THE NCLEX-RN TEST PLAN ADULT PHYSIOLOGAL INTEGRITY Adult Physiological Integrity comprises 46-54 percent of the actual

test content. This is 130 questions out of the maximum number of questions possible on the CAT (265). When answering these questions, remember: Maintaining the clients airway is always your first priority! There is always something a nurse can do before calling the provider! Client needs include: Physiological adaptation Physiological, psychosocial, and developmental health optimized Prevention of complications of medication administration and intravenous therapy Provision of basic care Well review organ systems going from head to toe, starting with the nervous system. THE NERVOUS SYSTEM REVIEW OF NEUROANATOMY AND PHYSIOLOGY The nervous system includes the central nervous system (C.N.S.), the peripheral nervous system (P.N.S.), and the autonomic nervous system (A.N.S.). The central nervous system is composed of the brain and spinal cord. The peripheral nervous system contains the cranial nerves and spinal nerves. The autonomic nervous system (A.N.S.) controls autonomic body functions, such as breathing and heartbeat. It maintains a stable internal environment for the body. The A.N.S. is divided into the sympathetic and parasympathetic nervous systems. The Autonomic Nervous System Sympathetic Parasympathetic Fight or Flight Maintains normal body functioning Increases heart rate and blood pressure Normalizes heart rate and blood pressure Increases respiratory rate Normalizes respiratory rate Decreases peristalsis Increases peristalsis Secretes epinephrine and norepinephrine Secretes acetylcholine Dilates pulmonary bronchioles Constricts pulmonary bronchioles THE NEURON The neuron is the functional unit of the nervous system:

Afferent neurons receive information from the periphery of the body and transmit it through the C.N.S. Efferent (motor) neurons conduct information (impulses) from the C.N.S. to muscles and glands. THE BRAIN BRAIN FRONTAL LOBE Personality, behavior Motor function Brocas area (aids in formulation of words) Concentration, abstract thought, memory TEMPORAL LOBE Hearing, taste, smell Wernickes area (interpretation of language) Interpretive area junction of temporal, parietal, and occipital lobes (integration of somatic, auditory, and visual association areas) PARIETAL LOBE Sensation determination of size, shape, weight, and texture of sensory input Awareness of body parts, orientation in space and spatial relationships (proprioception) OCCIPITAL LOBE Vision (reception and interception) CEREBELLUM Coordination of muscle groups

BRAIN STEM (includes midbrain, pons, and medulla) nerve pathways connecting the brain ans spinal cord cardiac, vasomotor, and respiratory centers

MIDBRAIN PONS MEDULLA

The thalamus and hypothalamus are in a region called the DIENCEPHALON, located between the cerebrum and the brain stem

THALAMUS: interpretation of sensation (pain, temperature, touch)

HYPOTHALAMUS: temperature control, water metabolism, control of hormonal secretion, heart rate, peristalsis, appetite control, thirst center, sleep-wake cycle. THE SPINAL CORD

REFLEX ARC An impulse received by the sensory receptor (i.e. pain) is carried is long the afferent pathway to the posterior horn of the spinal cord. An Interneuron creates a synapse between the posterior (sensory) horn and the anterior (motor) horn. The motor impulse is carried along the efferent pathway to the periphery, where the effector responds to the stimulus (i.e., withdrawing hand from a hot stove). THE TWELVE CRANIAL NERVES Review the names, order, and basic functions of the twelve cranial nerves here. We will go into more detail about the cranial nerves in the section on neurologic assessment. For now, just associate the cranial nerves with the peripheral nervous system. Number I II III IV V VI VII VIII IX X XI XII THE TWELVE CRANIAL NERVES Name Basic Function Olfactory Smell Optic Vision Oculomotor Eye movement Trochlear Eye movement Trigeminal Chewing, facial sensation Abducens Eye movement Facial Taste, facial movement Vestibulocochlear Hearing, balance Glossopharyngeal Taste (posterior tongue), swallowing Vagus Pharynx, respiratory, cardiac, and circulatory reflexes Spinal accessory Shoulders, head movement Hypoglossal Tongue movement

Memory tools include remembering that III, IV, and VI (oculomotor, trochlear, and abducent) control eye movement. (On the NCLEX-RN, questions will not require any more detailed knowledge of the cranial nerves.) If VII (facial) controls facial movement and taste, its domain is the anterior tongue, as opposed to the glossopharyngeal nerve (IX) that controls taste on the posterior tongue. XII (the hypoglossal nerve) controls tongue movement. REVIEW Before we review the basic neurologic assessment, quickly assess your retention of neuroanatomy and physiology by filling in the blanks: 3

______________________ Personality, behavior Motor function Brocas area (aids in formulation of words) Concentration, abstract thought, memory

BRAIN ______________________ Sensation determination of size, shape, weight, and texture of sensory input Awareness of body parts, orientation in space and spatial relationships (proprioception) _____________________ Vision (reception and interception) ___________________ Coordination of muscle groups

_________________________ Hearing, taste, smell Wernickes area (interpretation of language) Interpretive area junction of temporal, parietal, and occipital lobes (integration of somatic, auditory, and visual association areas)

____________________ (includes midbrain, pons, and medulla) nerve pathways connecting the brain ans spinal cord cardiac, vasomotor, and respiratory centers

________________ Connection between the brain and the periphery

The thalamus and hypothalamus are located in a region called the DIENCEPHALON, located between the cerebrum and the brain stem

SPINAL CORD ___________________ Impulses of touch , pressure vibration, and sense of position ___________________ Contains cell bodies that connect with afferent (sensory) fibers

___________________ Motor impulses conducted from motor cortex to anterior horn cells ___________________ Contains cell bodies that produce efferent(motor) fibers

___________________ Muscle tension and position sense (impulses carried to cerebellum) ___________________ (thoracic region only) Contains cells that produce autonomic fibers of the sympathetic nervous system ___________________ (rubrospinal, reticulospinal, vestibulospinal, and tectospinal tracts) Maintain muscle tone and control gross body movement (e.g. walking)

___________________ Impulses of pain and temperature sensation (lateral) Impulses of crude touch and pressure (anterior)

___________________ An impulse received by the sensory receptor is carried along the afferent pathway to the posterior horn of the spinal cord. An interneuron creates a synapse between the posterior (sensory) horn and the anterior (motor) horn. The motor impulse is carried along the efferent pathway to the periphery, where the effector responds to the stimulus. NEUROLOGIC ASSESSMENT 1. What is the first thing a nurse should assess to determine the presence of neurological changes? ____________________________ Your clients level of consciousness is the best early indicator of neurological status. Use of the Glasgow Coma Scale allows for a consistent and objective assessment of your clients neurological condition and provides an organized summary of a neurological assessment. THE GLASGOW COMA SCALE Eye Opening + Best motor Response + Best Verbal Response = Score

A score of 3 indicates severe neurologic impairment, while a score of 15 indicates a client responding appropriately to the neurologic exam. Eye Opening 4 Opens eyes spontaneously in response to an approaching person 3 Opens eyes in response to auditory stimuli 2 Opens eyes to painful stimuli 1 No eye opening Best Motor Response Decorticate Arms turn in and up, toward the cortex Decerebrate Rigid extension; arms fully extended; forearms pronated; wrists and fingers flexed; jaws clenched, neck extended, back may be arched; feet plantar flexed; may occur spontaneously, intermittently, or in response to a stimulus 6 Obeys simple commands (Squeeze my hand) 5 Attempts to move away from or remove painful stimuli 4 Moves without purpose in response to pain 3 Decorticate posturing in response to pain (hands move in and up, toward the cortex) 2 Decerebrate posturing in response to pain (arms straight and to the side) 1 No response to pain (unresponsive) Best Verbal Response 5 Oriented X 3 (to person, place, and time) 4 Conversant but confused 3 Uses words and phrases, but makes little sense 2 Responds with incomprehensible sounds 1 No verbalization CEREBRAL DYSFUNCTION Cerebral dysfunction is often described using the following terms. Review them and the label the scenarios below with the appropriate term. Agnosia: The inability to recognize common objects (may be visual, auditory, or tactile) Apraxia: The inability to perform a skilled motor task, assuming that the client is not paralyzed. Aphasia: the inability to communicate; can be expressive aphasia (the inability to speak or difficulty speaking) or receptive aphasia (the inability to understand spoken words, to receive information).

1.__ A client is able to follow all your commands during

physical examination. However, when you ask him about his medical history, his speech is hesitant, his word choice is inappropriate, and he appears extremely frustrated. 2. ____ While at a clients bedside, you observe a conversation between her and her husband. The husband asks her to pass him a pen (which is on the bedside table directly in front of her). The client stares at the table, but seems unable to recognize the object her husband is requesting. 3. ____ When asked if he is thirsty, client shakes his head yes. When you hand the client a cup filled with juice, he holds the cup and turns it around in his hands, but never brings the cup to his mouth to drink from it.

A. B. C. D.

agnosia Apraxia Expressive aphasia Receptive aphasia

4. ____ A client is awake and alert and seems aware of her surroundings. When you begin physical assessment, she stares at you blankly and is unable To follow any commands. RESPIRATORY PATTERNS AND CEREBRAL DYSFUNCTION Specific respiratory patterns are characteristically found with dysfunction at certain cerebral levels: VITAL SIGNS Cheyne-Stokes respirations respirations of increasing and decreasing depth, alternating with periods of apnea. May be caused by structural cerebral dysfunction or by metabolic problems, such as diabetic coma. Central neurogenic hyperventilation rapid respiration (>25/minute). Usually attributed to brain stem dysfunction Apneustic breathing prolonged inspiratory phase followed by a 2-3 second pause. Usually attributed to dysfunction in the respiratory center of the pons. Cluster breathing clusters of irregular breaths with periods of apnea at irregular intervals. Caused by lesions in the upper medulla and lower pons. Biots (ataxic) breathing completely irregular breathing pattern. Inidicates damage to the respiratory centers of the medulla.

CRANIAL NERVES IN ASSESSING NEUROLOGICAL STATUS

When assessing neurological status, it is important to review which cranial nerves correspond to different impairments as well as any specific nursing interventions that may be indicated. Cranial nerves, remember, are part of the P.N.S. Here we review the basics. Take this knowledge and apply it to the situations presented on the NCLEX-RN. Fill in the name of each cranial nerve in the boxes on the next page: CN I Fill in the Name ____________ Dysfunction Decreased sense of smell Interventions Inability to smell is often accompanied by impaired taste and weight loss. Smell serves as a warning for fire, spoiled food, etc. Clients require frequent reorientation to environment. Position objects around client in deference to visual field impairment. Intermittent eye patching for diplopia. Lubricate eyes to protect against corneal abrasions Caution in shaving and mouth care. Choose easy-to-chew foods with high caloric content. Protect corneas from abrasion by using lubricant. Cosmetic approach to hiding facial weakness. Oral hygiene. Account for decreased food intake. Safety! Move slowly to prevent nausea and emesis. Assist ambulation. Maintain airway. Prevent aspiration. Swallow therapy.

II

____________

Decreased visual acuity and visual fields

III IV VI V

____________ ____________ ____________ ___________

Double vision (diplopia)

3 (tri-) potential dysfunctions: decreased facial sensation, inability to chew, and decreased corneal reflexes Facial weakness and decreased taste (anterior tongue)

VII

____________

VIII

____________

IX X

___________ ____________

XI

___________

Decreased hearing, imbalance, vertigo (dizziness), tinnitus (ringing in ears) Dysarthria (difficulty speaking), dysphagia (difficulty swallowing), cardiac and respiratory instability Inability to turn shoulders Mobility aids. or turn head from side to Physical Therapy. side

XII

____________

Dysarthria, dysphagia

Maintain airway. Prevent aspiration. Swallow therapy.

ASSESSING MOTOR FUNCTION Further assessment of motor function includes observing gross motor movement, testing muscle strength, and evaluating the clients gait. Assessing cerebellar function includes evaluation of balance and coordination. For the NCLEX-RN, know that for Rombergs test, the client stands erect with feet together, first with eyes open and then closed. If he or she is unable to maintain balance with eyes closed, this is Rombergs sign and indicates cerebellar damage. Review reflexes that might appear on the NCLEX-RN: Deep tendon: Reflex response is graded from 0 (no response) to 4 (hyperactive), with 2 being normal (e.g., knee cap). Superficial: Reflexes elicited by lightly touching a particular area of the skin or mucous membrane. Commonly tested superficial reflexes include corneal, gag, abdominal, and perianal. Pathological: Babinskis reflex. When the sole of the foot is stroked from the heel to the ball of the foot, the toes should curl downward (negative Babinskis sign). If the toes fan upward, this is termed a positive Babinskis sign and is an abnormal response (after age 2) that suggests brain stem or spinal cord involvement. ASSESSING SENSORY FUNCTION In evaluating sensory function, numerous types of sensation awareness may be tested: superficial pain, deep pressure pain, heat and cold sensitivity, vibration sensitivity, texture discrimination, and proprioception (identification of the position of a body part). The dermatome map displays areas of spinal nerve innervation and assists in identifying the level of spinal cord damage. REVIEW Before we move on to disorders of the nervous system, label the different breathing patterns below and fill in the blank with the associated area of nervous system damage:

VITAL SIGNS 9

1. _____________ - respirations of increasing and decreasing depth, alternating with periods of apnea. May be caused by _________________ or by metabolic problems, such as _____________. 2. ___________________________-rapid respiration (>25/minute). Usually attributed to __________ dysfunction. 3. _____________________breathing-prolonged inspiratory phase followed by a 2-3 second pause. Usually attributed to dysfunction in the ______________center of the ______________. 4. _________breathing clusters of irregular breaths with periods of apnea at irregular intervals. Caused by lesions in the upper _____ and lower __________. 5. ____________breathing-completely irregular breathing pattern. Indicates damage to the respiratory centers of the ___________.

DISORDERS OF THE NERVOUS SYSTEM As we review disorders of the nervous system, remember that maintaining a patients airway is always the primary nursing intervention, unless, of course, there is no risk of airway compromise. Discerning the acuity of the situation (is airway compromise a possibility?) requires basic knowledge of the neurological disorders that may appear on the NCLEX-RN. Following are some neurologic situations and appropriate nursing interventions. The NCLEX-RN is not limited in its scope of material, so if you are unfamiliar with a scenario, use your common sense to guide your intervention. Remember, the correct answer is always in front of you! Many neurological disorders result in an altered level of consciousness, including loss of consciousness. Findings are dependent upon the specific cause of the change, but airway maintenance and safety remain the primary nursing concerns. Nursing care is also directed at maintaining skin integrity (preventing complication of immobility). SEIZURES Seizure disorders are recurrent disturbances in skeletal motor function, sensation, autonomic (automatic) function, consciousness, or behavior. Epilepsy is the term for chronic, recurrent seizures. Here is a brief list of the characteristics of each type of seizure:
TYPE OF SEIZURE GENERALIZED Tonic mal) Clonic (grand Aura, loss of consciousness, rigidity, repetitive limb movement, postictal lethargy and confusion ASSESSMENT

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Absence (petit mal) Myoclonic Atonic PARTIAL Simple Complex

Brief loss of consciousness, twitching or rolling of eyes Brief spasm of a single muscle group Sudden loss of muscle tone, brief loss of consciousness

Motor, sensory, or autonomic deficits without loss of consciousness Cognitive, psychosensory, psychomotor, or affective deficit; may be preceded by aura; brief loss of consciousness

General Intervention for All Seizures Maintain safety; move harmful objects out of the way; protect head Do not use a tongue blade or stick anything in the clients mouth. Allow free movement Teach client and family about safety and drug therapy

The interventions for all seizures are the same. So dont waste your time trying to memorize the specifics of each type, just stick to the basics. Dilantin (phenytoin sodium) is the most common anticonvulsant drug used to control seizures. For the NCLEX-RN, you need to know that it can only be administered in normal saline, and Dilantin levels are monitored to titrate dosage. The therapeutic Dilantin level is 10-20 mcg/ml. Phenobarbital is a barbiturate used to control seizures. Its main effects and side effects are on the C.N.S. Tegretol (carbamazepine) is used to control seizures that have not responded to other anticonvulsants.

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6. With which types of seizures is an aura present? A. _________________ B. _________________ 7. A. B. C. D. With which types of seizures is there a loss consciousness? __________________ __________________ __________________ __________________

INCREASED INTRACRANIAL PRESSURE Increased Intracranial pressure is caused by tumors, abscesses, edema, hemorrhage and/or inflammation. Remember, the skull is a fixed space. When one component expands, another part has to give. The client with increased I.C.P. presents with an altered level of consciousness, bradycardia, altered respirations, and projectile vomiting. The following nursing interventions in the presence of increased I.C.P. are directed at minimizing stimuli and promoting venous drainage: Maintain airway; limit suctioning to 15 seconds or less. Elevate head of bed about 30 degrees. Maintain neck in neutral position to promote venous drainage. Maintain quiet environment Prevent Valsalvas maneuver by ensuring proper bowel routine. Maintain fluid balance (Diuretics may be ordered by the provider to decrease fluid volume).

HEADACHES There are different kinds of headaches, each of which requires determination of the cause before treatment is initiated. Careful assessment of the circumstances and characteristics of the headache is imperative, as is environmental control to reduce frequency and acuity of the headache. The nurse is in a prime position to teach the client about alternative methods of pain control. MENINGITIS Meningitis is inflammation of the meninges of the brain and spinal cord. It is caused by bacteria (Haemophilus influenzae, Neisseria meningitides, and Diplococcus pneumoniae), viruses, or other microorganisms that infect the meninges. Here is a list of symptoms of meningitis and related nursing interventions: Assessment Findings Fever Lethargy Confusion Nuchal rigidity (stiff neck) 12

Kernigs sign Brudzinskis sign

Nursing Interventions Place client in isolation (depends on hospital protocol) Maintain client safety. Monitor vital signs and neurological status. Prepare client for lumbar puncture. (Antibiotics will be ordered by the provider.) Signs of Meningitis Kernigs Sign is present if the lower leg cannot extend due to pain and spasm when a client is lying supine with one leg bent over his abdomen. Brudzinskis sign is present if the clients hips and knees flex when he is lying supine with his head lifted towards his chest. ENCEPHALITIS Encephalitis is an inflammation of the brain caused by viruses, bacteria, fungi, or parasites and can occur in connection with disease such as measles, mumps, or chicken pox. Encephalitis (remember it is inflammation!) presents as a fever, headache, seizures, and stiff neck. Nursing care is the same as for a client with increased intracranial pressure and seizures. Interventions are also similar to those for meningitis. BRAIN ABSCESS A brain abscess is caused by an infection extending into the cerebral tissue or by organisms carried from other sites in the body (middle ear, mastoid, or sinus). An abscess is always some sort of infection that presents with the typical chills, fever, malaise, and elevated white blood cell count. Because this abscess is in the brain, headache may often times be a symptom. Provide nursing care for the client with an infection and increased intracranial pressure. (Remember, the head has a fixed volume; an abscess takes up unavailable space, thereby increasing the intracranial pressure.) Provide preoperative teaching if the client is to undergo a craniotomy to drain the abscess. BRAIN TUMORS Brain Tumors are divided into a number of categories, none of which is important for the NCLEXRN. What is important to remember is that nursing care for brain tumor clients is aimed at treating the deficits experienced by the individual client. In addition, the nurse should also provide the appropriate care for the client with increased intracranial pressure (the head has a fixed volume) and provide teaching applicable to the chosen treatment modality. CEREBROVASCULAR ACCIDENT

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Cerebrovascular accidents (C.V.A.s) are characterized by the gradual or rapid, nonconvulsive onset of neurologic deficits that fit a known vascular territory and last for at least 24 hours. They result from reduced cerebral blood flow and oxygen deprivation related to a thrombus (clot), embolism, or hemorrhage (bleeding). Often characterized by facial droop, lateral weakness, flaccidity, alterations in mental status can also be indicative of a C.V.A. Nursing care is directed at maintaining a patients airway in the face of mental status changes, and safety! The sensory and motor deficits often experienced by these clients require diligent nursing attention. The list below includes nursing concerns (following airway maintenance and safety) for the client with deficits related to a C.V.A.: Potential for aspiration: A swallowing evaluation is imperative to ascertain the extent of dysphagia caused by the C.V.A.; aspiration precautions must be maintained, food should be pureed (no liquid) and calorie-dense Altered nutritional status: Encourage pureed, calorie-dense foods; tube feedings may be indicated if nutritional intake is suboptimal. Altered elimination patterns Altered skin integrity Impaired communication Impaired vision ANEURYSMS An aneurysms is an outpouching of an artery. A cerebral aneruysm is the outpouching of a cerebral artery. Rupture of a cerebral aneurysm results in a subarachnoid hemorrhage. Neurological deficits may also occur if the aneurysm is compressing cranial nerves or is pressing on brain substance. Aneurysm rupture precautions are: Quiet, dark environment Head of the bed at 30-45 degrees Limit visitation to decrease stimuli Avoid Valsalvas maneuver Avoid rectal temperatures (vagal nerve stimulation) Suction only as absolutely necessary PARKINSONS DISEASE Parkinsons Disease is a progressive, degenerative disorder caused by dopamine (neurotransmitter) depletion, and resulting in a generalized decline in muscular function. Cardinal signs of Parkinsons disease are: Tremor at rest Rigidity Slow movement Shuffling gait Mask-like face Emotional lability 14

Autonomic symptoms: Drooling, sweating, constipation

The nurses primary responsibility for the client with Parkinsons disease is to maintain a safe environment in deference to the decline in muscular function. In addition, anti-Parkinsons medications have numerous side effects, including constipation, urine retention, blurred vision and dizziness. It is vital that the client be allowed to maximize his/her independence. A high calorie diet is recommended in order to minimize the effects of decreased food intake. MULTIPLE SCLEROSIS Multiple sclerosis is a progressive C.N.S. disorder caused by demyelination in the brain and spinal cord. Symptoms vary with the location of demyelination (look back at the anatomy of the brain and spinal cord) but may include visual deficits, diminished sensation, weakness, and paralysis. Nursing interventions are aimed at safety and maximizing the clients independence. Clients with multiple sclerosis should be encouraged to follow a diet low in saturated fat. MYASTHENIA GRAVIS Myasthenia gravis is an autoimmune disorder (the body is fighting itself) causing disturbances in the transmission of impulses from nerves to muscles resulting in extreme muscle weakness. This chart will help you remember the edrophonium chloride (Tensilon) test (the NCLEX loves this test).

Edrophonium Chloride (Tensilon) Test Differentiates between myasthenia gravis and a cholinergic crisis Id muscle strength improves with the administration of Tensilon, then myasthenia gravis is diagnosed. You should know by now that the primary nursing concern is safety and maintaining a patent airway when necessary. In a myasthenic crisis, the client will experience sensory deficits, including double vision, difficulty swallowing, ptosis (eye droop), restlessness, and sweating. As always, nutrition is a concern with these clients. Food should be high in calories, and tube (enteric) feedings may be indicated. Treatment for myasthenia gravis includes rest and antocholinesterase drugs (neostigmine or [Prostigmin], pyridostigmine or [Mestinon]. Observation for signs of a cholinergic crisis (the result of anticholinesterase overdose) is imperative. The following brief chart should help you remember the diagnostic test for, and signs of, a cholinergic crisis. Cholinergic Crisis Differentiates by a negative Tensilon test (symptoms worsen with Tensilon administration) Signs very similar to those of a myasthenic crisis except:

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Hypotension Bradycardia

DISORDERS OF THE CRANIAL NERVES Trigeminal neuralgia is a disorder involving the trigeminal nerve (cranial nerve V; tri-causing severe pain along the sensory distribution of the nerve. 8. Write in the parts of the body that the trigeminal nerve controls: A._________________ B._________________ C._________________ For clients with trigeminal neuralgia, small, frequent meals at lukewarm temperatures are recommended, and environmental temperature extremes should be avoided. Good oral hygiene and protective eye wear are also important. Bells palsy is disorder involving the facial nerve causing facial paralysis on one side. 9. The facial nerve is cranial nerve ____________. 10. The facial nerve controls _____________ and ____________. OTHER DISORDERS OF THE NERVOUS SYSTEM There are certain neurologic disorders you should recognize for the NCLEX-RN. Match the following syndromes with the appropriate definitions: A. Guillain-Barre 11. ______ Possibly an autoimmune disorder characterized by syndrome progressive ascending paralysis that most often ceases in B. Huntingtons approximately 4 weeks, with complete recovery taking 3-6 chorea months. The disease causes motor weakness symmetrically C. Lou Gehrigs and in an ascending fashion. The clients airway is compromised disease when the disease reaches the diaphragm. 12. ______A progressive, fatal, motor neuron disease causing muscular atrophy 13. ______An inherited disorder causing progressive atrophy of the basal ganglia and portions of the cerebral cortex. Cardinal symptoms include extreme emotional lability, dementia, and uncontrolled limb movements. NERVOUS SYSTEM INJURIES HEAD INJURIES Head injuries can occur in a variety of different settings. Traumatic injury is most often caused by car accidents, falls or assaults. Assessment findings are specific to the type of injury:

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Type of Injury Concussion Contusion Hemorrhage Fracture

Description A blow to the head causes the brain to strike the skull A blow to the head causes a bruise of the brain

Symptoms Headache, transient loss of consciousness, amnesia, nausea Decreased level of consciousness, aphasia, hemiplegia Blood accumulates in the head; Symptoms are specific to can be anywhere. location Skull is cracked or broken Headache at site, cerebrospinal fluid (C.S.F.) leakage from nose or ear

SPINAL CORD INJURIES Spinal cord injuries may be divided into traumatic and nontraumatic (tumors, hematomas, aneurysms, congenital decease) injuries. Assessment findings and treatment are based on the extent and level of the injury. Interventions may be divided into acute/emergency management and chronic management. Type of Injury Description Acute Injury Spinal shock Symptoms Absence of reflexes below the injury Flaccid paralysis Urine retention Hypotension Bradycardia Temperature lability Traction as indicated: Gardner-Wells (cervical tongs) Halo device Nursing Interventions Airway, breathing, circulation (ABC)! Immobilize client to prevent further injury Prevent complications of immobility

Chronic injury

Sensory and motor dysfunction may be partial or complete, based on level of spinal cord injury

ABC! Prevent complications of immobility Meticulous pin site care to prevent infection

Complications of immobility include skin breakdown (turn and position the client every 2-3 hours) and constipation. Increase fiber and fluids in the clients diet unless contraindicated. In addition, the formation of a deep vein thrombosis is a life-threatening complication of immobility. The client may be on low-dose heparin therapy and/or be wearing antiembolic stockings. THE EYE AND THE EAR ANTOMY OF THE EYE THE EAR

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Select words from the following list to fill in the crossword puzzle:
1 3 2

4 5

9 10 11

13

14

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Cataracts Coughing Cryotherapy Dependent Detached retina Glaucoma Intraocular pressure ACROSS 3. The ________ chart is used to assess visual acuity 5. Placing a tuning fork on the mastoid process until sound is no longer heard, and then holding it in front of the ear to test for air conduction is called the ____ test. 6. Tunnel vision, eye pain, and halos around lights are signs of ________. 7. _______ is contraindicated for postoperative eye surgery clients. 8. Signs of ______ include: blurred vision, milky white pupils, progressive vision loss, and a glare in bright light. 11. Nursing care for the client with a detached retina includes bed rest with the head of the bed flat, a bilateral eye patch, and positioning the client with the affected area in a _____ position. 14. __________: The formation of spongy bone in the labyrinth of the ear causing fixation of the stapes in the oval window. Client presents with progressive hearing loss, tinnitus, and conductive hearing loss.

Lacrimal duct Menieres disease Otosclerosis Rinnes Snellen Tonometer Webers DOWN 1. In order to prevent increased ________ clients should be taught to avoid stooping and lifting, coughing, sneezing, emotional upsets, and excessive fluids. 2. The _________ test uses a vibrating tuning fork placed on the midline of a clients skull to test for conductive vs. sensorineural hearing loss. 4. Flashes of light, floaters, and visual field deficits are signs of _________. 9. Intraocular pressure is measured by a _______; normal pressure is 10-20 mm Hg. 10. Recurrent and progressive vertigo, tinnitus, and hearing loss are indicative of _________. 12. To prevent systemic effects of miotics, pressure should be placed on the ________ after instillation. 13. _________ is a treatment for detached retina which is used to produce a chorioretinal scar to allow the retina to return to its normal position.

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EXERCISE ANSWERS 1. What is the first thing a nurse should assess to determine the presence of neurologic changes? Level of consciousness 2. C expressive aphasia Mr. Jones is able to follow all commands during your physical examination. However, when you ask him about his medical history, his speech is hesitant, his word choice is inappropriate, and he appears extremely frustrated. 3. A agnosia While at Ms. Smiths bedside, you observe a conversation between Ms. Smith and her husband. Mr. Smith asks her to pass him a pen (which is on the bedside table directly in front of her). Ms. Smith stares at the table, but seems unable to recognize which object her husband is requesting. 4. B apraxia When asked if he is thirsty, Mr. Mark shakes his head yes. When you hand Mr. Mark a cup filled with juice, he holds the cup and turns it around in his hands, but never brings the cup to his mouth to drink from it. 5. D receptive aphasia Miss Gray is awake and alert and seems aware of her surroundings. When you begin your physical assessment, Miss Gray stares blankly at you and is unable to follow any commands. 6. Cheyne-Stokes respirations respirations of increasing and decreasing depth, altering with periods of apnea. May be caused by structural cerebral dysfunction or by metabolic problems such as diabetic coma. 7. Central neurogenic hyperventilation rapid respiration (>25/minute). Usually attributed to brain stem dysfunction. 8. Apneustic breathing prolonged inspiratory phase followed by a 2-3 second pause. Usually attributed to dysfunction in the respiratory center of the pons. 9. Cluster breathing clusters of irregular breaths with periods of apnea at irregular intervals. Caused by lesions in the upper medulla and lower pons. 10. Biots (ataxic) breathing- completely irregular breathing pattern. Indicates damage to the respiratory centers of the medulla. 11. With which types of seizures is an aura present? A. complex partial B. tonic-clonic (grand mall) 12. With which types of seizures is there a loss of consciousness? A. Absence (petit mal) B. Atonic C. Complex partial D. Tonic-clonic (grand mall) 13. Write in the parts of the body that the trigeminal nerve controls: Facial sensation, corneal reflex, mastication muscles. 14. The facial nerve is cranial nerve VII. 15. The facial nerve controls facial movement and anterior taste. 16. A Guillan-Barre syndrome Possibly an autoimmune disorder characterized by progressive ascending paralysis that most often ceases in approximately 4 weeks, with complete recovery taking 3-6 months. The disease causes motor weakness

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symmetrically and in an ascending fashion. The clients airway is compromised when the disease reaches the diaphragm. 17. C Lou Gehrigs disease A progressive, fatal, motor neuron disease causing progressive muscular atrophy. 18. B Huntingtons chorea an inherited disorder causing progressive atrophy of the basal ganglia and portions of the cerebral cortex. Cardinal symptoms include extreme emotional lability, dementia, and uncontrolled limb movements. (Cross word puzzle answers p. 50) NCLEX-RN STYLE QUESTIONS 1. A head-injured, unconscious child requires skilled nursing care. Which is not a priority when caring for an unconscious child? (1) frequent neurologic checks (2) frequent vital signs (3) everyday weights (4) pain assessment 2. The nurse is performing a neurological assessment on a client with recent history of head injury. Which of the following is the most sensitive indicator of neurologic functioning? (1) motor ability (2) level of consciousness (3) speech pattern (4) memory 3. Which of the following assessment methodologies is most effective in eliciting response to pain in a comatose client? (1) using a nail bed pressure (2) pinching the clients nipple (3) squeezing the clients underarm (4) pricking the clients with a sharp object 4. A client has been diagnosed with a cerebellar disorder. Which of the following nursing diagnoses is based upon the assessment data for this disorder? (1) At risk for injury related to unsteady gait (2) ineffective breathing pattern related to respiratory muscle weakness (3) impaired verbal communication related to cranial nerve dysfunction (4) alteration in body temperature related to damage to the thermoregulatory center 5. The provider has ordered dilantin IV for a client with severe seizure activity newly admitted to the unit. Which of the following factors are a priority for the nurses administration of intravenous dilantin? (1) mix with solution of D5W piggy-backed with other infusions to ensure prompt administration of all medications needed. (2) Monitor carefully for hypertension. Muscular excitability, and hyperpnea.

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(3) Expect evidence of increased oxygen demand and uptake of oxygen by the myocardial cells resulting in increased pulse rate. (4) Before giving IV dilantin, assess the client for possible alcohol intake and amount consumed prior to coming to the hospital. 6. The nurse is caring for a client with increased intracranial pressure (ICP). Which of the following nurse interventions is related to the goal of establishing cerebral tissue perfusion? (1) perform passive range-of-motion to the neck (2) elevate the head of the bed 30. (3) Suction every 2 hours and prn. (4) Encourage coughing and deep breathing. 7. When a client has a generalized tonic-clonic seizure, the nursing priority is to (1) call the code for cardiac arrest (2) hold the clients extremities down (3) protect the client from immediate injury and allow free movement (4) place an oxygen mask on the client. 8. The nurse is caring for a client with a head injury. The nurse should be on the alert for signs of increased intracranial pressure, which include (1) a change in the level of consciousness (2) bilateral pupil size increase (3) narrowing pulse pressure (4) tachycardia 9. A client has had a craniotomy to remove a brain tumor. The postoperative orders include maintaining the head of the bed at 45 and turning the client from side to side. In positioning after a craniotomy, which of the following actions is contraindicated? (1) placing the client on the side with the head supported in a neutral position and hip flexed. (2) placing the client on the side with the head supported in a neutral position and a pillow between the clients knees. (3) placing the client on the back with both arms slightly elevated on pillows. (4) placing the client on the back with the head supported in a neutral position and the arms slightly elevated. NCLEX-RN STYLE ANSWERS 1. (1) CORRECT (3) ELIMINATE Weighing the unconscious child is not a priority The question asks for which is not a priority. Neurologic checks is a priority, as this would detect subtle changes that may require intervention. (2) ELIMINATE Vital signs are a priority, as abnormal findings may require intervention. (4) ELIMINATE Pain must be assessed very frequently, as it can cause an increase in intracranial pressure. Category 10 physiological adaptation

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2. (2) CORRECT

An alteration in the level of consciousness precedes all other neurologic changes, and is more reflective of generalized cerebral function. (1) ELIMINATE Motor ability is related to intact upper and lower motor neurons, and to an intact peripheral nervous system. Therefore, changes in motor ability are evidence of narrow and specific deviations. (3) ELIMINATE Deterioration in speech is too narrow a parameter upon which to base neurologic function. Alterations in speech may be related to speech centers of the brain, to a cognitive deficit, or simply to localized trauma to the tongue or other structures that influence the quality of speech. (4) ELIMINATE Memory changes are related to narrowly prescribed memory centers of the brain. Category 09 reduction of risk potential 3. (1) CORRECT Cerebellar disorders are characterized by lack of balance and coordination. Ataxia and rhythmic involuntary movements are also characteristic. (2) ELIMINATE Cerebellar dysfunction impairs coordinated voluntary movements. Respiratory muscle weakness is not characteristic. (3) ELIMINATE Cranial nerves originate mostly in the brainstem and not in the cerebellum. Cerebellar disease is related to balance and voluntary movement. (4) ELIMINATE Thermoregulatory centers are located in the hypothalamus and alterations in body temperature is not a characteristic of cerebellar dysfunction. Category 09 reduction of risk potential 4. (4) CORRECT Alcohol will cause acute potentiation of the central nervous system and will depress effects of dilantin. Alcohol will also increase the serum level of dilantin by competing at receptor sites. The provider should be informed if the nurse determines that the client has consumed alcohol. The provider may adjust the dose or select another medication to avoid severe CNS or respiratory complications. (1) ELIMINATE Dilantin must be mixed with normal saline only, and is incompatible with all other medications in solutions. (2) ELIMINATE Dilantin will cause hypotension and muscle weakness as a side effect. (3) ELIMINATE Administer cautiously in clients with myocardial insufficiency or heart block. Dilantin will cause decreased oxygenation of myocardial cells and depression of myocardial functioning. Category 08 pharmacological and parenteral therapies 5. (2) CORRECT Elevation of the head promotes venous return by the jugular veins,

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which is assisted by gravity. Increased intracranial pressure (ICP) is swelling of the brain, and elevating the head prevents further swelling. (1) ELIMINATE Neck motion causes intermittent flexion of the jugular veins, decreasing venous return and tissue perfusion and increasing intracranial pressure. (3) ELIMINATE Suctioning increases coughing and intra-abdominal pressure, which increases intracranial pressure. (4) ELIMINATE Coughing causes the use of the Valsalvas maneuver, increasing intrathoracic pressure and intracranial pressure. Category 09 reduction of risk potential 6. (3) CORRECT move freely. (1) ELIMINATE (2) ELIMINATE (4) ELIMINATE Safety is always the priority, and the client should be allowed to

Cardiac arrest codes should not be used for this purpose. Holding the extremities can lead to injury. Administration of oxygen is sometimes appropriate after a seizure, but the priority in this situation is safety. Category 02 safety and infection control 7. (1) CORRECT One of the earliest and most sensitive signs of increased intracranial pressure is a change in the level of consciousness. (2) ELIMINATE Unilateral change in pupil size is a sign of increased intracranial pressure. (3) ELIMINATE Widening pulse pressure is a sign of increased intracranial pressure. (4) ELIMINATE Bradycardia is a sign of increased intracranial pressure Category 09 reduction of risk potential 8. (1) CORRECT Proper positioning requires support of the neck in a neutral position to facilitate venous drainage. Pillows should always be placed between the knees. Hip flexion can cause increased intracranial pressure. (2) ELIMINATE This position is appropriate for a postop craniotomy patient. (3) ELIMINATE Arms should be slightly elevated to avoid dependent edema. (4) ELIMINATE This position is appropriate for a postop craniotomy patient. Category 09 reduction of risk potential 9. (3) CORRECT (1) ELIMINATE MS often affects a clients speech and swallowing abilities. Clients with multiple sclerosis (MS) do not develop increased intracranial pressure (2) ELIMINATE Seizures are not a common feature of MS. (4) ELIMINATE Hair loss is more common with thyroid disorders. Category 10 physiological adaptation

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