NRSG 421: Neuro || QUESTIONS WITH 100%
CORRECT ANSWERS!!
Normal neuro assesments correct answers - Sensation and movement, pupils (PERRLA),
general LOC, strength, AOx3, do they have a previous condition affecting neuro?, GCS
Early parkinson signs correct answers - Bradykinesia (slowing down in initiation and
execution of movement)
- Rigidity (increased muscle tone)
- Tremor at rest
-> 2 out of these 3 may have Parkinson's
Late parkinson signs correct answers - Dysphagia, gait, depression, drooling
Main concerns in parkinson correct answers - Falls and dysphagia are main safety concerns.
Making sure they are walking safely
Signs of stroke correct answers - Dropping, slurred speech, weakness, aphasia, fell over,
cannot track a pen
-> FAST-VAN
Stroke diagnostic tool correct answers - A CT scan in order to confirm medical diagnosis->
Dye is hard on kidneys, acts as a diuretic so important to hydrate after
Hold metformin 24 hours before and 48 hours after
- ECG if the stroke could have been caused by Afib
- Always confirm type of stroke before moving to treatment
TPA correct answers TPA in IH for 3 hours but max 4.5 hours (not ideal)
The nurse is completing an assessment on a client with a TBI from a basilar skull fracture.
The nurse is concerned there may be CSF leaking from the clients nose. Which of the
following reported assessment findings indicates the nurse needs more education?
A."the fluid looks clear and is testing positive for glucose"
B."I saw the halo sign on gauze during my assessment"
C."the client is reporting a headache and stiff neck"
D."I asked the client to blow their nose so I can assess if it continues to leak" correct answers
D
Avoid coughing, bearing down, give stool softners, low stimuli
CSF should be clear, not cloudy
Headache is one of the key early signs of CSF leak
Keep them flat if they have a CSF leak
Normal ICP correct answers 15 or less mmHg, anything more than 20 is bad
What can increase ICP correct answers Fluids, brain tumors, inflammation, aterial venous
malformation, hemmorgaic stroke, ischemic stroke (death to tissue causes inflammatory
response can cause swelling
, Earliest signs of increased ICP correct answers Earliest sign is decreased LOC earliest
symptom is headache
Cerebral perfusion pressure correct answers lower pressure that you need to prefuse properly.
If ICP goes up, CPP goes down. Nomral CPP is 70-100, minimum is 60
Late signs of increased ICP correct answers Seizures, decorticate or decerebrate posturing,
coma, hemipelegia, Babinski (toes should fan out in babies but any later this is a bad sign)
The nurse is caring for a client with increased intracranial pressure form a head injury. Which
trend in vital signs would indicate worsening condition? correct answers Increased temp,
decreased HR, increased BP, decreased RR
Aura correct answers They can feel a sign or sensation it is going to come on
The nurse enters the room of a client to complete an assessment. As she walks into the room
the client's facial expression goes from a smile to a blank stare and his extremities begin
jerking. The nurse knows the client is having a seizure. What is the most appropriate next
step the nurse should take? correct answers Move hazards out of the way, protect the head,
lay them onto their side of possible, do not restrain, don't put anything in their mouth
Confusion and altered LOC correct answers •Increased risks with the older adult.
•MMSE (max score is 30, 21 or less= cognitive impairment) MOCA (mild 18-25, moderate
10-17 to severe <10 impairment)- may be shown to be more sensitive to those with
Parkinson's- can both be used for cognitive screening- Dementia
•Geriatric depression scale can help to diagnose depression
•Use CAM and PRISME
AEIOUTIPS correct answers A = Alcohol (liver failure, thiamine deficiency), Acidosis
E = Epilepsy, Endocrine (hypo/hyperglycemia), Electrolytes, Environment
I = Insulin (i.e. hypo- or hyper-glycemia)
O = Overdose, Oxygen depravation (anoxia, hypoxia, hypercapnia)
U = Underdose, Uremia
T = Trauma, Tumor, Toxin
I = Infection
P = Psychiatric, Poison
S = Stroke, Sepsis, Shock, Seizure
autonomic dyreflexia correct answers •Sudden HTN
•Diaphoresis- above injury level
•Headache
•Bradycardia
•Neurological emergency
•T6 and above spinal cord injury
-> 3Bs- (bladder, bowel, breakdown-> bedswheets, holding, stuff too tight). SNS response to
noxious stimuli. Excessive HTN- SBP >150 or 40 over baseline. Can lead to stroke or
seizure.
SIADH correct answers •High ADH
•Early- Weak, muscle cramp
CORRECT ANSWERS!!
Normal neuro assesments correct answers - Sensation and movement, pupils (PERRLA),
general LOC, strength, AOx3, do they have a previous condition affecting neuro?, GCS
Early parkinson signs correct answers - Bradykinesia (slowing down in initiation and
execution of movement)
- Rigidity (increased muscle tone)
- Tremor at rest
-> 2 out of these 3 may have Parkinson's
Late parkinson signs correct answers - Dysphagia, gait, depression, drooling
Main concerns in parkinson correct answers - Falls and dysphagia are main safety concerns.
Making sure they are walking safely
Signs of stroke correct answers - Dropping, slurred speech, weakness, aphasia, fell over,
cannot track a pen
-> FAST-VAN
Stroke diagnostic tool correct answers - A CT scan in order to confirm medical diagnosis->
Dye is hard on kidneys, acts as a diuretic so important to hydrate after
Hold metformin 24 hours before and 48 hours after
- ECG if the stroke could have been caused by Afib
- Always confirm type of stroke before moving to treatment
TPA correct answers TPA in IH for 3 hours but max 4.5 hours (not ideal)
The nurse is completing an assessment on a client with a TBI from a basilar skull fracture.
The nurse is concerned there may be CSF leaking from the clients nose. Which of the
following reported assessment findings indicates the nurse needs more education?
A."the fluid looks clear and is testing positive for glucose"
B."I saw the halo sign on gauze during my assessment"
C."the client is reporting a headache and stiff neck"
D."I asked the client to blow their nose so I can assess if it continues to leak" correct answers
D
Avoid coughing, bearing down, give stool softners, low stimuli
CSF should be clear, not cloudy
Headache is one of the key early signs of CSF leak
Keep them flat if they have a CSF leak
Normal ICP correct answers 15 or less mmHg, anything more than 20 is bad
What can increase ICP correct answers Fluids, brain tumors, inflammation, aterial venous
malformation, hemmorgaic stroke, ischemic stroke (death to tissue causes inflammatory
response can cause swelling
, Earliest signs of increased ICP correct answers Earliest sign is decreased LOC earliest
symptom is headache
Cerebral perfusion pressure correct answers lower pressure that you need to prefuse properly.
If ICP goes up, CPP goes down. Nomral CPP is 70-100, minimum is 60
Late signs of increased ICP correct answers Seizures, decorticate or decerebrate posturing,
coma, hemipelegia, Babinski (toes should fan out in babies but any later this is a bad sign)
The nurse is caring for a client with increased intracranial pressure form a head injury. Which
trend in vital signs would indicate worsening condition? correct answers Increased temp,
decreased HR, increased BP, decreased RR
Aura correct answers They can feel a sign or sensation it is going to come on
The nurse enters the room of a client to complete an assessment. As she walks into the room
the client's facial expression goes from a smile to a blank stare and his extremities begin
jerking. The nurse knows the client is having a seizure. What is the most appropriate next
step the nurse should take? correct answers Move hazards out of the way, protect the head,
lay them onto their side of possible, do not restrain, don't put anything in their mouth
Confusion and altered LOC correct answers •Increased risks with the older adult.
•MMSE (max score is 30, 21 or less= cognitive impairment) MOCA (mild 18-25, moderate
10-17 to severe <10 impairment)- may be shown to be more sensitive to those with
Parkinson's- can both be used for cognitive screening- Dementia
•Geriatric depression scale can help to diagnose depression
•Use CAM and PRISME
AEIOUTIPS correct answers A = Alcohol (liver failure, thiamine deficiency), Acidosis
E = Epilepsy, Endocrine (hypo/hyperglycemia), Electrolytes, Environment
I = Insulin (i.e. hypo- or hyper-glycemia)
O = Overdose, Oxygen depravation (anoxia, hypoxia, hypercapnia)
U = Underdose, Uremia
T = Trauma, Tumor, Toxin
I = Infection
P = Psychiatric, Poison
S = Stroke, Sepsis, Shock, Seizure
autonomic dyreflexia correct answers •Sudden HTN
•Diaphoresis- above injury level
•Headache
•Bradycardia
•Neurological emergency
•T6 and above spinal cord injury
-> 3Bs- (bladder, bowel, breakdown-> bedswheets, holding, stuff too tight). SNS response to
noxious stimuli. Excessive HTN- SBP >150 or 40 over baseline. Can lead to stroke or
seizure.
SIADH correct answers •High ADH
•Early- Weak, muscle cramp
