Care of Patients with Comprised Multiple Health States: Neurological

A client is being monitored for transient ischemic attacks. The client is oriented, can open the eyes spontaneously, and follows commands. What is the Glasgow Coma Scale score?

15

The family of a client with a cerebrovascular accident (CVA) asks the nurse why the client is not able to speak. What is the best response by the nurse?

"Paralysis of the muscles responsible for producing speech is causing difficulty with speaking."

A client recently experienced a stroke with accompanying left-sided paralysis. The family voices concerns about how to best interact with the client. They report the client does not seem aware of their presence when they approach the client on the left side. What advice should the nurse give the family?

"The client may be unaware of their left side. You should approach them on the right side."

A nurse is providing education to the family of a client scheduled for discharge. The client, who has severe cognitive impairments, is a recent quadriplegic. The family has questions about the need to perform range-of-motion of exercises with the client. What information should the teaching session include? Select all that apply.

"Use sheepskin pads in the bed and wheelchair." "Friction and shear increase a paralyzed client's risk of pressure ulcers."

It is the night before a client is to have a computed tomography (CT) scan of the head without contrast. What should the nurse tell the client to do to prepare for this test?

"You will need to hold your head very still during the examination."

A nurse is assessing a client with a brain injury. What is a client's cerebral perfusion pressure (CPP) when the blood pressure (BP) is 90/50 mm Hg and the intracranial pressure (ICP) is 21? Round to the nearest whole number.

42

A client with a head injury is being monitored for increased intracranial pressure (ICP). The client's blood pressure is 90/60 mm Hg and the ICP is 18 mm Hg; therefore their cerebral perfusion pressure (CPP) is

52 mm Hg.

The nurse is observing a client with cerebral edema for evidence of increasing intracranial pressure and monitors the blood pressure for signs of widening pulse pressure. The client's current blood pressure is 170/80 mm Hg. What is the client's pulse pressure? Record your answer using a whole number.

90

Following surgery for removal of a brain tumor, a client is coughing and short of breath and has a "bad" feeling. The nurse obtains the following vital signs: blood pressure of 80/60 mm Hg, pulse rate of 120 bpm, and respiratory rate of 30 shallow breaths/min. What should the nurse do first?

Activate the rapid response team (RRT).

The nurse is preparing to administer propranolol to a client for control of migraine headaches. The client also has a prescription for sumatriptan as needed for a headache. The client's pulse rate is 56 bpm. What should the nurse do next?

Assess blood pressure.

A client suddenly loses consciousness. What should the nurse do first?

Assess for responsiveness.

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The health care provider ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is reporting of a headache. Which intervention by the nurse is best?

Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes.

A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?

Call the health care provider immediately.

The nurse is assessing the level of consciousness in a client with a head injury who has been unresponsive for the last 8 hours. Using the Glasgow Coma Scale, the nurse notes that the client opens their eyes only as a response to pain, responds with sounds that are not understandable, and has an abnormal extension of their extremities. What should the nurse do?

Chart the client's level of consciousness as coma.

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

Check the equipment.

A nurse is assessing a client who recently experienced a stroke. The client has a left facial droop, hemiparesis of the upper left extremity, and diplopia. Which nursing intervention is most appropriate for this client?

Consistently place client care items in the same location.

The nurse is monitoring a client with increased intracranial pressure (ICP). What indicator(s) would be the most critical for the nurse to monitor? Select all that apply.

systolic blood pressure cerebral perfusion pressure (CPP)

A nurse working on a neurologic floor has received reports on four clients. After identifying priority assessment data for each client, which client should the nurse investigate first?

the client admitted after a head injury in a motor vehicle who reports nausea

A client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by

turning the client's head suddenly while holding the eyelids open.

A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor?

unequal pupil size

The nurse is assessing a client recovering from a hemorrhagic cerebral vascular accident (CVA) that occurred 7 days ago. Which assessment finding should be reported to the health care provider?

worsening headache

A client who had a massive stroke exhibits decerebrate posture. What are the characteristics of this posture? Select all that apply.

wrist pronation. stiff extension of the arms and legs. plantar flexion of the feet. opisthotonos.

A client has been admitted to the medical-surgical unit from the emergency department with a diagnosis of left-sided cerebrovascular accident (brain attack). The nurse has observed that breathing is of a snoring quality. Order the items in nursing care priority for this client. All options must be used.

Position the client on the side with the head of the bed slightly elevated. Initiate oxygen therapy via nasal cannula as ordered. Assess the client's ability to communicate needs to the health care team. Place all items that the client may need to the left side of the bed. Arrange for the discharge planner to meet with the family.

A nurse is working with a client who is on the rehabilitation unit after a cerebrovascular accident (or brain attack). To support the client in developing independence with activities of daily living, which of the following is the most important action for the nurse to take?

Reinforce participation and success in tasks accomplished.

An older adult client has been bedridden since a cerebrovascular accident that resulted in total right-sided paralysis. The client has become increasingly confused, is occasionally incontinent of urine, and is refusing to eat. In planning the client's care, which of the following factors should the nurse consider as most critical in contributing to skin breakdown in this client?

Right-sided paralysis.

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?

Risk for injury related to neurologic deficit

A client is taking phenytoin as an antiepileptic medication. What should the nurse instruct the client to do?

Schedule twice-yearly dental examinations.

The nurse is assisting a client who has had a cerebrovascular accident (CVA) learn self-care skills. Which approach will be most effective?

Teach the client to put on clothing on the affected side first.

The nurse is caring for a client with a diagnosis of cerebrovascular accident (CVA) with left-sided hemiparesis. What would be important nursing measures in the acute phase of care? Select all that apply.

Turn and position every 2 hours. Perform passive range of motion on the affected side. Support the affected side with pillows.

The client with a head injury receives mannitol during surgery to help decrease intracranial pressure. Which finding indicates that the drug is having the desired effect?

Urine output increases.

After completing initial assessment rounds, which client should the nurse discuss with the health care provider (HCP) first?

a client who was admitted from the emergency department last evening after a blow to the head who is now vomiting and confused as to time and place

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

absence of reflexes along with flaccid extremities

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)?

administering a stool softener as ordered

A nurse has received a shift report on four clients. Which client should the nurse assess first?

an older adult returning to the unit after having a carotid endarterectomy

Which action is contraindicated for a client with seizure precautions?

assessing the client's oral temperature with a glass thermometer

Which is the nurse's best rationale for positioning a client with decreased level of consciousness related to a head injury?

avoidance of impeding venous outflow

The nurse is assessing a client with a head injury for decerebrate posturing. Which position indicates the client has decerebrate posturing?

back arched, rigid extension of all four extremities

A client has received thrombolytic treatment for an ischemic stroke. The nurse should notify the health care provider (HCP) if there is a rapid increase in which vital sign?

blood pressure

The client is experiencing parasympathetic responses to pain. What response(s) should the nurse assess the client for? Select all that apply.

bradycardia weakness

A client with thrombocytopenia has a severe headache. The nurse should interpret this finding as resulting from which underlying cause?

cerebral bleeding

The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider (HCP) about which early change in the client's condition?

decrease in the level of consciousness (LOC)

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include

diminished responsiveness.

Which nursing assessments would indicate a decline in the condition of a client 2 hours after admission for a subdural hematoma?

disorientation, increasing blood pressure, bradycardia, and bradypnea

A client with a cerebral embolus is receiving intravenous (IV) recombinant tissue-type plasminogen activator (rt-PA). The nurse should evaluate the client for which expected therapeutic outcome of this drug therapy?

dissolved emboli

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates

dysfunction in the brain stem.

The nurse is taking care of a client with a spinal cord injury. The extent of the client's injury is shown below. Which finding is expected when assessing this client?

dysfunction of bowel and bladder

An older adult client has suffered a cerebrovascular accident (CVA). The right side of the client's face has visible ptosis. The nurse would be alert to which finding?

dysphagia

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. The client is incontinent and has a tarry stool. Their blood pressure is 90/50 mm Hg, and hemoglobin is 10 g. Which nursing intervention is a priority for this client?

elevating the head of the bed to 30 degrees

The children of an older adult client who has suffered an ischemic stroke have informed the nurse that an herbalist will be coming to their parent's bedside tomorrow to make recommendations for client's care. Which considerations should the nurse prioritize in light of the practitioner's planned visit?

ensuring any complementary therapies are safe when combined with their prescribed therapy

To assess a client's cranial nerve function, a nurse should assess

gag reflex.

Prior to administering plasminogen activator (t-PA) to a client admitted with a stroke, the nurse should verify which information about the client? Select all that apply.

has had symptoms of the stroke less than 3 hours has a blood pressure within normal limits does not have active internal bleeding

A client has left-sided paralysis. The nurse should document this condition as left-sided

hemiplegia

A health care provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?

heparin sodium

The nurse is assessing a client with a head injury. On admission, the pupils were equal; now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. What would this change in neurologic status suggest to the nurse?

increased intracranial pressure

When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the health care provider immediately because these findings may reflect which complication?

increased intracranial pressure (ICP)

A nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what complication of ICP monitoring?

infection

The nurse administers mannitol to the client with increased intracranial pressure (ICP). Which parameter requires close monitoring?

intake and output

A client is receiving intravenous mannitol for treatment of a brain tumor. The client's intracranial pressure before administration of the mannitol was 14 mm Hg. Which assessment finding indicates that the medication is attaining a therapeutic effect?

intracranial pressure of 10 mm Hg

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?

keeping the client in one position to decrease bleeding

The nurse is teaching the family of a client with dysphagia about decreasing the risk for aspiration while eating. Which measure(s) should the nurse include in the teaching plan? Select all that apply.

maintaining an upright position while eating introducing foods on the unaffected side of the mouth keeping distractions to a minimum

A client comes to the emergency department reporting of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What do these manifestations indicate?

meningeal irritation

A nurse is caring for an unconscious client recovering from a closed-head injury following placement of a percutaneous endoscopic gastrostomy (PEG) tube. Which action has the highest priority?

Elevate the head of the bed during and after the PEG tube feedings.

A client arrives in the emergency department with an ischemic stroke. What should the nurse do before the client receives tissue plasminogen activator (t-PA)?

Identify the time of onset of the stroke.

The nurse is directing the care team as they plan to move a person with a possible spinal cord injury. The nurse should direct the team to move the client using which procedure?

Immobilize the head and neck to prevent further injury.

The nurse is planning care for a client in the first 24 hours after admission for a thrombotic stroke. Which assessment is a priority for the nurse to make during this time?

pupil size and response

A client who suffered a stroke has a nursing diagnosis of ineffective airway clearance. The goal of care for this client is to mobilize pulmonary secretions. Which intervention helps meet this goal?

repositioning the client every 2 hours

The nurse observes that the right eye of an unconscious client does not close completely. Which nursing intervention is most appropriate?

Lightly tape the eyelid shut.

After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays have not been read, so the nurse does not know whether the client has a cervical spinal injury. The nurse develops a plan of care and includes which action?

Maintain the client in a flat position, except for logrolling as needed.

The nurse should complete which of the following assessments on a client who has received tissue plasminogen activator or alteplase recombinant therapy?

Neurologic signs frequently throughout the course of therapy.

A client with a subdural hematoma needs a feeding tube inserted due to inadequate swallowing ability. How would the nurse best explain this to the family?

Nutrients are needed; however, eating and drinking without control of the swallowing reflex can result in aspirational pneumonia.

When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP?

rising blood pressure and bradycardia

A nurse is comparing the neurological status of a client who suffered a head injury with the status on the previous shift. Using the Glasgow Coma Scale, the nurse determines that the client's score has changed from 11 to 15. Which responses did the nurse assess in this client? Select all that apply.

spontaneous eye opening orientation to person, place, and time