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NEUROLOGICAL DISORDERS OF THE ADULT PT--NCLEX REVIEW Questions and Answers 100% Solved 2024/2025
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NEUROLOGICAL DISORDERS OF THE ADULT PT--NCLEX REVIEW Questions and Answers 100% Solved 2024/2025
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NEUROLOGICAL DISORDERS OF THEADULT PT--NCLEX REVIEW
The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk
for increased intracranial pressure. Pending specific health care provider prescriptions, the
nurse should safely place the client in which positions? Select all that apply.
a.) Head midline
b.) Neck in neutral position
c.) HOB elevated 30-45 degrees
d.) Head turned to the side when flat in bed
e.) Neck & jaw flexed forward when opening the mouth - ANSANSWERS=A, B, & C
RATIONALE:
Use of proper positions promotes venous drainage from the cranium to keep ICP from elevating.
The head of the pt at risk for or w/increased ICP should be positioned so that it is in neutral
midline position. The HOB should be raised 30-45 degrees. The nurse should avoid flexing or
extending the pts neck or turning the pts head from side to side
The nurse is assessing the nasal dressing on a client who had a transsphenoidal resection of
the pituitary gland. The nurse notes a small amount of serosanguineous drainage that is
surrounded by clear fluid on the nasal dressing. Which nursing action is most appropriate?
a.) Document the findings
b.) Reinforce the dressing
c.) Notify the HCP
d.) Mark the area of drainage w/a pen and monitor for further drainage - ANSANSWER=C
RATIONALE:
CSF leakage after cranial surgery may be detected by noting drainage that is serosanguineous
surrounded by an area of straw-colored or pale drainage. The physical appearance of CSF
drainage is that of a halo. If the nurse notes presence of this type of drainage, the HCP needs to
be notified. The remaining options are inappropriate nursing actions
NEUROLOGICAL ASSESSMENT:
1.) Assessment of Risk Factors: - ANS-Trauma
-Hemorrhage
-Tumors
-Infection
,-Toxicity
-Metabolic disorders
-Hypoxic conditions
-HPTN
-Cigarette smoking
-Stress
-Aging process
-Chemicals, either ingestion or environmental exposure
NEUROLOGICAL ASSESSMENT:
3.) Assessment of LOC: - ANS#2) Assessment of Cranial Nerves (look in notes*)
-Assess the pts behavior to determine LOC (e.g. alertness, confusion, delirium,
unconsciousness, stupor, coma), assessment becomes increasingly invasive as the pt is less
responsive
-Speak to the pt
-Assess appropriateness of behavior & conversation
-Lightly touch the pt (as culturally appropriate)
** *LOC IS THE MOST SENSITIVE INDICATOR OF NEUROLOGICAL STATUS* **
NEUROLOGICAL ASSESSMENT:
4) Assessment of VS: - ANSMonitor for BP & pulse changes, which may indicate increased ICP
NEUROLOGICAL ASSESSMENT:
5.) Assessment of Respirations: - ANS1.) Cheyne-Stokes:
-Rhythmic w/periods of apnea
-Can indicate a metabolic dysfxn or dysfxn in the cerebral hemisphere or basal ganglia
2.) Neurogenic Hyperventilation:
-Regular rapid & deep sustained respirations
-Indicates a dysfxn in the low midbrain & middle pons
3.) Apneustic:
-Irregular respirations w/pauses at the end of inspiration & expiration
-Indicates a dysfxn in the middle or caudal pons
4.) Ataxic:
-Totally irregular in rhythm & depth
-Indicates a dysfxn in the medulla
,5.) Cluster:
-Clusters of breath w/irregularly spaced pauses
-Indicates a dysfxn in the medulla & pons
NEUROLOGICAL ASSESSMENT:
6.) Assessment of Temperature: - ANS-An elevated temperature increases the metabolic rate of
the brain
-An elevation in temperature may indicate a dysfxn of the hypothalamus or brainstem
-A slow rise in temperature may indicate infection
NEUROLOGICAL ASSESSMENT:
7.) Assessment of Pupils: - ANS-Unilateral pupil dilation-->indicates compression of cranial
nerve III (oculomotor)
-Midposition fixed pupils-->indicates midbrain injury
-Pinpoint fixed pupils-->indicate pontine damage
NEUROLOGICAL ASSESSMENT:
8.) Assessment of Posturing: - ANS-Posturing indicates a deterioration of the condition
1.) Flexor (Decorticate posturing):
-Pt flexes 1 or both arms on the chest & may extend the legs stiffly
-Flexor posturing indicates a nonfxning cortex
2.) Extensor (Decerebrate posturing):
-Pt stiffly extends 1 or both arms and possibly the legs
-Extensor posturing indicates a brainstem lesion
3.) Flaccid Posturing
-Pt displays no motor response in any extremity
NEUROLOGICAL ASSESSMENT:
9.) Assessment of Reflexes: - ANS1.) BABINSKI REFLEX:
-Dorsiflexion of the big toe, and fanning of the other toes; elicited by firmly stroking the lateral
aspect of the sole of the foot
-Is a pathological or abnormal reflex in anyone older than 2 years and represents the presence
of CNS dx
2.) CORNEAL (BLINK) REFLEX:
-Involuntary closure of the eyelids in response to stimulation of the cornea
-Loss of the blink reflex indicates a dysfxn of cranial nerve V (trigeminal)
, 3.) GAG REFLEX:
-Contraction of pharyngeal muscle, elicited by touching the back of the throat
-Loss of the gag reflex indicates a dysfxn of cranial nerves IX & X (Glossopharyngeal & Vagus)
NEUROLOGICAL ASSESSMENT:
10.) Assessment of Meningeal Irritation: - ANSGENERAL FINDINGS:
-Irritability
-Nuchal rigidity
-Severe, unrelenting HA's
-Generalized muscle aches and pains
-N/V
-Fever & chills
-Tachycardia
-Photophobia
-Nystagmus
-Abnormal pupil rxn & eye movement
BRUDZINKSKI'S SIGN:
-Involuntary flexion of the hip & knee when the neck is passively flexed; indicated meningeal
irritation
KERNIG'S SIGN:
-Loss of the ability of a supine pt to straighten the leg completely when it is fully flexed at the
knee and hip; indicates meningeal irritation
MOTOR RESPONSE:
-Hemiparesis, hemiplegia, & decreased muscle tone
-Cranial nerve dysfxn, especially cranial nerves III, IV, VI, VII, & VIII (Oculomotor, Trochlear,
Abducens, Facial, & Acoustic)
MEMORY CHANGES:
-Short attention span
-Personality & behavioral changes
-Bewilderment
NEUROLOGICAL ASSESSMENT:
11.) Assessment of the Autonomic System: - ANS1.) Sympathetic Fxns, Adrenergic Responses:
-Increased pulse & BP
-Dilated pupils
-Decreased peristalsis
-Increased perspiration
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