Neurological Problems (Exam Mode) By Rnpedia.Com

The priority for interdisciplinary care for the patient experiencing a migraine headache is pain management. All of the other nursing diagnoses are accurate, but none of them is as urgent as the issue of pain, which is often incapacitating. Focus: Prioritization

Taking vital signs is within the education and scope of practice for a nursing assistant. The nurse should perform neurologic checks and document the seizure. Patients with seizures should not be restrained; however, the nurse may guide the patient’s movements as necessary. Focus: Delegation/supervision

The changes that the nursing assistant is reporting are characteristics of myasthenia crisis, which often follows some type of infection. The patient is at risk for inadequate respiratory function. In addition to notifying the physician, the nurse should carefully monitor the patient’s respiratory status. The patient may need incubation and mechanical ventilation. The nurse would notify the physician before giving the suppository because there may be orders for cultures before giving acetaminophen. This patient’s vital signs need to be re-checked sooner than 1 hour. Rescheduling the physical therapy can be delegated to the unit clerk and is not urgent. Focus: Prioritization

Meningococcal meningitis is spread through contact with respiratory secretions so use of a mask and gown is required to prevent spread of the infection to staff members or other patients. The other actions may not be appropriate but they do not require intervention as rapidly. The presence of a family member at the bedside may decrease patient confusion and agitation. Patients with hyperthermia frequently complain of feeling chilled, but warming the patient is not an appropriate intervention. Checking the pupil response to light is appropriate, but it is not needed every 30 minutes and is uncomfortable for a patient with photophobia. Focus: Prioritization

The priority action during a generalized tonic-clonic seizure is to protect the airway. Administration of lorazepam should be the next action, since it will act rapidly to control the seizure. Although oxygen may be useful during the postictal phase, the hypoxemia during tonic-clonic seizures is caused by apnea. Checking the level of consciousness is not appropriate during the seizure, because generalized tonic-clonic seizures are associated with a loss of consciousness. Focus: Prioritization

The first priority for the patient with an SCI is assessing respiratory patterns and ensuring an adequate airway. The patient with a high cervical injury is at risk for respiratory compromise because the spinal nerves (C3 – 5) innervate the phrenic nerve, which controls the diaphragm. The other assessments are also necessary, but not as high priority. Focus: Prioritization

The patient’s history and assessment data indicate that he may have a chronic subdural hematoma. The priority goal is to obtain a rapid diagnosis and send the patient to surgery to have the hematoma evacuated. The other interventions also should be implemented as soon as possible, but the initial nursing activities should be directed toward treatment of any intracranial lesion. Focus: Prioritization

A patient with a seizure disorder should not take over-the-counter medications without consulting with the physician first. The other three statements are appropriate teaching points for patients with seizures disorders and their families. Focus: Delegation/supervision

Exercises are used to strengthen the back, relieve pressure on compressed nerves and protect the back from re-injury. Ice, heat, and firm mattresses are appropriate interventions for back pain. People with chronic back pain should avoid wearing high-heeled shoes at al times. Focus: Prioritization

The priority interventions for the patient with GBS are aimed at maintaining adequate respiratory function. These patients are risk for respiratory failure, which is urgent. The other findings are important and should be reported to the nurse, but they are not life-threatening. Focus: Prioritization, delegation/supervision

Alteplase is a clot buster. With patient who has experienced hemorrhagic stroke, there is already bleeding into the brain. A drug like alteplase can worsen the bleeding. The other statements are also accurate about use of alteplase, but they are not pertinent to this patient’s diagnosis. Focus: Prioritization

The nursing assistant’s training and education include taking and recording patient’s vital signs. The nursing assistant may assist with turning and repositioning the patient and may remind the patient to cough and deep breathe but does not teach the patient how to perform these actions. Assessing and monitoring patients require additional education and are appropriate to the scope of practice for professional nurses. Focus: Delegation/supervision

This patient is the most stable of the patients listed. An RN from the medical unit would be familiar with administration of IV antibiotics. The other patients require assessments and care from RNs more experienced in caring for patients with neurologic diagnoses. Focus: Assignment.

Positioning the patient in a sitting position decreases the risk of aspiration. The nursing assistant is not trained to assess gag or swallowing reflexes. The patient should not be rushed during feeding. A patient who needs to be suctioned between bites of food is not handling secretions and is at risk for aspiration. This patient should be assessed further before feeding. Focus: Delegation/supervision

At this time, based on the patient’s statement, the priority is Self-Care Deficit related to fatigue after physical therapy. The other three nursing diagnoses are appropriate to a patient with MS, but they are not related to the patient’s statement. Focus: Prioritization

The patient’s statement indicates impairment of adjustment to the limitations of the injury and indicates the need for additional counseling, teaching, and support. The other three nursing diagnoses may be appropriate to the patient with SCI, but they are not related to the patient’s statement. Focus: Prioritization

The husband’s statement about lack of sleep and anxiety over whether the patient is receiving the correct medications are behaviors that support this diagnosis. There is no evidence that the patient’s cardiac output is decreased. The husband’s statements about how he monitors the patient and his concern with medication administration indicate that the Risk for Ineffective Therapeutic Regimen Management and falls are not priorities at this time.
Focus: Prioritization

Urinary tract infections are a frequent complication in patient with multiple sclerosis because of the effect on bladder function. The elevated temperature and decreased breath sounds suggest that this patient may have pyelonephritis. The physician should be notified immediately so that antibiotic therapy can be started quickly. The other patients should be assessed soon, but do not have needs as urgent and this patient. Focus: Prioritization

Patients with right cerebral hemisphere stroke often present with neglect syndrome. They lean to the left and when asked, respond that they believe they are sitting up straight. They often neglect the left side of their bodies and ignore food on the left side of their food trays. The nurse would need to remind the student of this phenomenon and discuss the appropriate interventions. Focus: Delegation/supervision

The LPN/LVN can set up the equipment for oxygen and suctioning. The RN should perform the complete initial assessment. Padded side rails are controversial in terms of whether they actually provide safety and ay embarrass the patient and family. Tongue blades should not be at the bedside and should never be inserted into the patient’s mouth after a seizure begins. Focus: Delegation/supervision.

The traveling is relatively new to neurologic nursing and should be assigned patients whose conditions are stable and not complex. The newly diagnosed patient will need to be transferred to the ICU. The patient with C4 SCI is at risk for respiratory arrest. All three of these patients should be assigned to nurses experienced in neurologic nursing care. Focus: Assignment

These signs and symptoms are characteristic of autonomic dysreflexia, a neurologic emergency that must be promptly treated to prevent a hypertensive stroke. The cause of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for poor catheter drainage, bladder distention, or fecal impaction is the first action that should be taken. Adjusting the room temperature may be helpful, since too cool a temperature in the room may contribute to the problem. Tylenol will not decrease the autonomic dysreflexia that is causing the patient’s headache. Notification of the physician may be necessary if nursing actions do not resolve symptoms. Focus: Prioritization

Leukopenia is a serious adverse effect of phenytoin and would require discontinuation of the medication. The other data indicate a need for further assessment and/or patient teaching, but will not require a change in medical treatment for the seizures. Focus: Prioritization

The nursing assistant should assist the patient with morning care as needed, but the goal is to keep this patient as independent and mobile as possible. Assisting the patient to ambulate, reminding the patient not to look at his feet (to prevent falls), and encouraging the patient to feed himself are all appropriate to goal of maintaining independence. Focus: Delegation/supervision

The new graduate RN who is oriented to the unit should be assigned stable, non-complex patients, such as the patient with stroke. The patient with Parkinson’s disease needs assistance with bathing, which is best delegated to the nursing assistant. The patient being transferred to the nursing home and the newly admitted SCI should be assigned to experienced nurses. Focus: Assignment

Untreated bacterial meningitis has a mortality are approaching 100%, so rapid antibiotic treatment is essential. The other interventions will help reduce CNS stimulation and irritation, and should be implemented as soon as possible. Focus: Prioritization

The inability to recognize a family member is a new neurologic deficit for this patient, and indicates a possible increase in intracranial pressure (ICP). This change should be ommunicated to the physician immediately so that treatment can be initiated. The continued headache also indicates that the ICP may be elevated, but it is not a new problem. The glucose elevation and weight gain are common adverse effects of dexamethasone that may
require treatment, but they are not emergencies. Focus: Prioritization

LPN education and team leader responsibilities include checking for the therapeutic and adverse effects of medications. Changes in the residents’ memory would be communicated to the RN supervisor, who is responsible for overseeing the plan of care for each resident. Assessment for changes on the Mini-Mental State Examination and developing the plan of care are RN responsibilities. Assisting residents with personal care and hygiene would be delegated to nursing assistants working the LTC facility. Focus: Delegation

Checking and observing for signs of pressure or infection are within the scope of practice of the LPN/LVN. The LPN/LVN also has the appropriate skills for cleaning the halo insertion sites with hydrogen peroxide. Neurologic examination requires additional education and skill appropriate to the professional RN. Focus: Delegation/supervision

The experienced nursing assistant would know how to reposition the patient and how to reapply compression boots, and would remind the patient to perform activities he has been taught to perform. Assessing for redness and swelling (signs of deep venous thrombosis {DVT}) requires additional education and still appropriate to the professional nurse. Focus: Delegation/supervision

Administration of medications is included in LPN education and scope of practice. Collection of data about the seizure activity may be accomplished by an LPN/LVN who observes initial seizure activity. An LPN/LVN would know to call the supervising RN immediately if a patient started to seize. Documentation of the seizure, patient teaching, and planning of care are complex activities that require RN level education and scope of practice. Focus: Delegation

All of the strategies, except straight catheterization, may stimulate voiding in patients with SCI. Intermittent bladder catheterization can be used to empty the patient’s bladder, but it will not stimulate voiding. Focus: Prioritization

Medications such as estrogen supplements may actually trigger a migraine headache attack. All of the other statements are accurate. Focus: Prioritization

NA education and scope of practice includes taking pulse and blood pressure measurements. In addition, NAs can reinforce previous teaching or skills taught by the RN or other disciplines, such as speech or physical therapists. Evaluation of patient response to medication and development and individualizing the plan of care require RN-level education and scope of practice. Focus: Delegation