Neurological Nursing Flashcards

A patient with a subarachnoid hemorrhage suddenly develops worsening headache, photophobia, and neck stiffness. Which complication is most likely occurring?

Answer: Rebleeding

Sudden worsening of headache after subarachnoid hemorrhage is the classic sign of rebleeding, the most dangerous early complication.

Which Glasgow Coma Scale score indicates severe traumatic brain injury?

Answer: 8 or below

A GCS score of 8 or below classifies a traumatic brain injury as severe and typically requires intubation to protect the airway.

A nurse is caring for a patient post-craniotomy. Which finding requires IMMEDIATE intervention?

Answer: Pupils unequal and non-reactive

Unequal, non-reactive pupils post-craniotomy indicate uncal herniation and brainstem compression, requiring immediate intervention.

What is the priority nursing intervention for a patient experiencing status epilepticus?

Answer: Protect the airway and administer IV benzodiazepine

Airway protection and rapid administration of IV benzodiazepines (such as lorazepam) are the immediate priorities in status epilepticus.

A patient with Guillain-Barré syndrome is admitted. Which assessment finding is most critical to monitor?

Answer: Respiratory rate and tidal volume

Ascending paralysis in Guillain-Barré syndrome can involve respiratory muscles, making respiratory function the most critical assessment.

Which position is most appropriate for a patient with increased intracranial pressure (ICP)?

Answer: Head of bed elevated 30 degrees, neck midline

Elevating the HOB to 30 degrees with the neck in midline promotes venous drainage from the brain, helping to reduce ICP.

A patient with a C5 spinal cord injury is at greatest risk for which complication during the acute phase?

Answer: Respiratory failure

A C5 injury affects the phrenic nerve (C3-C5), significantly impairing diaphragm function and placing the patient at high risk for respiratory failure.