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Disclaimer
Medicine and nursing are continuously changing practices. The author and publisher have reviewed all information in this book with resources
believed to be reliable and accurate and have made every effort to provide information that is up to date with best practices at the time of
publication. Despite our best efforts we cannot disregard the possibility of human error and continual changes in best practices the author,
publisher, and any other party involved in the production of this work can warrant that the information contained herein is complete or fully
accurate. The author, publisher, and all other parties involved in this work disclaim all responsibility from any errors contained within this work
and from the results from the use of this information. Readers are encouraged to check all information in this book with institutional guidelines,
other sources, and up to date information. For up to date disclaimer information please visit: http://www.nrsng.com/about.

NCLEX, NCLEX-RN are registered trademarks of the National Council of State Boards of Nursing, INC. and hold no affiliation or support of this
product.

All Rights Reserved. No part of this publication may be reproduced in any form or by any means, including scanning, photocopying, or
otherwise without prior written permission of the copyright holder. This book is intended for entertainment purposes only and does not imply
legal, medical, financial or other professional advice. The reader should seek the help of a competent professional for all matters.

Photo Credits:

All photos are original photos taken or created by the author or rights purchased at Fotolia.com. All rights to appear in this book have been
secured.

Some images within this book are either royalty-free images, used under license from their respective copyright holders, or images that are in
the public domain. Images used under a creative commons license are duly attributed, and include a link to the relevant license, as per the
author's instructions. All Creative Commons images used under the following license. All works in the public domain are considered public
domain given life of the author plus 70 years or more as required by United States law.

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Neurological Disorders

Increased Intracranial Pressure (ICP)

By Rocque BG, Bakaya MK [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

Increasing ICP can lead to brain herniation

1. Overview
a. Normal ICP: 5-15mmHg
b. ICP can elevate due to trauma, hemorrhage, tumor, hydrocephlaus, inflammation
c. The cranial vault is rigid, increased ICP can limit cerebral perfusion, impeded CSF
absorption and lead to herniation of brain tissue causing death
2. NCLEX Points
a. Assessment
i. Levels of Consciousness

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Conscious Normal Assessment of LOC involves checking orientation: people who are able promptly
and spontaneously to state their name, location, and the date or time are said to
be oriented to self, place, and time, or "oriented X3". A normal sleep stage from
which a person is easily awakened is also considered a normal level of
consciousness. "Clouding of consciousness" is a term for a mild alteration of
consciousness with alterations in attention and wakefulness.
Confused Disoriented; People who do not respond quickly with information about their name, location,
impaired thinking and the time are considered "obtuse" or "confused". A confused person may be
and responses bewildered, disoriented, and have difficulty following instructions. The person
may have slow thinking and possible memory time loss. This could be caused by
sleep deprivation, malnutrition, allergies, environmental pollution, drugs
(prescription and nonprescription), and infection.

Delirious Disoriented; Some scales have "delirious" below this level, in which a person may be restless
restlessness, or agitated and exhibit a marked deficit in attention.
hallucinations,
sometimes delusions

Somnolent Sleepy A somnolent person shows excessive drowsiness and responds to stimuli only
with incoherent mumbles or disorganized movements.
Obtunded Decreased alertness; In obtundation, a person has a decreased interest in their surroundings, slowed
slowed psychomotor responses, and sleepiness.
responses

Stuporous Sleep-like state (not People with an even lower level of consciousness, stupor, only respond
unconscious); by grimacing or drawing away from painful stimuli.
little/no spontaneous
activity

Comatose Cannot be aroused; Cannot be aroused; no response to stimuli

no response to
stimuli

ii. headache
iii. Cushing's Triad
1. abnormal respirations
2. widening pulse pressure
3. reflex bradycardia
iv. elevated temp
v. pupilary changes
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vi. posturing
vii. seizures
viii. positive Babinski reflex
b. Therapeutic Management
i. monitory respiratory status
ii. monitor pupil changes
iii. avoid sedatives and CNS depressants
iv. Hypocapnia (PaCO2 30-35 mmHg) will lead to cerebral vasoconstriction leading
to decreased ICP
v. monitor temperature
vi. prevent shivering
vii. decrease stimuli
viii. monitor electrolytes
ix. avoid Valsalva's maneuver
x. Ventricular drain and ICP monitoring
xi. Assess neuro status q 1-2 hours
xii. elevate HOB to at least 30 degrees
xiii. Osmotic diuretics and corticosteroids

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Stroke

By INFARCT.jpg: Lucien Monfils derivative work: Suraj (INFARCT.jpg) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL
(http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons

Right MCA Infarct

1. Overview
a. Neurological deficit caused by decreased blood flow to a portion of the brain
b. May be ischemic or hemorrhagic
c. Lack of blood flow greater than 10 minutes can cause irreversible damage
d. Risk factors:
i. HTN
ii. Diabetes
iii. atherosclerosis
iv. cardiac dysrhythmias
v. substance abuse
vi. obesity
vii. oral contraceptives
viii. anticoagulant therapy
e. Diagnosed via: CT, MRI, cerebral arteriogram (hemorrhagic and late ischemic)
2. NCLEX Points
a. Assessment

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i. contralateral manifestations (opposite side of stroke)

ii. FAST
1. facial droop
2. arms - does one arm drift?
3. speech problems
4. time - call 9-1-1
iii. dependent on location
1. Aphasia - speech difficulty
a. Expressive - understands but unable to communicate verbally
b. Receptive - unable to comprehend spoke and written word
c. Global - language dysfunction
d. Interventions
i. provide adequate time for client to respond
ii. repeat names of individuals and objects frequently
iii. use a picture board
iv. provide only one instruction at a time
2. Apraxia - inability to perform tasks
3. Hemianopsia - blindness in half the vision field
a. instruct client to turn head to capture the entire vision field
b. approach client from unaffected side
c. provide food and objects to unaffected side
4. Dysphagia - difficulty swallowing
b. Therapeutic Management
i. involve speech therapy
ii. ischemic stroke
1. permissive hypertension
2. antithrombitic therapy
3. carotid endartecomy
4. thrombectomy
5. monitor neurological status
iii. hemorrhagic stroke
1. coiling or clipping of aneurysm
2. monitor neurological status
iv. seizure precautions
v. monitor level of consciousness
vi. monitor neurological status
vii. maintain quiet, calm environment
viii. assess need for assistive devices
ix. involve physical and occupational therapy

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Seizure Disorder
View the NRSNG.com video on Seizures here: https://youtu.be/lr2G34fl4Fg

1. Overview
a. Abnormal excessive discharge of electrical activity in the brain
b. Types
i. Generalized - both hemispheres
1. Tonic-clonic
2. absence
3. myoclonic
4. atonic
ii. Partial - one hemisphere
1. simple partial
2. complex partial
c. Risk factors
i. genetics
ii. trauma
iii. tumors
iv. toxicity
v. infection
vi. cerebral bleeding or swelling
vii. acute febrile state
d. Status epilepticus - persistent seizure activity with little or no break
2. NCLEX Points
a. Assessment
i. assess for Aura (sensation that warns of impending seizure)
ii. Postictal state (period after seizure): memory loss, sleepiness, impaired speech
iii. assess type, onset, duration
b. Therapeutic Management
i. Maintain patent airway
1. turn client to side
2. have O2 and suction equipment available after the seizure
3. DO NOT force anything into the mouth during the seizure (including bite
block)
ii. prevent injury
1. bed to the lowest position
2. padded side rails
3. loosen restrictive clothing
4. DO NOT try to restrain client
iii. Document onset, preceding events, duration, and postictal events
iv. Medications
1. Anitepileptics
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2. Diazepam, Lorazepam, phenobarbital are often given during seizure

activity
v. Educate client and family on importance of medication compliance
vi. Educate family on care during seizure

Parkinson's Disease
1. Overview
a. Degenerative neurological disorder caused by atrophy of substantia negra leading to
depletion of dopamine. This leads to termination of acetylcholine inhibition which
causes symptoms.
b. Dopamine plays a role in the inhibition of excitatory impulses. When this
neurotransmitter is depleted acetylcholine is no longer inhibited.
c. Slow, progressive disease.
d. client becomes progressively debilitated and self-care dependent
2. NCLEX Points
a. Assessment
i. bradykinesia: slow movements due to muscle rigidity
ii. resting tremor
iii. Pill rolling - tremors in hands and fingers
iv. Akinesia
v. blank facial expression
vi. shuffling steps, stooped stance, drooling
vii. dysphagia
b. Therapeutic Management
i. Assistive devices
ii. involvement of speech, physical, and occupational therapy
iii. monitor diet to insure proper caloric intake
1. increase fluid intake
2. high protein
3. high fiber
iv. Assess ability to swallow prior to anything by mouth
v. Use rocking movement to initiate movement
vi. encourage client to ambulate multiple times a day
vii. participate in active and passive range of motion activities
viii. avoid foods high in Vitamin B6 (blocks effects of antiparkinsonian drugs)
ix. small, frequent, nutrient dense foods
x. Medication therapy
1. dopaminergics, dopamine agonists, anticholinergics
2. goal is to increase the level of dopamine in the CNS
3. eventually drugs become ineffective

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Multiple Sclerosis

1. Overview
a. Chronic, progressive demyelinization of the neurons in the CNS
b. Remission and exacerbation
c. Primarily ages 20-40 years old
2. NCLEX Points
a. Assessment
i. fatigue
ii. tremors
iii. spasticity of muscles
iv. bladder dysfunction
v. decrease peripheral sensation (pain, temperature, touch)
vi. visual disturbances
vii. emotional instability
b. Therapeutic Management
i. No cure - supportive therapy
ii. energy conservation
iii. maintain adequate fluid intake 2000 mL/day
iv. provide bowel and bladder training

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v. encourage activity independence

vi. regulate temperatures on water heaters, baths, and heating pads
vii. insure in home safety (rugs, cords, etc)

Myasthenia Gravis

1. Overview
a. Chronic progressive disorder of the PNS which affects transmission of nerve impulses
b. Onset often caused by precipitating factors (stress, hormone disturbance, infection,
trauma, temperature)
c. Insufficient secretion of acetylcholine with excessive secretion of cholinesterase
2. NCLEX Points
a. Assessment
i. weakness/fatigue
ii. diplopia (double vision) and ptosis (drooping eyelid)

By James Heilman, MD (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via

Wikimedia Commons
iii. monitor respiratory status
1. swallowing, respirations, tachypnea, abnormal ABG, breath sounds,
difficulty breathing
iv. Cholinergic crisis: severe muscle weakness due to overmedication; cramps,
diarrhea, bradycardia, bronchial spasm
1. Assessment
a. N/V, diarrhea
b. hypotension
c. blurred vision
2. Intervention
a. withhold medication
b. administer antidote
v. Myasthenic crisis: acute exacerbation of disease, sudden severe motor
weakness, risk of respiratory failure, caused by insufficient medication dosage
1. Assessment
a. increase pulse, respirations, bp
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b. anoxia and cyanosis

c. bowel and bladder dysfunction
2. Intervention
a. increase medication
vi. Tensilon test
1. used to confirm diagnosis
a. client at risk of vfib and cardiac arrest have atropine available
b. Therapeutic Management
i. monitor respiratory status
ii. maintain suction and emergency equipment
iii. insure proper medication
iv. monitor feeding and insure proper nutrition
1. schedule medication 30-40 minutes prior to meals
v. provide adequate eye care
vi. instruct client to avoid temperature extremes, emotional stress, drugs, alcohol,
and exposure to infection
vii. educate on signs of cholinergic and myasthenic crisis

NCLEX Cram - Neurological Disorders

1. Glasgow Coma Scale

Score 1 2 3 4 5 6
Eyes Does not Opens to painful Opens to voice Opens N/A N/A
open stimuli spontaneously
Verbal Makes no Incomprehensible Utters Confused, Oriented, N/A
sound sounds inappropriate disoriented converses
words normally
Motor Makes no Extension to Flexion to Withdraws to Localizes to Obeys
movements painful stimuli painful stimuli painful stimuli pain commands
2. Hypothalamus
a. regulates body temperature
b. regulates response to sympathetic and parasympathetic nervous system
c. produces hormones secreted by pituitary gland and hypothalamus
3. Pons
a. regulates breathing
4. CT Scan

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a. assess for allergy to contrast, shellfish, iodine if dye is used

b. provide adequate fluids to flush dye if used
5. MRI
a. remove all metal objects from patients
b. determine if client has a pacemaker - cannot complete MRI with pacemaker
6. Cerebral Angiography
a. assess for allergies to dye
b. maintain flat bed rest or at the position the physician orders
c. assess insertion site for swelling, hematoma, and bleeding
7. Level of consciousness is the most essential indicator of neurological status
8. Pupil Assessment
a. Pupils equal and react to light
b. Pupil reacts slowly to light
c. Dilated pupil (compressed cranial nerve III)
d. Bilateral pupilary dilation, fixed (ominous)
e. Bilateral pinpoint (pons damage)

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9. Client position
a. Decorticate
i. flexes both arms on chest (toward CORd)
ii. cortex damage

b. Decerebrate
i. extends arms and/or legs
ii. brainstem lesion
c. Flaccid
i. no motor response to stimuli
10. Babinski test
a. dorsiflexion of the big toe indicating neurologic damage

11. Hyperthermia can increase cerebral O2 demands and lead to hypoxia

a. initiate seizure precautions
12. Halo Sign
a. CSF will separate from blood when placed on a white sterile background
13. Do not suction or blow nose with traumatic head injury or pituitary surgery
14. Diabetes insipidus results from inadequate secretion of ADH and can be manifested as copious
amounts of urine output. This reflects damage to the pituitary gland.
15. Immobilize clients when spinal injury is suspected
16. Clean pin sites on halo traction devices daily
a. Do not shower
b. keep pin sites clean, assess skin, report any redness or swelling
17. Turn spinal patients using the log rolling technique
18. Trigeminal Neuralgia
a. damage to fifth cranial nerve

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b. severe pain to cheeks, lips, gums

c. extreme temperatures may exacerbate symptoms
d. client should avoid hot or cold foods and fluids
19. Bell's Palsy
a. sudden weakness in the muscles on one half of face
b. usually resolves within 6 months without treatment
c. steroids and antivirals may be provided
d. protect eyes from dryness
e. chew food on unaffected side

By James Heilman, MD (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL

(http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons
20. Guillain-Barre Syndrome
a. monitor respiratory status closely
21. West Nile Virus
a. symptoms develop 3-14 days after being bitten by infected mosquito
b. fever, headache, tremors, seizures, coma, vision loss
c. DEET bug spray should be worn

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22. Meningitis
a. inflammation of the brain and spinal cord membranes due to infection by virus,
bacteria, or fungus, protozoa

b. CSF is analyzed to determine diagnosis

i. cloudy, WBC, Glucose
c. Nuchal rigidity
d. photophobia
e. lethargy
f. altered level of consciousness
g. positive Kernig and Burdzinski's sign
h. client should be placed in isolation
i. administer analgesics and antibiotics
j. initiate seizure precautions
k. Assess for ICP
l. Transmission usually occurs in areas of population density and crowded living spaces

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