Neurological Nursing Care Flashcards

A patient with suspected increased intracranial pressure (ICP) is admitted to the medical-surgical unit. Which nursing intervention is the priority?

Answer: Elevate the head of bed to 30–45 degrees

Elevating the head of bed to 30–45 degrees promotes venous drainage and helps reduce intracranial pressure.

Which assessment finding in a post-stroke patient indicates a deteriorating neurological status requiring immediate notification of the provider?

Answer: New onset confusion and unequal pupils

New onset confusion combined with unequal pupils (anisocoria) signals herniation or expanding hemorrhage and is a neurological emergency.

A nurse is caring for a patient with a seizure disorder. Which action is MOST important during an active tonic-clonic seizure?

Answer: Turn the patient to the side and protect the head

Positioning the patient on their side prevents aspiration of secretions and protecting the head reduces injury during a tonic-clonic seizure.

Which Glasgow Coma Scale (GCS) score indicates a severe traumatic brain injury?

Answer: 3–8

A GCS score of 3–8 is classified as severe traumatic brain injury, indicating significant neurological compromise.

A patient is receiving IV phenytoin for seizure management. The nurse should monitor for which priority adverse effect?

Answer: Cardiac dysrhythmias

IV phenytoin administered too rapidly can cause severe cardiac dysrhythmias, including bradycardia and heart block.

When performing a neurological assessment, the nurse asks the patient to identify a familiar object placed in their hand without looking. This test evaluates:

Answer: Stereognosis

Stereognosis is the ability to identify objects by touch alone, testing sensory cortex and parietal lobe integration.