HESI Case Studies: N311: Neuro – Flashcards
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"Have you had any headaches? If so, describe frequency and location." Headaches can indicate hypertension or intracranial bleeding." "When you passed out, did you hit your head? If so, what part of your head did you hit?" [always important to assess for head injury] "Do you have any numbness, tingling, or weakness in your extremities?" [this analyzes sensory function due to possible stroke or neuropathy] "Do you have any difficulty speaking or swallowing?" [these diffculties are associated with stroke.
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when the eliciting data about the possible neuro problems, which questions should the RN ask the client?
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BP and heart rate and rhythm [hypotension and bradycardia can cause a loss of consciousness. Bradycardia may also be a sign of increased intracranial pressure. If the client has hypertension, it places her at increased risk for hemorrhagic stroke. If the client has cardiac irregularity, such as a fib, she should be evaluated and treated to prevent embolic stroke.]
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based on pt recent hx of los of consciousness and falling, what additional assessment takes priority?
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"Does the dizziness occur when you change positions?" [postural hypotension may cause client to fall when going from lying to sitting.] did it feel like the room was suddenly spinning before you fell? [indicates vertigo, relaed to alterations of vestibular apparatus of the ear. if nerve is damaged, the client may experience equilibrium and balance issues.] do you ever feel light headed or dizzy? [could indicate poor cerebral perfusion due to hypotension or carotid occlusion, which could cause loss of consciousness.]
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to determine what happened to the client when she experienced loss of consciousness, the RN should ask Mrs. Richardsom which questions?
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affirm the client's difficulty and question her about when this first started. [this action demonstrates caring and enable the RN to obtain a more complete hx related to oset of symptoms]
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During the pt interview, the RN observes pt speech pattens. Ms. Richardson seems to have difficulty choosing/forming some words. What action should the RN take?
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Syncope [syncope is a sudden loss of strength or temporary loss of consciousness, which the client described as passing out.]
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Pt demonstrates difficulty speaking and previously reported feeling weak, passing out, and falling at home. Her vitals are.... What terminology should accurately be included in documentation?
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client ability to comprehend what is being asked [aphasia should be assessed to determine if the client has lost ability to comprehend info (receptive aphasia) or the ability to express herself (esperessive aphasia). Most commonly, the client experiences both, referred to as global aphasia.]
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the RN documents that pt had difficulty forming some words and phrases. Before describing this finding on the assessment form, what additional data should the RN consider?
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oriented to situation. [the client's statement that she needs to notify her daughter that she is in the hospital indicates shhe is oriented to situation. Lack of knowledge of room nuumbr does not relect disorientation or memory loss.]
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Pt interview continues, RN assesses mental status. Pt occasionally struggles to choose and form words, but seems comfortable and relaxed. The RN provides a quiet, calm environment, allowing the client ample time to respond to interview questions. Mrs. Richardson asks the RN what her room number is, stating she needs to lt her daughter know where she is. Which assessment by the RN accurately reflects the client statement?
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question her about how she arrived at the hospital today. [this action provides information related to the client's recent memory. the RN should ask questions with verifiable answers to ensure the client does not make up responses.]
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to assess pt recent memory more completely, what action shoulthe RN take?
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the client indicated the need to notify her daughter that she is in the hospital. [the client's recognition of the need to notify her daughter that she is in the hospital is an indication of good judgment.]
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Which interview data provides the RN with information related to the client's judgment?
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III, IV, VI Oculomotor, Trochlear, Abducens
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The RN observes the client moving her eyes through the six cardinal fields of gaze by following an objext or fingers without moving her head. Which cranial nevres are tested when the RN is ealuating the extra ocular movments?
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hold a penlight to the side of the eye [It is ready as soon as the client opens her eyes.]
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After noting the size and shape of the client's pupils, the RN tests the pupillary response to light. After the RN asks the client to close both eyes what is the next action the RN should take?
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observe for symmetrical facial movement [th RN observes for symmetric movement provides data related to the function of the facial nerve, CN VII]
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to continue the CN assessment, the RN asks pt to first smile, then frown, then show her teeth. While the client performs these task, what should RN do?
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apply resistance to shoulders. [testing pt ability to shrug shoulders equally.]
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The RN tests cranial nerve XI by asking the client to shrug her shoulders. What action should the RN do?
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ask the client to touch her thumb to each finger [smooth, coordinated movements of the small muscles should be observed.]
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Since the pt is laying in bed, which action should the RN take to obsevre sall muscle movement and coordination?
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squeeze my fingers wiith both hands at same time. [easier to differentiate weakness in one side when assessed bilaterally.]
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It is observed that pt lacks coordintion when touching thumb to fingers on left hand and decides to assess upper extremity muscle strength, RN instucts client to grip two fingers of each hand. What instruction should the RN provide next?
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perform a palmar drift test [used to assess upper extremity weakness. Client is asked to hold up both arms with the palms up and eyes closed for 10-20 sec. Weak arm will drift downward.
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Pt left upper extremity seems weaker. What additional assessment should RN perform to validate finding of unilateral upper extremity weakness?
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vibration [the client's ability to sense vibration is assessed by placing a vibrant tuning fork on a bony surface.]
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the RN uses a tuning fork to evaluate what sensory function?
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place a comb in client's handd and ask her to ID object. Stereogenesis is the ability to recognize objects by touch and should be assessed with a readily recognizable object.
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RN asks pt to close her eyes. RN places tuning fork in palm of pt left had and asks her to ID what she is holding. PT is unable to ID tuning fork. What action should the RN take?
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Strike the thumb with reflex hammer.
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RN continues assessment by evaluating pt DTRs. RN begin by testing biceps reflect. With the client's forearm resting on the RN's forearm and the RN's thumb over the biceps tendon, what action should the RN take next to test the client's biceps reflex?
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explain to the client that reflex response was normal. [client's response was normal and should be documented as a +2.]
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RN observes contraction of biceps muscle and flexion of the forearm. What action should RN take in response?
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call the client's name [the RN should begin with the least amount of stimulus and progress to the greatest amount.]
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After admission assessment, the RN returns to pt room and notes a change in condition. Slurring words, no movement in left side, unresponsive. What stimuli should the RN use first to attempt to elicit a response from the client?
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motor response [best motor response is assessed using GCS ad is based on a 6 point scale ranging from none to obeys command for movements.] verbal response [best verbal response is assessed using GCS and is based on 5 point scale ranging from none to oriented.] eye opening response [best eye opening response is assessed using GCS and is based on a 4 point scale ranging from none to spontaneous.]
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GCS. What data should the RN obtain to complete this rating?
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POA
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in assessing the client's end of life wishes, the RN remembers that pt husband is deceases. It is most important to communicate with whom?
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organ donor status [
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what additional info related to end of life wishes is most important for RN to assess?
