Adaptive Quizzes Chapter 65- Neuro Assessment and Chapter 67- Strokes

- Carotid endarterectomy If narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a carotid endarterectomy (surgical removal of atherosclerotic plaque) is a treatment option.

A 76-year-old client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? - Stent placement - Removal of the carotid artery - Percutaneous transluminal coronary artery angioplasty - Carotid endarterectomy

- Call the physician immediately. The nurse should notify the physician immediately because the headache may be an indication that the aneurysm is leaking. Sitting with the client is appropriate but only after the physician has been notified of the change in the client's condition. The physician will decide whether or not administration of an analgesic is indicated. Informing the nurse manager isn't necessary.

A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform? - Sit with the client for a few minutes. - Administer an analgesic. - Inform the nurse manager. - Call the physician immediately.

- Diastolic pressure of 110 mm Hg

After the patient has received tPA, the nurse knows to check vital signs every 30 minutes for 6 hours. Which of the following readings would require calling the provider? - Heart rate of 100 - Respiration of 22 - Systolic pressure of 180 mm Hg - Diastolic pressure of 110 mm Hg

- First 2 to 12 hours Aneurysm rebleeding occurs most frequently during the first 2 to 12 hours after the initial hemorrhage and is considered a major complication.

Aneurysm rebleeding occurs most frequently during which time frame after the initial hemorrhage? - First 2 to 12 hours - First 48 hours - First week - First 2 weeks

Spatial-perceptual deficits Clients with right hemispheric stroke exhibit partial perceptual deficits, left visual field deficit, and paralysis with weakness on the left side of the body. Left hemispheric damage causes aphasia, slow, cautious behavior, and altered intellectual ability.

The nurse has just received report on a client in the ED being transferred to the acute stroke unit with a diagnosis of a right hemispheric stroke. Which findins does the nurse understand is indicative of a right hemispheric stroke? - Aphasia - Spatial-perceptual deficits - Slow, cautious behavior - Altered intellectual ability

- It cushions the brain and spinal cord. It acts as a shock absorber and cushions the spinal cord and brain against injury caused by sudden or extreme movement.

What is the function of cerebrospinal fluid (CSF)? - It cushions the brain and spinal cord. - It acts as an insulator to maintain a constant spinal fluid temperature. - It acts as a barrier to bacteria. - It produces cerebral neurotransmitters.

- Ensure that no client care equipment containing metal enters the room where the MRI is located. For client safety the nurse must make sure no client care equipment that contains metal or metal parts (e.g., portable oxygen tanks) enters the room where the MRI is located.

What safety actions does the nurse need to take for a client receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)? - Securely fasten the client's portable oxygen tank to the bottom of the MRI table after the client has been positioned on the top of the MRI table - Check the client's oxygen saturation level using a pulse oximeter after the client has been placed on the MRI table - Note that no special safety actions need to be taken - Ensure that no client care equipment containing metal enters the room where the MRI is located.

- The day the patient has the stroke Although rehabilitation begins on the day the patient has the stroke, the process is intensified during convalescence and requires a coordinated team effort.

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? - The day before the patient is discharged - After the patient has passed the acute phase of the stroke - After the nurse has received the discharge orders - The day the patient has the stroke

- Lack of deep tendon reflexes Damage to the lower motor neurons may cause decreased muscle tone, flaccid muscle paralysis, and a decrease in or loss of reflexes.

A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment? - Limited attention span and forgetfulness - Visual agnosia - Lack of deep tendon reflexes - Auditory agnosia

- Visual agnosia Visual agnosia is the loss of ability to recognize objects when seeing them. stereognosis is the inability to identify an object by touch.

A client has sustained a head injury to the occipital area. He cannot identify a familiar object by looking at it. The nurse knows that this deficit is which of the following? - Visual agnosia - Positive Romberg - Ataxia - Astereognosis

- Encourage the client to drink liberal amounts of fluids The nurse should encourage the client to take liberal fluids and should inspect the injection site for swelling or hematoma. These measures help restore the volume of cerebrospinal fluid extracted. The client is administered antihistamines before a test only if he or she is allergic to contrast dye and contrast dye will be used. The client should be encouraged to rest, because sensory stimulation tends to magnify discomfort.

A client has undergone a lumbar puncture as part of a neurological assessment. The client is put under the care of a nurse after the procedure. Which important postprocedure nursing intervention should be performed to ensure the client's maximum comfort? - Administer antihistamines according to the physician's prescription - Keep the room brightly lit and play soothing music in the background - Help the client take a brisk walk around the testing area - Encourage the client to drink liberal amounts of fluids

- Nimodipine PO Medication may be effective in the treatment of vasospasm. Based on one theory, that vasospasm is caused by an increased influx of calcium into the cell, medication therapy may be used to block or antagonize this action and prevent or reverse the action of vasospasm if already present. The most frequently used calcium channel blocker is nimodipine. The other interventions and medications are not used to treat vasospasms.

A transcranial Doppler ultrasonography detects cerebral vasospasms in a client experiencing lethargy 8 days following a subarachnoid hemorrhage. The nurse anticipates which therapeutic intervention? - Fluid restriction - Nitroprusside IV - Nimodipine PO - Phenytoin IV

- Elevating the head of the bed to 30 degrees Because the client's gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the client's risk of aspiration. Checking the stools, performing ROM exercises, and keeping the skin clean and dry are important, but preventing aspiration through positioning is the priority.

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client? - Checking stools for occult blood - Performing range-of-motion (ROM) exercises on the left side - Keeping skin clean and dry - Elevating the head of the bed to 30 degrees

- Aspirin

If warfarin is contraindicated as a treatment for stroke, which medication is the best option? - Dipyridamole - Aspirin - Clopidogrel - Ticlodipine

- flaccid muscles. Lower motor neuron lesions cause flaccidity, muscle atrophy, decreased muscle tone, and loss of voluntary control. Upper motor neuron lesions cause increased muscle tone. Upper motor neuron lesions cause no muscle atrophy. Upper motor neuron lesions cause hyperactive and abnormal reflexes.

Lower motor neuron lesions cause - increased muscle tone. - flaccid muscles. - no muscle atrophy. - hyperactive and abnormal reflexes.

Provide a dimly lit environment. Elevate the head of bed 30 degrees. Administer docusate per order.

The nurse is caring for a client diagnosed with a subarachnoid hemorrhage resulting from a leaking aneurysm. The client is awaiting surgery. Which nursing interventions would be appropriate for the nurse to implement? Select all that apply. - Permit friends to visit often. - Provide a dimly lit environment. - Elevate the head of bed 30 degrees. - Ambulate the client every hour. - Administer docusate per order.

- Establishing eye contact The following strategies should be used by the nurse to encourage communication with a client with aphasia: face the client and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the client time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the client uses and handles an object, say what the object is. It helps to match the words with the object or action.

The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client? - Speaking loudly - Establishing eye contact - Avoiding the use of hand gestures - Speaking in complete sentences

VIII Cranial nerve VIII (acoustic) can be checked to assess equilibrium status.

The provider orders the Romberg test for a patient. The nurse tells the patient that the provider wants to evaluate his equilibrium by assessing which cranial nerve? III VII VIII X

- use short, simple sentences. Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.

When communicating with a client who has sensory (receptive) aphasia, the nurse should: - allow time for the client to respond. - speak loudly and articulate clearly. - give the client a writing pad. - use short, simple sentences.

- Neglect of the left side This client would have deficits on the left side. Expressive aphasia typically occurs with left-hemisphere stroke.

Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere? - Inability to move the right arm - Neglect of the left side - Neglect of the side opposite to the hemisphere affected - Expressive aphasia

- Lamotrigine (Lamictal)

Which of the following antiseizure medication has been found to be effective for post-stroke pain? - Lamotrigine (Lamictal) - Phenytoin (Dilantin) - Carbamazepine (Tegretol) - Topiramate (Topamax)

- Facial The vestibulocochlear (VII) cranial nerve is responsible for hearing and equilibrium. The oculomotor (III) cranial nerve is responsible for the muscles that move the eye and lid, pupillary constriction, and lens accommodation. The trigeminal (V) cranial nerve is responsible for facial sensation, corneal reflex, and mastication. The facial (VII) nerve controls facial expression and muscle movement.

Which of the following cranial nerves is responsible for salivation, tearing, taste, and sensation in the ear? - Vestibulocochlear - Oculomotor - Facial - Trigeminal

- Psychosis, disorientation, delirium, insomnia, and hallucinations Korsakoff syndrome is a personality disorder characterized by psychosis, disorientation, delirium, insomnia, and hallucinations.

Which set of symptoms characterize Korsakoff syndrome? - Psychosis, disorientation, delirium, insomnia, and hallucinations - Severe dementia and myoclonus - Tremor, rigidity, and bradykinesia - Choreiform movement and dementia

- Speak slowly and clearly to assist the client in forming the sounds. Nursing management of the client with receptive aphasia includes speaking slowing and clearly to assist the client in forming the sounds.

Which statements reflect the nursing management of a client with receptive aphasia? - Encourage the client to repeat sounds of the alphabet. - Speak clearly to the client in simple sentences; use gestures or pictures. - Speak slowly and clearly to assist the client in forming the sounds. - Frequently reorient the client to time, place, and situation.

- Agnosia

Which term refers to the failure to recognize familiar objects perceived by the senses? - Agnosia - Agraphia - Apraxia - Perseveration

- Apraxia

Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis? - Agnosia - Agraphia - Perseveration - Apraxia

- Left-sided cerebrovascular accident (CVA) When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? - Transient ischemic attack (TIA) - Left-sided cerebrovascular accident (CVA) - Right-sided cerebrovascular accident (CVA) - Completed Stroke

- Increased urine output The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.

A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant? - Decreased level of consciousness (LOC) - Elevated blood pressure - Increased urine output - Decreased heart rate

- Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours before the test The client is advised to refrain from taking sedative drugs or consuming food or drinks that contain caffeine for at least 8 hours before the test, because these may interfere with the EEG result

A client is scheduled for an EEG. The client inquires about any diet-related prerequisites before the EEG. Which diet-related advice should the nurse provide to the client? - Avoid eating food for at least 8 hours before the test - Include an increased amount of minerals in the diet - Decrease the amount of minerals in the diet - Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours before the test

- Restrict fluids before surgery. Before surgery, the nurse should restrict fluids to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting.

A client on your unit is scheduled to have intracranial surgery in the morning. Which nursing intervention helps to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting? - Restrict fluids before surgery. - Administer prescribed medications. - Administer preoperative sedation. - Administer an osmotic diuretic.

- Migraines often coincide with menstrual cycle. Changes in reproductive hormones as found during menstrual cycle can be a trigger for migraine headaches and may assist in the management of the symptoms.

A client who complains of recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action? - Cluster headaches can cause severe debilitating pain. - Migraines often coincide with menstrual cycle. - Tension headaches are easier to treat. - Headaches are the most common type of reported pain.

- Ask the client if he has trouble breathing. The nurse should first assess the client's breathing. A complication of a carotid endarterectomy is an incisional hematoma, which could compress the trachea causing breathing difficulty for the client. Although the other measures are important actions, they aren't the nurse's top priority.

A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first? - Ask the client if he has trouble breathing. - Take the client's blood pressure. - Ask the client if he has a headache. - Place antiembolism stockings on the client.

XII Cranial nerve XII, the hypoglossal nerve, controls tongue movements involved in swallowing and speech. The tongue should be midline, symmetrical, and free from tremors and fasciculations. The nurse tests tongue strength by asking the client to push his tongue against his cheek as the nurse applies resistance. To test the client's speech, the nurse may ask him to repeat the sentence, "Round the rugged rock that ragged rascal ran." The trochlear nerve (IV) is responsible for extraocular movement (inferior medial). The glossopharyngeal nerve (IX) is responsible for swallowing movements and throat sensations. It's also responsible for taste in the posterior third of the tongue. The abducent nerves (VI) are responsible for lateral extraocular movements.

A nurse is performing a neurologic assessment on a client. The nurse observes the client's tongue for symmetry, tremors, and strength, and assesses the client's speech. Which cranial nerve is the nurse assessing? IV IX VI XII

- Cerebral spinal fluid leakage at the puncture site The headache is caused by cerebral spinal fluid (CSF) leakage at the puncture site. The supply of CSF in the cranium is depleted so that there is not enough to cushion and stabilize the brain. When the client assumes an upright position, tension and stretching of the venous sinuses and pain-sensitive structures occur.

A nurse is preparing a client for a lumbar puncture. The client has heard about post-lumbar puncture headaches and asks what causes them. The nurse tells the client that these headches are caused by which of the following? - Cerebral spinal fluid leakage at the puncture site - Damage to the spinal cord - Traumatic puncture - Not ambulating soon enough after the procedure

- "Remain prone for 2 to 3 hours." The headache is caused by cerebral spinal fluid (CSF) leakage at the puncture site. The supply of CSF in the cranium is depleted so that there is not enough to cushion and stabilize the brain. When the client assumes an upright position, tension and stretching of the venous sinuses and pain-sensitive structures occur. The headache may be avoided if the client remains prone for 2 to 3 hours after the procedure.

A nurse is preparing a client for lumbar puncture. The client has heard about post-lumbar puncture headaches and asks how to avoid having one. The nurse tells the client that these headches can be avoided by doing which of the following after the procedure? - "Remain prone for 2 to 3 hours." - "Remain NPO for 6 hours." - "Ambulate as soon as possible." - "Remain on bedrest for 3 days."

- Moderate amounts of low-fat dairy products The DASH diet is high in fruits and vegetables, moderate in low-fat dairy products, and low in animal protein.

A nurse is teaching about ischemic stroke prevention to a community group and emphasizes that control of hypertension, which is the major risk factor for stroke, is key to prevention. Ways to control hypertension include the Dietary Approaches to Stop Hypertension (DASH) diet. This diet includes which of the following? - Moderate amounts of low-fat dairy products - Moderate amounts of animal protein - High amounts of low-fat dairy products - Moderate amounts of fruits and vegetables

- Keeping the client in one position to decrease bleeding The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? - Positioning the client to prevent airway obstruction - Keeping the client in one position to decrease bleeding - Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess - Maintaining the client in a quiet environment

- 190 mm Hg/120 mm Hg Elevated blood pressure (systolic >185; diastolic >110 mm Hg) is a contraindication to tPA.

A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is: - 170 mm Hg/105 mm Hg - 175 mm Hg/100 mm Hg - 185 mm Hg/110 mm Hg - 190 mm Hg/120 mm Hg

210 mm H2O CSF pressure with the patient in a lateral recumbent position is normally 70 to 200 mm H2O. Pressures of more than 200 mm H2O are considered abnormal.

A nurse notes on the electronic medical record of a post-lumbar puncture patient an abnormal CSF value. Which of the following is the minimal level that is an abnormal value? 140 mm H2O 160 mm H2O 190 mm H2O 210 mm H2O

- Intracerebral hemorrhage About 80% of hemorrhagic strokes are intracerebral, and they are caused primarily by uncontrolled hypertension.

A nurse practitioner provides health teaching to a patient who has difficulty managing hypertension. This patient is at an increased risk of which type of stroke? - Intracerebral hemorrhage - Subarachnoid hemorrhage - Hemorrhage due to an aneurysm - Arteriovenous malformation

- Speech. Broca's area (left frontal lobe region in most people), critical for motor control of speech.

A patient has been diagnosed with damage to Broca's area of the left frontal lobe. To document the extent of damage, the nurse would assess the patient's: - Speech. - Vision. - Hearing. - Balance.

- Dysfunction of the vagus nerve The vagus nerve (cranial nerve X) controls the gag reflex and is tested by depressing the posterior tongue with a tongue blade. An absent gag reflex is a significant finding, indicating dysfunction of this nerve.

A patient is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the patient has? - Dysfunction of the spinal accessory nerve - Dysfunction of the acoustic nerve - Dysfunction of the facial nerve - Dysfunction of the vagus nerve

- Lioresal (Baclofen) Spasticity, particularly in the hand, can be a disabling complication after stroke. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity (although the effect is temporary, typically lasting 2 to 4 months) (Teasell, Foley, Pereira, et al., 2012). Other treatments for spasticity may include stretching, splinting, and oral medications such as baclofen (Lioresal).

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem? - Diphenhydramine (Benadryl) - Lioresal (Baclofen) - Heparin - Pregabalin (Lyrica)

- Noncontrast computed tomography (CT) An initial head CT scan will determine whether or not the patient is experiencing a hemorrhagic stroke. An ischemic infarction will not be readily visible on initial CT scan if it is performed within the first few hours after symptoms onset; however, evidence of bleeding will almost always be visible.

Which of the following is the initial diagnostic in suspected stroke? - Noncontrast computed tomography (CT) - CT with contrast - Magnetic resonance imaging (MRI) - Cerebral angiography

- Bleeding Bleeding is the most common side effect of tPA. The patient is closely monitored for bleeding (at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness).

Which of the following is the most common side effect of tissue plasminogen activator (tPA)? - Bleeding - Headache - Increased intracranial pressure(ICP) - Hypertension