LVN Neuro Exam Questions with Verified Answers

Health History: Neurological Symptoms - Answer- Pain Seizures Dizziness and Vertigo Visual Disturbances Muscle Weakness Abnormal Sensation Health History: Risk Factors - Answer- Trauma Hemorrhage Tumors Infection Toxicity Metabolic Disorder Hypoxic condition Hypertension Stress Cigarette Smoking Aging Process Chemicals, either ingestion or environmental exposure Focused Neurologic Physical Examination/Assessing Consciousness and Cognition - Answer- Mental Status: behavior, orientation, immediate and remote memory Intellectual Function: IQ, serial 7s, recite 5 digits backwards, ability to recognize everyday objects Thought Content: is thought content appropriate and reasonable Emotional Status: does the patient's mood match their affect (facial expression) Language Ability: can patient answer questions, can they read a sentence, aphasia is a deficiency in language function Level of Consciousness (LOC): MOST SENSITIVE INDICATOR OF NEUROLOGICAL STATUS Assessing Consciousness and Cognition - Answer- *If patient has decreased LOC, cranial and motor nerve assessment is priority Cheyne-Stokes: - Answer- rhythmic with periods of apnea, can indicate a metabolic dysfunction or dysfunction in the cerebral hemisphere or basal ganglia Neurogenic Hyperventilation: - Answer- regular, rapid, and deep sustained respirations. Indicates a dysfunction in the low midbrain and middle pons Apneustic: - Answer- Irregular respirations with pauses at the end of inspiration and expiration, indicates dysfunction in the middle or caudal pons Ataxic: - Answer- totally irregular in rhythm and depth, indicates a dysfunction in the medulla Cluster: clusters of breaths with irregularly spaced pauses, indicates a dysfunction in the medulla and pons Level of Consciousness: - Answer- If patient is not alert or able to follow commands, observe for eye opening; note verbal and/or motor response to stimuli, if any; and type of stimuli needed to obtain a response. Noxious stimuli first, then painful stimuli if no response is observed Vital Signs: - Answer- Monitor for blood pressure or pulse changes which may indicate increased intracranial pressure (ICP) A rise in blood pressure with widening pulse pressure, slowing of the pulse, elevated temperature, abnormal respirations. A change in vital signs is a late sign or neurologic deterioration. Fever increases the metabolic rate of the brain, may indicate a dysfunction of the hypothalamus or brainstem Examining the Motor System - Answer- Evaluate individual muscle groups by assessing their size, tone, strength, coordination and balance Note any evidence of atrophy or involuntary movement (tremors or tics) Test muscle strength have having client flex & extend extremities against resistance: compare and rate both sides Examining the Motor System - Answer- 5 = full power 4 = fair but not full strength 3 = just enough to overcome force 2 = can move but not overcome force 1 = weak muscle contraction but no movement 0 = no contraction or movement PUPILS - Answer- Assess and compare size, shape and reactivity. Normally about 3mm in size, round and react briskly to light. Changes from one evaluation to the next may indicate neurologic deterioration. **** It is normal for the elderly to have smaller pupils bilaterally, they also react slower to light. *** Unilateral pupil dilation indicates compression of the third cranial nerve Midposition fixed pupil is an ominous sign which indicates midbrain injury Pinpoint fixed pupils indicates pons damage or drug use Sensory Function - Answer- Pain Temperature Light touch Vibration and position sense Tactile discrimination- ID an object placed in hand with eyes closed Deep Tendon Reflexes - Answer- Biceps Reflex Triceps Reflex Brachioradialis Reflex Patellar Reflex Achilles Reflex Clonus - hyperactive reflex always indicates CNS disease, Superficial Reflexes - Answer- corneal, gag Pathological Reflexes - Answer- Babinski Reflex: abnormal for the toes to fan out Abnormal finding in adult Normal finding in Infant Flexor (Decorticate Posturing) - Answer- patient flexes one or both arms on the chest and may extend the legs stiffly, indicates a nonfunctioning cortex Extensor (Decerebrate Posturing): - Answer- patient stiffly extends one or both arms and possibly the legs, indicates a brainstem lesion Flaccid Posturing: - Answer- the patient displays no motor response in extremity Glasgow Coma Scale - Answer- Measures Eye opening Best verbal response Best motor response 8 indicates coma Initiate nursing care for a patient in a coma. Monitor any patient with decreased LOC for: contractures, DVT, pressure ulcers, and interrupted family processes. Age Related Changes - Answer- Brain weight decreases Loss of neurons-1% per year after 50 General decline (Blood flow and Metabolism) Pupils-smaller and slower to react to light Reflexes slowed Altered sleep/wake cycle Decreased ability to regulate temperature Decrease in nerve velocity CT Scan - Answer- Patient may be NPO 4-8 hours before scan if with contrast Assess kidney function (BUN and creatinine) and shellfish/iodine allergy Procedure is painless and takes 15-20 minutes. Give sedative as ordered for patients who cannot stay still. Post-Procedure Observe for delayed allergic reaction Encourage fluid intake MRI/ Nursing interventions - Answer- Creates images of intracranial structures without radiation MRI screening must be done prior to scan Patients with some metal implants cannot be exposed to MRI because the magnet can cause metal to move in the body. Special oxygen equipment, ventilators, and infusion pumps must be used. Make sure that no patient care equipment that contains metal or metal parts enters the room. The patient must be assessed for the presence of medication patches with foil backing (nicotine) that may cause a burn. NO METAL OBJECTS NEAR MAGNET. Contrast may be used Contraindicated in pregnant women d/t increase in amniotic fluid temperature caused by MRI Cerebral Angiography - Answer- An x-ray of the cerebral circulation with a contrast agent injected into a selected artery. A valuable tool in investigating vascular disease or anomalies. Used to determine vessel patency, identify presence of collateral circulation, and provide detail on vascular anomalies that can be used in planning interventions. Cerebral Angiography - Answer- Performed by threading a catheter through the femoral artery in the groin and up to the desired vessel. X-ray images are obtained as the contrast agent flows through the vessels. May also be used for placing coils in an aneurysm or arteriovenous malformation. Uses computer-based images taken after injection of contrast media to assess abnormalities in cerebral, carotid, and vertebral blood vessels Cerebral Angiography (prep) - Answer- Patient prep Informed consent required Check BUN and Creatinine to ensure kidney function-(to be able to clear contrast agent) Patient should be well hydrated Clear liquids may be permitted up to time of exam Inform radiologist if there is an allergy to contrast media, shellfish, or iodine Remove any metal from head area Assess and mark pulses prior to procedure Tell patient a "dye" will be injected and radiographs taken as the patient lies on a stretcher. When media is injected, patient may feel flushed, warm, nauseated, and report a salty taste. Cerebral Angiography (post) - Answer- Post-procedure Apply pressure to puncture site-femoral site -may place sandbag to site to maintain pressure Assess peripheral pulses Monitor for bleeding Monitor color and temperature of extremity to detect possible embolism Extremity used to inject contrast media; may be immobilized for a specified period of time Assess circulation and neurologic function Allergic response to contrast media causes hives, nausea, swollen salivary glands, treat with antihistamines as ordered Lumbar Puncture - Answer- Insertion of a spinal needle through L3 and L4 or L4 and L5 interspace into the lumbar subarachnoid space to obtain cerebrospinal fluid (CSF), measure CSF fluid or pressure, or administer medications LP Contraindication - Answer- Contraindicated in patients with increased ICP because the procedure will cause a rapid decrease in the pressure within the CSF around the spinal cord, leading to brain herniation Pre-procedure: LP - Answer- Informed consent Explain the procedure Who is responsible for obtaining informed consent? Empty bladder During LP procedure - Answer- Position the client in lateral recumbent position (side lying) and have client draw knees up to the abdomen and chin onto the chest Assist with the collection of specimens (label the specimens in sequence) Maintain strict asepsis Very important to maintain pt. positioning during the procedure Post procedure LP - Answer- Monitor vital signs and neurological signs (assess for numbness or tingling, or pain in the extremities) CSF or bleeding from the puncture site Position the client flat as prescribed: the risk of headache may be reduced by lying flat for a specific period after the procedure Encourage fluids Monitor input and output Promptly deliver labeled specimens to the lab. The first specimen is usually discarded because it may contain blood from the puncture. Lumbar headache: - Answer- may be treated with a blood patch, which is created by injecting a small amount of the patient's blood into the puncture site to seal it and prevent further loss of CSF. Also treated with bed-rest, analgesic, and fluids. Electroencephalography (EEG) - Answer- Tumors, brain abscesses, blood clots, and infection may cause abnormal patterns in electrical activity. The amplified activity of the neurons between any two of these electrodes is recorded on moving pape. Electroencephalography (EEG) - Answer- Represents a record of the electrical activity generated in the brain Obtained through electrodes applied on the scalp Provides assessment of cerebral electrical activity Useful for diagnosing and evaluating seizure disorders, coma, or organic brain syndrome EEG - Answer- -Patient lies quietly with both eyes closed -May be asked to hyperventilate for 3-4 minutes or look at bright, flashing light for phobic stimulation -Activation procedures are done to evoke abnormal electrical discharges, such as seizure potentials -Pt may be deprived of sleep the night before the EEG -Anti-seizure agents, tranquilizers, stimulants, and depressants should be withheld 24-48 hours prior to EEG as these meds may alter EEG patterns or mask the abnormal wave patterns of seizure disorders -Meal is not omitted-low glucose may alter results ICP - Answer- Normal ICP is 5-15 mmHg Causes Cerebral edema Hemorrhage Space-occupying lesions Injury Increased CSF Infection Pathophysiology (ICP) - Answer- The skull is an empty cavity with rigid sides and an opening at the bottom. This cavity contains the brain tissue (1400g), blood (75ml), and CSF (75ml). These are the components that exert pressure in the cranium. Normally ICP is 5-15mmHg (15mmHg- being the upper limit of normal) Hypothalamic impairment- - Answer- resulting in loss of temperature control. As ICP compresses the tissue around the hypothalamus, it becomes ischemic and unable to regulate body temperature Widening pulse pressure. - Answer- ICP elevations evoke an increase in systolic blood pressure with little or no associated increase in diastolic pressure. Initially, heart rate may be slightly accelerated. As ICP compresses the center for cardiac control in the brain stem, the heart rate becomes slow and irregular. Respiratory pattern altered related to the extent of tissue compression REMEMBER-Changes in pulse, respiratory pattern, and blood pressure is late sign of increasing ICP CUSHING'S TRIAD- - Answer- Hypertension, bradycardia, and a widening pulse pressure is generally associated with increased ICP, but it is unreliable in determining the severity of neurologic compromise. Physiology/Pathophysiology - Answer- 1. brain suffers trauma 2. brain swelling or bleeding increases intracranial volume 3.Rigid cranium allows no room for expansion so ICP increases. 4. Pressure on blood vessels causes blood flow to slow 5. cerebral hypoxia and ischemia occur 6. ICP continues to rise. Brain may herniate 7. Cerebral blood flow ceases Increased ICP - Answer- In early stages of ischemia, vasomotor centers are stimulated and the blood pressure rises to maintain adequate cerebral blood flow. Usually this is accompanied by slow bounding pulse and respiratory irregularities Increases in carbon dioxide in the blood and brain causes cerebral vasodilation, leading to a increase in cerebral blood flow which causes an increase in ICP Decrease in carbon dioxide causes vasoconstriction, limiting blood flow to brain. Increased ICP - Answer- At a certain point, the brain's ability to auto-regulate is ineffective and decompensation (ischemia and infarction) begins Significant changes in LOC and vital signs Cushing's Triad - Considered a late sign: At this point brain herniation occurs Bradycardia, increase SBP, decrease DBP, wide pulse pressure decrease RR Early signs of ICP - Answer- Change in level of consciousness (LOC) - most sensitive and earliest indicator Confusion Restlessness Headache Abnormal respirations Elevated temperature Pupillary changes Vomiting Late signs of ICP - Answer- LOC continues to deteriorate until the patient is comatose The pulse rate and respiratory rate decrease Blood pressure increases and widen pulse pressure Projectile vomiting Hemiplegia or decorticate or decerebrate posturing Loss of brain stem reflexes (pupillary, corneal, gag, and swallow reflexes) is ominous sign ICP Infant - Answer- BULGING FONTANELS CRANIAL SUTURE SEPARATION INCREASED HEAD CIRCUMFERENCE HIGH-PITCHED CRY ICP/ MINDCRUSHED - Answer- Mental status changes *earliest sign* - restless, confused Irregular resp patterns Nerve changes to optic and oculomotor - pupil changes Decorticate and decerebrate posturing Crushing triad *late sign* HR, SBP, DBP, wide pulse pressure, RR Reflex - positive babinski Unconscious *late sign* Seizures Headache Emesis - vomiting without nausea, maybe be projectile Deterioration of motor function - hemiplegia ICP Medical Treatment - Answer- Osmotic diuretics: Mannitol Fluid restrictions Elevate HOB 30 to 45 degrees Helps avoid increased ICP Avoids impinging venous drainage Hyperventilation Corticosteroids: Dexamethasone Lower body temperature Maintain Cardiac output Intraventricular catheter to drain and monitor ICP Decreasing Cerebral Edema: - Answer- Osmotic diuretics- (MANNITOL) Corticosteroids-(Dexamethasone) Lowering body temperature-decreases cerebral edema by reducing the oxygen and metabolic requirements of the brain, thus protecting the brain from continued ischemia Osmotic diuretics - Answer- Dehydrates the brain tissue and reduces cerebral edema act by drawing water across intact membranes, reducing the volume of the brain and extracellular fluid. used in coordination with fluid restriction An indwelling urinary catheter should be in place to monitor I&O If the patient is receiving osmotic diuretics serum osmolality should be assessed to determine hydration status Immediate management to relieve increased ICP - Answer- requires decreasing cerebral edema, lowing the volume of CSF, or decreasing cerebral blood volume while maintaining Cerebral perfusion. These goals are accomplished by administering osmotic diuretics, restricting fluids, draining CSF, controlling fever, maintaining systemic blood pressure and oxygenation, and reducing cellular metabolic demands. Reducing Cerebrospinal fluid and Intracranial Blood Volume: - Answer- Hyperventilation-as oxygen delivery to cerebral tissue become more impaired, the level of carbon dioxide in the tissue increases. Increased carbon dioxide leads to dilation of cerebral blood vessels, thereby increasing the cerebral blood volume and ICP Monitored by Arterial Blood gases and Pulse oximetry Controlling Fever: antipyretic & hypothermia blanket Ventriculostomy catheter- - Answer- used for monitoring ICP, a fine-bore catheter is inserted into a lateral ventricle preferably in the non-dominant hemisphere of the brain. The catheter is connected by a fluid filled system to a transducer, which records the pressure in the form of an electrical impulse. This also allows CSF to drain, particularly during acute increases in pressure. Strict aseptic technique is used when changing the drainage bag. Maintaining Cerebral Perfusion: - Answer- Maintain cardiac output-by using fluid volume and inotropic (influencing the force of muscular contractility) agents, such as Dobutamine and Levophed. Effectiveness of cardiac output is reflected in the Cerebral perfusion pressure (CPP) Want to maintain this at greater than 70 mm Hg. A lower CPP indicates that the cardiac output is insufficient to maintain adequate cerebral perfusion. CPP= MAP - ICP CPP= MAP-CVP Nursing Management - Answer- -Monitor respiratory status and prevent hypoxia -Avoid administration of Morphine to prevent hypoxia -Mechanical ventilation is maintained as prescribed -Maintain body temperature -Prevent shivering, which can increase ICP -Decrease stimuli: darken room, tv off, limit visitors -Monitor electrolyte levels and acid-base balance -Strict I & O's: indwelling FC -Fluid restrictions: 1200 mL/day or as prescribed -Elevate HOB 30 degrees -If osmotic diuretic used- monitor daily weights and serum osmolality -Output 200ml/hr. for 2 consecutive hours m