCk(disorientation, krestlessness,klethargy)
-Pupillaryksigns,ksluggishkreaction,kthekoculomotorknervek(III)kiskcompressed
-Fixedkandkdilatedkpupil-calledkblownkpupil-OminousksignkthatkmustkbekreportedktokthekphysiciankASAP.
-Ipsilateralkpupilkthatkiskunable ktokconstrictkandkremainskdilated
-ChangeskinkBPkandkpulse.kRisingksystolickandkwideningkpulsekpressure
-Cushing'skresponse-wideningkpulse kpressure,kincreasedksystolickBPkandkbradycardiaktogether.
-Respiratorykproblemsk(Cheyne-Stokeskorkdeepkandkstertorus).kAtaxic
Ataxia?k- kCORRECTkANSWER-Impairedkabilityktokcoordinatekmovement.
,Aphasia?k-kCORRECTkANSWER-
Aphasiakiskankabnormalkneurologickconditionkinkwhichkthe klanguage kfunctionkiskdefectivekorkabsentkbecaus
e kbecause kofkankinjuryktokcertainkareaskofkthekcerebralkcortex-
Broca'skareakinkthe kfrontalklobekandkWernicke'skareakinkthekposteriorkpartkofkthe ktemporal klobe.
Aphasiakincludeskallkarekofklanguagge,kincludingkspeech,kreading,kwritingkandkunderstanding. kAphasiakhask
beenksubdividedkaskfollows:
-
Sensorykorkreceptive kaphasia:kInabilityktokcomprehendkthekspokenkwordkorkwrittenkword.kWernicke'skarea
kinkthe ktemporal klobekiskassociated kwithklanguage kcomprehension.
-
Motorkorkexpressive kaphasia:kInabilityktokuseksymbolskofkspeech.kBroca'skareakinkthe kfrontalklobekmediate k
motorkspeech.
-Global kaphasia:kInabilityktokunderstandkthe kspokenkwordkorktoksspeak-
PathologickconditionskinkbothkBroca'skandkWernicke'skareas.
Anomiakiskakformkof kAphasiakcharacterizedkbykinabilitykytokname kobjects.
Dysarthriakiskdifficult,kpoorlykarticulatedkspeechkgenerallykcausedkbykinterference kinkcontrol koverkthe kmusc
leskof kspeechkandkdamagektokcentralkorkperipheral knerve.
Agnosia?k-kCORRECTkANSWER-
Agnosiakiskthektotalkorkpartial klosskofkthekabilityktokrecognizekfamiliarkobjectskbyksight,ktouchkorkhearing,kork
tokrecognize kfamiliarkpeople kthroughksensorkstimulikaskakresultkof korganickbrainkdamage.
Whatkare kthe kLate ksymptomskof kICP?k-kCORRECTkANSWER-Late ksigns:
-Cushing'skressponse-widenedkpulsekpressurekwithkincreasedksystolickBP,kbradycardia
-DilatedkPupils
-Abnormal krespirations
-Hyperthermia
-PositivekBabinski'skreflex
-Posturingk(Decorticate korkDecerebrate)
-Changeskinkmotorkfunctionkfromkweaknessktokhemipledgia.
, Whatkpositionkthe kpatientkshouldkbe kinkforklumbarkpuncture korkspinal ktap?k-kCORRECTkANSWER-
The kpatientkiskusuallykpositionedkonkthe kside kwithkthee kknee kandkheadkflexedkatkankacutekangle.kThiskallow
skforkmaximumklumbarkflexionkandkseparationkofkthekinterspinouskspace.kCSFktapkiskdone kbetweenkthekL4-
L5korkL5-S1kinterspace.
Afterkthe kprocedurekthekpatientkliekflatkforkseveral khours.
Whatknursingkpost-procedure kactionkwouldkbe kappropriatekrightkafterkthekpatientkhadkmyelogram?k-
kCORRECTkANSWER--MonitorkpunctureksitekforkbleedingkandkleakingkofkCSF
-applykpressure ktokthekpuncture ksite
-Positionkpatientkflatkforkseveralkhours
-Assesskthekstrengthkandksensationkof kthe klowerkextremities
-Headache,knauseakandkvomitingkarekcommon
-Prepare kpt.kforkCTkscan,kusuallykdonek4-6khourskpost-myelogram
-Encourage kfluids
-MonitorkVS,kI&O's
Pt.kiskpost-
lumbarkpuncture, kwhatkfinding/observationkwouldkbekofkconcernkandkwouldkrequirektokcallkthekMD?k-
kCORRECTkANSWER--LeakagekofkCSF
-ChangeskinkLOC
-Decreasedkstrengthkandksensationkinklowerkextremities
-bleedingkfromkpunctureksite
Whatknursingkinstructionskare kgivenktokpt.kwhokiskgoingktokhavekCTkofkthekhead?k-kCORRECTkANSWER--
Obtainkankinformedkconsentkifkakdyekiskgoingktokbekused
-AssesskforkallergiesktokIodine,kshellfish,kcontrastkdyes
-Instructkclientkonkthekneedktoklie kstillkandkflatkduringkprocedure
-instructkthe kclientktokremove kanykmetalkobjectsksuchkaskjewlery,khairpins,kwigs
-Instructktokholdkbreathkwhenkindicated
-Initiate kankIV kline