65

NEUROSENSORY SYSTEM

ACUTE HEAD INJURY

K
Problem
- Trauma to the head, leading to brain injury and bleeding within the brain
- Classified according to brain injury: fracture, haemorrhage, trauma
- Fracture can be: depressed, comminuted or linear
- Haemorrhage can be: epidural, subdural, intracerebral, subarachnoid
Manifestation
- Disorientation to place, time and person
- Unequal pupil size, loss of pupillary reaction
Causes
- Vehicular accident
- Blunt or penetrating trauma
- Fall

E Test Results
- CT scan: shows hemorrhage, cerebral edema, shift of midline structures
- MRI: shows hemorrhage, cerebral edema
Treatment
- Cervical collar: until neck injury is ruled out
- Anticonvulsant: phenytoin (Dilantin)
- Barbiturates: phenobarbital if ICP is not controlled by diuretics
- Osmotic diuretic: mannitol (Osmitrol)
- Dopamine: to maintain cerebral tissue perfusion
- Glucocorticoids: Dexamethasone; to reduce cerebral edema
Intervention
- Assess neurologic and respiratory status

Y -
-
Observe for signs of increase ICP: 20mmHg above for more than 10 min.
Monitor hemodynamic variables, ICP and cerebral perfusion pressure
- Allow rest period between nursing activities

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AMYOTROPIC LATERAL SCLEROSIS

(Lou Gehrig’s disease)

Problem
- Progressive decrease in motor function of the upper and lower motor neuron

K system resulting to distorted or blocked nerve impulse.

Manifestation
- Muscle weakness of hands and feet
- Awkwardness of fine finger movement
- Dysphagia
Causes
- Unknown
- Genetic predisposition
- Slow acting virus
- Nutritional deficiency related to disturbance in enzyme metabolism

E Test Results
- Elevated creatinine kinase level
- EMG: decreased amplitude of evoked potentials

Treatment
- Neuroprotective agents: riluzole (Rilutek)
- Symptomatic treatment

Interventions
- Assess neurologic and respiratory status
- Assess swallowing and gag reflex

Y -
-
Devise an alternate method when necessary
Suction the oropharynx as necessary

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BELL’S PALSY

Problem

K - Damage to the 7th cranial nerve producing unilateral facial weakness or

paralysis

Manifestation
- Inability to close eyes effectively on the affected side
- Pain around the jaw or ears
- Unilateral facial weakness

Causes
- Blockage of facial nerve resulting from: infection, hemorrhage, tumor,
meningitis, local trauma

E Test Results
- EMG: helps predict the level of expected recovery by distinguishing temporary
conduction defects from a pathologic interruption of nerve fibers

Treatment
- Moist heat
- Corticosteroid: prednisone (Deltasone) to reduce facial nerve edema and

Intervention
- Watch out for adverse reaction to prednisone: G.I distress and fluid retention

Y
- Apply moist head to affected side of the face
- Massage the client’s face 2-3 times daily for 5-10 minutes
- Give reassurance that recovery is possible in 2-8 weeks

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PRACTICE QUESTIONS

1. A nurse noticed a clear fluid draining from the nose of a client who had head
trauma 3 hours ago. This may indicates which of the following condition?
a. Basilar skull fracture
b. Cerebral concussion
c. Cerebral palsy
d. Sinus infection
2. A 20 year old client with mild concussion suffered after vehicular accident is
discharged from the emergency department. Before discharge, he complains
of headache. When offered Acetaminophen, his mother tells the nurse that
headache is so and she would like her son to have something stronger.
Which of the following responses by the nurse is appropriate?
a. “Your son had a mild concussion, Acetaminophen is strong enough”.
b. “Aspirin is avoided because of the danger of Reye’s syndrome in children
or young adults”
c. “Narcotics are avoided after a head injury because they may hide a
worsening condition”.
d. “Stronger medication may lead to vomiting, which increases intracranial
pressure”.
3. A client with head trauma develops a urine output of 300 ml/hr, dry skin
and dry mucous membranes. Which of the following nursing intervention is
the most appropriate to perform immediately?
a. Evaluate urine specific gravity
b. Anticipate treatment for renal failure
c. Provide emollients to the skin to prevent breakdown
d. Slow the IV fluids rate and notify the physician.
4. Which of the following signs and symptoms of increased intracranial pressure
(ICP) after head trauma would appear first?
a. Bradycardia
b. Large amount of very dilute urine
c. Restlessness and confusion
d. Widened pulse pressure
5. A 34 year old client has been hit on the head by a baseball bat. The nurse
notes clear fluid draining from his ears and nose. Which of the following
nursing intervention should be done first?
a. Position the client flat in bed
b. Check the fluid for dextrose with a dipstick
c. Suction the nose to maintain airway patency
d. Insert nasal and ear packing with sterile gauze
6. When discharging a client from the emergency department after a head
trauma, the nurse teaches the guardian to observe for a lucid interval. Which
of the following statements best describes a lucid interval?

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a. An interval when the client speech is garbled

b. An interval when the client is alert but can not recall recent events
c. An interval when the client is oriented but the become somnolent
d. An interval when the client has a warning symptom such as visual
disturbances
7. Which of the following statements about Amyotrophic Lateral Sclerosis is not
true?
a. The disease is progressive and degenerative in nature
b. The disease will cause a decrease in motor functions
c. There is progressive degeneration of the sensory neuron system
d. The disease is more common in males than females
8. Which of the following nursing diagnosis is most applicable to a client with
amyotrophic lateral sclerosis?
a. Ineffective health maintenance
b. Impaired physical mobility
c. Ineffective airway clearance
d. Imbalance nutrition less than body requirements
9. Which of the following test will confirm the diagnosis of amyotrophic lateral
sclerosis?
a. Visual evoke potential scan
b. Electromyography (EMG)
c. Intracranial pressure test
d. Creatine kinase level monitoring
10. Which of the following nerve is affected in Bell’s palsy?
a. Hypoglossal
b. Facial
c. Trigeminal
d. Oculomotor
11. Which of the following group of drugs is commonly used to manage Bell ’s
palsy?
a. Corticosteroid
b. Beta adrenergic blockers
c. Sympathomimetic drugs
d. Cephalosporins
12. Which of the following health teaching should the nurse exclude when
providing care to a client newly diagnose with Bell’s palsy?
a. Use an eye patch to cover the eye
b. Avoid exposure to dust and winds
c. Perform facial exercises
d. Apply cold compress to the face to reduce pain

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BRAIN ABCESS
Problem
- Free or encapsulated collection of pus that usually occurs in the temporal

K lobe, cerebellum and frontal lobe.

Manifestations

- Headache
- Confusion
- Drowsiness

Causes

- Subdural empyema
- Infection (otitis media, sinusitis, mastoiditis)

Test Results

E -
-
Enhanced CT scan reveals the abscess site.
A CT-guided stereotactic biopsy may be performed to drain and culture the
abscess

Treatment

- Penicillinase-resistant antibiotics: nafcillin (Unipen), methicillin (Staphcillin)

- Surgical aspiration or drainage of abscess

Intervention

- Frequently assess neurological status, especially cognition and mentation,

speech, and sensorimotor and cranial nerve function.

Y - After surgery, continue frequent neurological assessment. Monitor vital signs

and intake and output.
- Watch for signs of meningitis (nuchal rigidity, headaches, chills, sweats).
- Position the patient on the operative side.
- Measure drainage (Jackson-Pratt) or other types of drains as instructed by the
surgeon.

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K Problem
BRAIN TUMOR

- Abnormal mass found in the brain resulting from unregulated cell growth and
cell division

Manifestations
- Vary depending on location of tumor
- Frontal: aphasia, memory loss personality changes
- Temporal: aphasia, seizures
- Parietal: sensory impairment
- Occipital: hemi-anopsia, visual hallucinations

E Causes

- Genetic
- Environmental

Test Results
- CT scan shows location and size of tumor
- MRI also shows location and size of tumor
Treatment
- Craniotomy
- Anticonvulsant: phenytoin (Dilantin)
- Glucocorticoid: dexamethasone (Decadron)

Y
- H2-receptor antagonists: cimetidine (Tagamet), ranitidine (Zantac)
- Mucosal barrier frontier: sucralfate (Carafate)
Intervention
- Assess neurological and respiratory status.
- Assess for increased ICP.
- Monitor for signs and symptoms of syndrome of inappropriate antidiuretic
hormone (edema, weight gain, high urine specific gravity).

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CATARACT

K Problem
- A normally clear, transparent and crystalline lens becomes opaque that could
possibly lead to vision loss

Manifestation
- Dimmed or blurred vision
- Poor night vision
- Yellow, gray, or white pupil

Cause

E
- Aging
- Blunt or penetrating trauma
- Diabetes mellitus

Test Results
- Ophthalmoscopy or slit-lamp examination confirms the diagnosis by revealing
a dark area in the normally homogeneous red reflex.

Treatment
- Extracapsular cataract extraction or intracapsular lens implant

Y Intervention
- Provide a safe environment for the patient.
- Modify the safe environment to help the patient meet his self-care needs (for
example, by placing items on the unaffected side).

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PRACTICE QUESTIONS
1. Which of the following conditions in a risk factor for the development of
cataracts in a 40-year old client?
a. History of frequent streptococcal throat infections
b. Maternal exposure to rubella during pregnancy
c. Increased intraocular pressure
d. Prolonged use of steroidal anti-inflammatory agents
2. A client who had cataract surgery should be told to call his physician if he
has which of the following conditions?
a. Blurred vision
b. Eye pain
c. Glare
d. Itching
3. Clear fluid is draining from the nose of a client who had a head trauma 3
hours ago. This may indicate which of the following conditions?
a. Basilar skull fracture
b. Cerebral concussion
c. Cerebral palsy
d. Sinus infection
4. A 19-year-old client with a mild concussion is discharged from the emergency
department after surgery from chronic brain abscess. Before discharge, he
complains of a headache. When offered acetaminophen, his mother tells the
nurse the headache is severe and she would like her son to have something
stronger. Which of the following responses by the nurse is appropriate?
a. “Your son had a mild concussion, acetaminophen is strong enough.”
b. “Aspirin is avoided because of the danger of Reye’s syndrome in children
or young adults.”
c. “Narcotics are avoided after a head injury because they may hide a
worsening condition.”
d. "Stronger medications may lead to vomiting, which increases the
intracranial pressure (ICP)."
5. A client diagnosed of brain tumor is admitted to the hospital with a
subarachnoid hemorrhage has complaints of severe headache, nuchal
rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP)
would be contraindicated in this client in which of the following
circumstances?
a. Vomiting continues.
b. Intracranial pressure (ICP) is increased.
c. The client needs mechanical ventilation.
d. Blood is anticipated in the cerebrospinal fluid (CSF).
6. For a patient with occipital lobe brain tumor, the nurse should expect which
of the following manifestation?
a. Decrease hearing acuity

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b. Homonymous hemianopsia
c. Inability to identify small objects
d. Impaired swallowing
7. Which of the following values is considered normal for intracranial pressure
(ICP)?
a. 0 to 15 mm Hg
b. 25 mm Hg
c. 35 to 45 mm Hg
d. 120/80 mm Hg
8. Which of the following intervention should the nurse give a highest priority
for a patient post extracapsular cataract extraction
a. Providing a diet as tolerated by the patient
b. Monitoring intake and output
c. Provision of safety
d. Monitoring of vital signs every 4 hours
9. Which of the following part of the eye is exactly affected in a client with
cataract?
a. Optic disc
b. Lens
c. Cornea
d. Choroid layer
10.What is the use of phenytoin (Dilantin) being included in the pharmacologic
management of brain tumor?
a. To decrease intracranial pressure
b. To prevent disturbances in brains electrical activity
c. To prevent further inflammation
d. To improve muscle tone

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K Problem
CEREBRAL ANEURYSM

- Outpouching of cerebral artery due to the weakness of its middle layer mostly
asymptomatic until it ruptures
Manifestation
- Headache (commonly described by the patient as the worst he has ever had)
Causes
- Head trauma
- Atherosclerosis
- Congenital weakness

E Test Results
- Cerebral angiogram identifies the aneurysm.
- CT scan shows a shift of intracranial midline structures, blood in
subarachnoid space.
Treatment
- Aneurysm clipping
- Anticonvulsant: phenytoin (Dilantin)
- Calcium channel blocker: nimodipine (Nimotop) preferred to prevent cerebral
vasospasm
- Glucocorticoid: dexamethasone (Decadron)
- Stool softener: docusate sodium (Colace)

Y Intervention
- Assess neurological status.
- Administer crystalloid solutions after aneurysm clipping.
- Take vital signs every 1 to 2 hours initially and then every 4 hours when the
patient becomes stable.
- Allow a rest period between nursing activities.

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K
ENCEPHALITIS
Problem
- Severe inflammation and swelling of the brain tissue due to mosquito borne or
a tick borne virus
Manifestation
- Meningeal irritation (stiff neck and back) and neuronal damage (drowsiness,
coma, paralysis, seizures, ataxia, and organic psychoses)
- Sudden onset of fever
- Headache
- Vomiting

Causes

E - Exposure to virus
Test Results

- Blood studies identify the virus and confirm diagnosis.

- Cerebrospinal fluid (CSF) analysis identifies the virus.

Treatment:
- Endotracheal intubation and mechanical ventilation
- Nasogastric tube feedings or total parenteral nutrition
- Anticonvulsants: phenytoin (Dilantin), phenobarbital (Luminal
- Analgesic and antipyretics:
- Diuretics: furosemide (Lasix) or mannitol (Osmitrol) to reduce cerebral

Y -
swelling
Corticosteroid: dexamethasone (Decadron) to reduce cerebral and edema
Intervention

- Assess neurologic function often. Observe the patient’s mental status and
cognitive abilities.
- Maintain adequate fluid but avoid fluid overload. Measure and record intake
and output accurately.
- Assist with range-of-motion exercises.
- Maintain a quite environment. Darken the room.

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GLAUCOMA

K
Problem
- Damage to the optic nerve resulting from increase intraocular pressure that
may lead to blindness if not treated.
Manifestation
- Chronic open-angle glaucoma (overproduction or obstructed flow of aqueous
humor). Initially asymptomatic
- Acute angle-closure glaucoma (obstruction in the outflow of aqueous humor
due to anatomically narrow pathway.
- Acute ocular pain
- Blurred vision
- Dilated pupil
- Halo vision

E Causes
- Diabetes mellitus
- Family history
- Previous eye trauma or surgery
Test Results
- Ophthalmoscopy shows atrophy and cupping of optic nerve head.
- Tonometry shows increased intraocular pressure.
Treatment
- Chronic open-angle glaucoma
 Alpha agonist: brimonidine (Alphagan)
 Beta-adrenergic antagonist: timolol (Timoptic)

Y - Acute angle-closure glaucoma

 Cholinergic agent: pilocarpine
 Laser iridectomy or surgical iridectomy if pressure doesn’t decrease with
drug therapy
Intervention
- Assess eye pain and administer medication as prescribed.
- Modify the environment

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PRACTICE QUESTIONS
1. A client with a subdural hematoma was given mannitol to decrease
intracranial pressure (ICP). Which of the following results would best show
the mannitol was effective?
a. Urine output increases.
b. Pupils are 8 mm and nonreactive.
c. Systolic blood pressure remains at 150 mm Hg.
d. Blood urea-nitrogen (BUN) and creatinine levels return to normal.
2. A client with glaucoma is for IOP monitoring. Which of the following
instruments is used to record intraocular pressure?
a. Goniometer
b. Ophthalmoscope
c. Slit lamp
d. Tonometer
3. When developing a teaching session on glaucoma for the community, which
of the following statements would the nurse stress?
a. Glaucoma is easily corrected with eye-glasses.
b. White and Asian individuals are at the higher risk for glaucoma.
c. Yearly screening for people ages 20 to 40 years is recommended.
d. Glaucoma can be painless and vision may be lost before the person is
aware of a problem.
4. For a client having an episode of acute narrow-angle glaucoma, a nurse
expects to give which of the following medications?
a. Acetazolamide (Diamox)
b. Atropine
c. Furosemide (Lasix)
d. Urokinase (Abbokinase)
5. Which of the following symptoms would occur in a client with a detached
retina?
a. Flashing lights and floaters
b. Homonymous hemianopia
c. Loss of central vision
d. Ptosis
6. A client underwent an enucleation of the right eye for a malignancy. Which of
the following interventions will the nurse perform?
a. Instilling miotic as ordered to the affected eye
b. Teaching the client to clean the prosthesis in soap and water
c. Assessing reactivity of the pupils to light and accommodation
d. Teaching the client to prevent straining at stool leading to increased
intraocular pressure
7. A client with encephalitis is unable to recall anything from the moment of the
injury or to retain memories of the recent events. This is known as:
a. Anterograde amnesia

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b. Retrograde amnesia
c. Post event amnesia
d. Ante natal amnesia
8. Which of the following is not a common symptoms found in a patient with
possible encephalitis?
a. Irritability
b. Convulsive seizures
c. Delirium
d. Headache
9. Which of the following drug is given to prevent further spasm of cerebral
artery in a client with presenting manifestations of cerebral aneurysm?
a. Phenytoin (Dilantin)
b. Calcium channel blocker
c. Corticosteroid
d. Diuretics
10. Which of the following statement about cerebral aneurysm is not true?
a. The disease is not treatable
b. Stool softener can be given to prevent increase in ICP
c. Most patient has initial complaint of headache
d. The exact cause of the disease is unknown

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GUILLAIN BARRE SYNDROME

Problem

K
- Fatal form of polyneuritis in which your body’s immune system attack your
peripheral nerves and eventually paralyzing your body.
Manifestation
- Muscle weakness (ascending from the legs to arms)
Causes
- Cell mediated immune response with an attack to peripheral nerves
- Demyelination of the peripheral nerves
- Respiratory infection
Test Results
- A history of preceding febrile illness (usually a respiratory tract infection) and
typical clinical features suggest Guillain-Barre syndrome.

E
- CSF protein level begins to rise, peaking in 4 to 6 weeks. The CSF white blood
cell count remains normal but, in severe disease, CSF pressure may rise
above normal.
Treatment
- Anticoagulants: heparin, warfarin (Coumadin)
- Corticosteroid: prednisone (Deltasone)
- Endotracheal intubation or tracheotomy if the patient has difficulty clearing
secretions; possibly mechanical ventilation
- Plasmapheresis with IVIG.
Intervention
- Watch for ascending sensory loss, which precedes motor loss.
- Assess and treat respiratory dysfunction.

Y - If respiratory failure becomes imminent, establish an emergency airway with

an endotracheal tube.
- If aspiration can’t be minimized by diet and position modification, expect to
provide nasogastric feeding.
- Inspect the patient’s legs regularly for signs of thrombophlebitis (localized
pain, tenderness, erythema, edema, and positive Homans’ sign).

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HUNTINGTONS DISEASE

K Problem
- Degeneration in the cerebral cortex and basal ganglia causing chronic
involuntary and irregular movement, with cognitive deterioration and ending
in dementia

Manifestation

- Dementia (can be mild at first but eventually disrupts the patient’s

personality)
- Gradual loss of musculoskeletal control, eventually leading to total
dependence

Causes

E - Genetic transmission: autosomal dominant (each child has 50% chance of

inheriting the disease)

Test results

- Position emission tomography defects the disease.

- Deoxyribonucleic acid analysis detects the disease

Treatment

- Antidepressant: imipramine (Tofranil) to help control choreic movements

- Antipsychotics: chlorpromazine (Thorazine) and haloperidol (Haldol) to help
control choreic movements

Y - Supportive, protective treatment aimed to relieving symptoms (because

Huntington’s disease has no known cure)

Intervention

- Provide physical support by attending to the patient’s basic needs, such as

hygiene, skin care, bowel, and bladder care, and nutrition.
- Look for signs for possible suicide. Control the patient’s environment to
protect him from suicide or other self-inflicted injury.
- Pad the side rails of the bed but avoid restraints.

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MENIERE’S DISEASE
Problem

K - Severe vertigo, sensorineural hearing loss and tinnitus due to dysfunction in

the inner ear (labyrinth- part of the ear that produces balance).
Manifestations
- Sensorineural hearing loss
- Severe vertigo
- Tinnitus
Causes
- ANS dysfunction constricting blood vessel supplying the inner ear
- Overproduction or decrease absorption of endolymp
Test results
- Audiometric studies indicate a sensorineural hearing loss and loss of

E discrimination and recruitment.

Treatment
- Restriction of sodium intake to less than 2 g/day
- Anticholinergic: atropine (may stop an attack in 20 to 30 minutes)
- Acetazolamide (Diamox): prevent build-up of fluid in the inner ear
Intervention
- Advise the patient against reading and exposure to glaring lights.
- Keep the side rails of the patient’s bed up. Tell him not to get out of the bed
or walk without assistance.
- Instruct the patient to avoid sudden position changes and tasks that vertigo
makes hazardous.

Y Before surgery
- If the patient is vomiting, record fluid intake and output and characteristics
of vomitus. Administer antiemetic as necessary, and give small amounts of
fluid frequently.
After surgery
- Tell the patient to expect dizziness and nausea for 1 or 2 days after surgery.

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PRACTICE QUESTIONS
1. During an acute episode of Meniere’s disease, the nurse should instruct the
client to limit which of the following content in the diet?
a. Carbohydrate
b. Protein
c. Sodium
d. Calcium
2. Which of the following signs and symptoms possess a greatest danger to the
client with Meniere’s disease.
a. Sensorineural hearing loss
b. Severe vertigo
c. Tinnitus
d. Loss of appetite
3. A client admitted with a neurological problem indicates to the nurse that
magnetic resonance imaging (MRI) may be done. The nurse interprets that
the client may be ineligible for the diagnostic procedure based on the client’s
history of:
a. hypertension
b. heart failure
c. chronic obstructive pulmonary disorder
d. pacemaker
4. An unconscious client with suspected GBS is receiving mechanical
ventilation. Which nursing diagnosis takes priority?
a. ineffective airway clearance related to inability to expectorate
b. risk for impaired skin integrity related to immobility
c. imbalance nutrition less than body requirement related to dysphagia
d. Self-care deficit related to unconsciousness
5. Which symptom is an early indicator of hypoxia in a client with Huntington’s
disease who is semi-conscious?
a. hypotension
b. cyanosis
c. decreased respiration
d. restlessness
6. Which of the following is the reason why craniotomy is done as part of the
management in the patient with increase intracranial pressure due to
overproduction of endolymp.
a. To relieve pressure
b. To relieve edema
c. To lessen inflammatory process
d. To increase CSF production
7. Ascending paralysis is common in which of the following disorder?
a. Guillain Barre Syndrome
b. Cerebrovascular accident
c. Huntington’s chorea
d. Myasthenia gravis

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8. Wilma, His sister and a nurse is suctioning the tracheostomy tube of James.
Which of the following, if made by Wilma indicates that she is committing an
error.
a. Hyperventilating James with 100% oxygen before and after suctioning
b. Instilling 3 to 5 ml normal saline to loosen up secretion
c. Applying suction during catheter withdrawal
d. Suction the client every hour
9. The physician orders the following for the client with Menieres disease. Which
of the following should the nurse question?
a. Dipenhydramine [Benadryl]
b. Out of bed activities and ambulation
c. Atropine sulfate
d. Diazepam (Valium)
10.A client with a closed head injury following an attack of vertigo is confused,
drowsy, and has unequal pupils. Which of the following nursing diagnosis is
most important at this time?
a. Altered level of cognitive function
b. High risk for injury
c. Altered cerebral tissue perfusion
d. Sensory perceptual alteration

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MULTIPLE SCLEROSIS
Problem

K
- Demyelination in the neurons of the brain and spinal cord resulting in the
impairment of impulse transmission
Manifestations
- Nystagmus, diplopia, blurred vision, optic neuritis
- Weakness, paresthesia, impaired sensation, paralysis
Causes
- Autoimmune response
- Environment and genetic factors
- Slow acting or latent viral infection
Test Results
- CT scan eliminates other diagnoses such as brain or spinal cord tumors.
- MRI eliminates other diagnoses such as brain or spinal cord tumors

E Treatment
- Plasmapheresis (for antibody removal)
- Cholinergic: bethanechol (Urecholine)
- Glucocorticoids: prednisone (Deltasone), dexamethasone (Decadron),
corticotropin (ACTH)
- Immunosuppressants: interferon beta-1b (Betaseron), cyclophosphamide
(Cytoxan), methotrexate (Folex)
- Skeletal muscle relaxants: dantrolene (Dantrium), baclofen (Lioresal)

Intervention
- Assess changes in motor coordination, paralysis, or muscular weakness and

Y -
report changes.
Encourage the patient to express feelings about changes in body image.
- Establish a bowel and bladder program.
- Maintain activity, as tolerated (alternating rest and activity).

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MYASTHENIA GRAVIS

Problem

K
- Disturbance in the transmission of nerve impulse at the neuromuscular
junction due to deficiency in acetylcholine receptor sites.
Manifestation
- Dysphagia, drooling eyelid
- Muscle weakness and fatigability (typically, muscles are strongest in the
morning but weaken throughout the day, especially after exercise)
- Profuse sweating

Causes
- Autoimmune disorder
- Excessive cholinesterase

E
- Insufficient acetylcholine
Test results
- EMG shows decreased amplitude of evoked potentials.
- Neostigmine (Prostigmin) or edrophonium (Tensilon) test relieves symptoms
after medication administration – a positive indication of the disease
Treatment
- Anticholinesterase: neostigmine (Prostigmin), pyridostigmine (Mestinon),
ambenonium (Mytelase)
- Glucocorticoids: prednisone (Deltasone), dexamethasone (Decadron),
corticotropin (ACTH)
- Immunosuppressants: azathioprine (Imuran), cyclophosphamide (Cytoxan)

Y Intervention
- Assess neurologic and respiratory status.
- Assess swallowing and gag reflexes.
- Watch the patient for choking while eating.

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OTOSCLEROSIS

K Problem
- Overgrowth of the ear spongy bone around the oval window preventing sound
waves from being transmitted to the cochlea resulting in conductive hearing
loss

Manifestation
- Progressive hearing loss
- Tinnitus

Causes
- Familial tendency

E Test Results
- Audiometric testing confirms hearing loss.

Treatment
- Stapedectomy and insertion of a prosthesis to restore partial or total hearing
- Hearing aid

Intervention
- Develop alternative means of communication.

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PRACTICE QUESTIONS
1. When prioritizing care, which of the following clients should the nurse assess
first?
a. A 17-year-old client 24-hours post-appendectomy
b. A 33-year-old client with a recent diagnosis of Guillain-Barré syndrome
c. A 50-year-old client 3 days post-myocardial infarction
d. A 50-year-old client with diverticulitis
2. A client is newly diagnosed with myasthenia gravis. Client teaching would
include which of the following conditions as the cause of this disease?
a. A post-viral illness characterized by ascending paralysis
b. Loss of the myelin sheath surrounding peripheral nerves
c. Inability of basal ganglia to produce sufficient dopamine
d. Destruction of acetylcholine receptors causing muscle weakness
3. Which of the following conditions is an early symptom commonly seen in
myasthenia gravis?
a. Dysphagia
b. Fatigue improving at the end of the day
c. Ptosis
d. Respiratory distress
4. One hour after receiving pyridostigmine bromide (Mestinon), a client reports
difficulty swallowing and excessive respiratory secretions. The nurse notifies the
physician and prepares to administer which of the following medications?
a. Additional Mestinon
b. Atropine
c. Edrophonium (Tensilon)
d. Neostigmine (Prostigmin)
5. Which of the following pathophysiologic processes are involved in multiple
sclerosis (MS)?
a. Destruction of the brain stem and basal ganglia in the brain
b. Degeneration of the nucleus pulposus, causing pressure on the spinal
cord
c. Chronic inflammation of rhizomes just outside the central nervous system
d. Development of demyelination of the myelin sheath, interfering with nerve
transmission
6. Which of the following measures would be included in teaching for the client
with multiple sclerosis (MS) to avoid exacerbation of the disease?
a. Patching the affected eye
b. Range-of-motion (ROM) exercises
c. Swimming
d. Urine retention
7. Which of the following conditions or activities may exacerbate multiple sclerosis
(MS)?
a. Pregnancy
b. Range-of-motion (ROM) exercises
c. Swimming
d. Urine retention
8. A client with suspected multiple sclerosis (MS) undergoes a lumbar puncture.
Which of the following abnormalities is typically found in cerebrospinal fluid
(CSF) of clients with MS?

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a. Blood or increased red blood cells

b. Elevated white blood cells (WBCs) or pus
c. Increased glucose concentrations
d. Increased protein levels

9. Which of the following is the main problem in the client with otosclerosis?
a. Soundwaves does not reach the inner ear
b. Excessive soundwaves enters the labyrinth of the inner ear
c. Inability of the oval window to transmit soundwaves
d. Loss of soundwaves from middle to the inner ear

10.Which of the following terms describes involuntary, jerking, rhythmic

movements of the eyes?
a. Diplopia
b. Exophthalmos
c. Nystagmus
d. Oculogyric crisis

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PARKINSON’S DISEASE
Problem

K - Progressive degenerative disorder of the CNS due to dopamine deficiency,

resulting to impairment in the area of the brain responsible for control of
voluntary movement.
Manifestation
- Pill-rolling tremors, tremors at rest
- Masklike facial expression
- Shuffling gait, stiff joints, dyskinesia, cogwheel rigidity, stooped posture
Causes
- Cerebrovascular disease
- Drug induced
- Repeated head trauma

E Test Results
- EEG reveals minimal slowing of brain activity.

Treatment
- Antidepressant: amitriptyline (Elavil)
- Antiparkinsonian agents: levodopa (Larodopa), carbidopa-levodopa (Sinemet),
benztropine (Cogentin)

Intervention
- Assess neurologic and respiratory status.

Y
- Reinforce gait training.
- Reinforce independence in care.

RETINAL DETACHMENT
Problem

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- Development of a hole or tear in the retina that sips vitreous fluid resulting in
the separation of this semi-transparent layer from the choroid (middle
vascular coat between the retina and sclera).

Manifestation
- Painless change in vision (floaters and flushes of light)
- With progression of detachment, painless vision loss may be described as a
“veil, curtain,” or “cobweb” that eliminates part of visual field
Causes
- Aging
- Diabetic Neurovascularization
- Inflammatory process

Test Results
- Indirect ophthalmoscope retinal tear or detachment.
- Slit-lamp examination shows retinal tear or detachment

Treatment
- Scleral buckling to reattach the retina

Intervention
- Postoperatively instruct the patient to lie on his back or on his unoperated
side.
- Discourage straining during defecation, bending down, and hard coughing,
sneezing, or vomiting.

SPINAL CORD INJURY

Problem

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- Damage to the spinal cord due to traumatic force on the vertebral column
resulting in partial or full loss of motor or sensory functions or both.
Manifestation
- Loss of bowel and bladder control
- Paralysis below the level of the injury
- Paresthesia below the level of the injury

Causes
- Vehicular accidents
- Congenital anomalies
- Falls
- Infections
Test Results
- CT scan shows spinal cord edema, vertebral fracture, and spinal cord
compression.
- MRI shows spinal cord edema, vertebral fracture, and spinal cord
compression
Treatment
- Flat position, with neck immobilized in a cervical collar
- Maintenance of vertebral alignment through Crutchfield tongs and Halo
brace
- Surgery for stabilization of the upper spine such as insertion of Harrington
rods
- Glucocorticoid: methylprednisolone (Solu-Medrol) given as infusion
immediately following injury (improves neurologic recovery when
administered within 8 hours of injury)
- Muscle relaxant: dantrolene (Dantrium)
Intervention
- Assess neurologic and respiratory status.
- Assess for spinal shock.
- Check for autonomic dysreflexia (sudden extreme rise in blood pressure)

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PRACTICE QUESTIONS

1. When evaluating the extent of Parkinson’s disease, a nurse observes for

which of the following conditions?
a. Bulging eyeballs
b. Diminished distal sensation
c. Increased dopamine levels
d. Muscle rigidity
2. Which of the following statements best describes the cause of Parkinson’s
disease?
a. Loss of the myelin sheath surrounding peripheral nerves
b. Degeneration of the substantia nigra, depleting dopamine
c. Bleeding into the brain stem, resulting in motor dysfunction
d. An autoimmune disorder that destroys acetylcholine receptors
3. Which of the following symptoms occurs initially in Parkinson’s disease?
a. Akinesia
b. Aspiration of food
c. Dementia
d. Pill rolling movements of the hand

4. To evaluate the effectiveness of levodopa, carbidopa (Sinemet), a nurse would

watch for which of the following results?
a. Improved visual acuity
b. Decreased dyskinesia
c. Reduction in short-term memory
d. Lessened rigidity and tremor
5. Two days after starting therapy with trihexyphenidyl (Artane), a client
complains of a dry mouth. Which of the following nursing interventions
would best relieve the client’s dry mouth?
a. Offer the client ice chips and frequent sips of water
b. Withhold the drug and notify the physician
c. Change the client’s diet to clear liquid until the symptoms subside
d. Encourage the use of supplemental puddings and shakes to maintain
weight
6. A client comes to the emergency department after hitting his head in a motor
vehicle accident. He’s alert and oriented. Which of the following nursing
interventions should be done first?
a. Assess full range of motion (ROM) to determine the extent of injuries.
b. Call for an immediate chest X-ray.
c. Immobilize the client’s head and neck.
d. Open the airway with the head-tilt-chin-lift maneuver.
7. A client with a C6 spinal injury would most likely have which of the following
symptoms?
a. Aphasia
b. Hemiparesis
c. Paraplegia
d. Tetraplegia

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8. A 30-year old client is admitted to the progressive care unit with a C5

fracture from a motorcycle accident. Which of the following assessments
would take priority?
a. Bladder distention
b. Neurologic deficit
c. Pulse oximetry readings
d. The client’s feelings about the injury
9. While in the emergency department, a client with C8 quadriplegia develops a
blood pressure of 80/44 mm Hg, pulse of 48 beats/minute, and respiratory
rate of 18 breaths/minute. The nurse suspects which of the following
conditions?
a. Autonomic dysreflexia
b. Hemorrhagic shock
c. Neurogenic shock
d. Pulmonary embolism
10.A client with a cervical spine injury has Gardiner-Wells tongs inserted for
which of the following reasons?
a. To hasten wound healing
b. To immobilize the surgical spine
c. To prevent autonomic dysreflexia
d. To hold bony fragments of the skull together
11.Which of the following symptoms would occur in a client with a detached
retina?
a. Flashing lights and floaters
b. Homonymous hemianopia
c. Loss of central vision
d. Ptosis
12.A client at the eye clinic reports difficulty seeing at night. This may result
from which of the following nutritional deficiencies?
a. vitamin A
b. vitamin B6
c. vitamin C
d. vitamin K

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CEREBROVASCULAR ACCIDENT

K
Problem
- Sudden impairment of cerebral circulation resulting in a serious damage or
necrosis in one or more blood vessels supplying the brain
Manifestation
- Headache
- Mental impairment
- Nuchal rigidity
- Coma
Causes
- Thrombus, embolus
- Hypertension
- Vasospasm

E - Cerebral arteriosclerosis
Test Results
- CT scan reveals intracranial bleeding, infarct (shows up 24 hours after the
initial symptoms), or shift of midline structures
- Digital subtraction angiography reveals occlusion or narrowing of vessels.
- MRI shows intracranial bleeding, infarct, of shift of midline structures.
Treatment
- Anticoagulants: heparin, warfarin (Coumadin), ticlopidine
- Anticonvulsant: phenytoin (Dilantin)
- Glucocorticoid: dexamethasone (Decadron)
- Thrombolytic therapy: tissue plasminogen activator given within the first 3

Y hours of an ischemic stroke, to restore circulation to the affected brain tissue

and limit the extent of brain injury
Intervention
- Take vital signs every 1 to 2 hours initially and then every 4 hours when the
patient becomes stable.
- Elevate the head of the bed 30 degrees.
- Conduct a neurologic assessment every 1 to 2 hours initially and then every
4 hours when the patient becomes stable.

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TRIGEMINAL NEURALGIA
Problem

K - Painful disorder of one or more branches of fifth cranial nerve that produces
paroxysmal attack of excruciating facial pain

Manifestation
- Excruciating pain in the facial area
Causes
- May be related to compression of the nerve root

Test Results
- Observation during the examination shows the patient favoring (splinting) the
affected area. To ward off a painful attack, the patient commonly holds his

E face immobile when talking. He may also leave the affected side of his face
unwashed and unshaven or protect it with a coat or shawl.

Treatment
- Anticonvulsants: carbamazepine (Tegretol) or phenytoin (Dilantin) may
temporarily relieve or prevent pain.
- Microsurgery for vascular decompression

Intervention
- Observe and record the characteristics of each attack, including the patient’s
protective mechanisms.

Y -
-
Provide adequate nutrition in small, frequent meals at room temperature.
If the patient is receiving phenytoin, watch for adverse effects, including
ataxia, skin eruptions, gingival hyperplasia, and nystagmus.
- Advise the patient to place food in the unaffected side of his mouth when
chewing, to brush his teeth and rinse mouth often, and to see a dentist twice
a year to detect activities.
- After surgical decompression of the root or partial nerve dissection, check
neurologic and vital signs often.

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PRACTICE QUESTIONS
1. An elderly client had a stroke and can only see the nasal visual field on one side
and the temporal portion on the opposite side. Which of the following terms
correctly describes this condition?
a. Astereognosis
b. Homonymous hemianopia
c. Oculogyric crisis
d. Receptive aphasia
2. A client had an embolic stroke. Which of the following conditions places a client
at risk for thromboembolic stroke?
a. Atrial fibrillation
b. Bradycardia
c. Deep vein thrombosis (DVT)
d. History of myocardial infarction (MI)
3. A heparin infusion at 1,500/hour is ordered for a 65-year old client with a stroke
in evolution. The infusion contains 25,000 units of heparin in 500 ml of saline
solution. How many milliliters per hour should be given?
a. 15 ml/hour
b. 30 ml/hour
c. 45 ml/hour
d. 50 ml/hour
4. To maintain airway patency during a CVA in evolution, which of the following
nursing interventions is appropriate?
a. Thicken all dietary liquids
b. Restrict dietary and parenteral fluids.
c. Place the client in the supine position.
d. Have tracheal suction available at all times.
5. For a client with CVA, which of the following criteria must be fulfilled before the
client is feed?
a. The gag reflex returns.
b. Speech returns to normal.
c. Cranial nerves III, IV, and VI are intact.
d. The client swallows small sips of water without coughing.
6. Which of the following diets would be least likely to lead to aspiration in a client
who had a stroke with residual dysphagia?
a. Clear liquid
b. Full liquid
c. Mechanical soft
d. Thickened liquid
7. The nurse keeps on instructing the client recovering from CVA to do deep
breathing and coughing technique while in bed. The purpose of this intervention
is to:
a. Help expand the lung and remove secretions
b. To improve the appetite while in bed
c. To alleviate an increased in ICP
d. To stop inflammatory process
8. The doctor’s order Mannitol (Osmitrol) to a patient post vehicular accident with
head injury. The nurse knows that this was given for which purpose?

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a. To increase ICP
b. To reduce cerebral edema
c. To decrease possibility of bleeding
d. To reduce inflammatory process
9. Risk factors for cerebrovascular accident do not include which of the following?
a. Hypertension
b. Emphysema
c. Diabetes mellitus
d. Obesity

10.Which of the following intervention is east important in the client with trigeminal
neuralgia?
a. Note the characteristics of each attack
b. Giving 2-3 regular meals a day
c. Monitoring of vital signs after surgical decompression
d. Instruct the patient to report to the doctor signs of infection

11.The nurse is discussing the purpose of an encephalogram with the family of a

client with massive cerebral hemorrhage and loss of consciousness. The nurse
should tell the family that the test measures which of the following?
a. extent of intracranial bleeding
b. site of brain injury
c. electrical activity of the brain
d. percent of functional brain tissue

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