Med Surg 1020 Exam 3

The nurse is planning psychosocial support for the family of the patient who had a stroke. What factor will have the greatest impact on family coping? Specific patient neurologic deficits The patient's ability to communicate Rehabilitation potential of the patient Presence of complications of a stroke

Correct Answer: Rehabilitation potential of the patient Rationale: Although a patient's neurologic deficit might initially be severe, the ability of the patient to recover is most likely to positively impact the family's coping. Providing explanations and emotional support beginning in the acute phase through the rehabilitation phase will facilitate coping. Emphasizing successes will offer the most realistic hope for the patient's rehabilitation and helps maintain hope for the patient's future abilities.

Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? Slow, fearful performance of tasks Overestimation of physical abilities Difficulty judging position and distance Impulsivity and impatience at performing tasks

Correct Answer: Slow, fearful performance of tasks Rationale: Patients with a left-sided stroke (right hemiplegia) are often slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-sided stroke.

A female patient presents to the emergency department reporting the most severe headache of her life. Which type of stroke should the nurse anticipate? TIA Embolic stroke Thrombotic stroke Subarachnoid hemorrhage

Correct Answer: Subarachnoid hemorrhage Rationale: Headache is common in a patient who has a subarachnoid hemorrhage or an intracerebral hemorrhage. A TIA is a transient loss of neurologic function usually without a headache. A headache may occur with an ischemic embolic stroke, but severe neurologic deficits are the initial symptoms. The ischemic thrombotic stroke manifestations progress in the first 72 hours as infarction and cerebral edema increase.

Which characteristic should the nurse associate with a focal seizure? The patient lost consciousness during the seizure. The seizure involved both sides of the patient's brain. The seizure involved lip smacking and repetitive movements. The patient fell to the ground and became stiff for 20 seconds.

Correct Answer: The seizure involved lip smacking and repetitive movements. Rationale: Complex focal seizure is often characterized by lip smacking and automatisms (repetitive movements that may not be appropriate). Loss of consciousness, bilateral brain involvement, and a tonic phase are associated with generalized seizure activity.

The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions? (Select all that apply.) Ticlopidine Clopidogrel Enoxaparin Dipyridamole Enteric-coated aspirin Tissue plasminogen activator (tPA)

Correct Answer: Ticlopidine Clopidogrel Dipyridamole Enteric-coated aspirin Rationale: Aspirin is the most frequently used antiplatelet agent. Other drugs to prevent clot formation include clopidogrel, dipyridamole, ticlopidine, combined dipyridamole and aspirin, and anticoagulant drugs such as oral warfarin. Tissue plasminogen activator is a fibrinolytic medication used to treat ischemic stroke, not prevent TIAs or strokes.

Which intervention is most appropriate when communicating with a patient with aphasia after a stroke? Present several thoughts at once so the patient can connect the ideas. Ask open-ended questions to give the patient the opportunity to speak. Use simple, short sentences with visual cues to enhance comprehension. Finish the patient's sentences to minimize frustration associated with slow speech.

Correct Answer: Use simple, short sentences with visual cues to enhance comprehension. Rationale: When communicating with a patient with aphasia, the nurse should present one thought or idea at a time. Ask questions that can be answered with a "yes," "no," or simple word. Use visual cues and allow time for the patient to comprehend and respond to conversation.

The patient with a brain tumor is being monitored for increased intracranial pressure (ICP) with a ventriculostomy. What nursing intervention is priority? Administer IV mannitol as ordered. Ventilator use to hyperoxygenate the patient. Use strict aseptic technique with dressing changes. Be aware of changes in ICP related to cerebrospinal fluid leaks.

Correct Answer: Use strict aseptic technique with dressing changes. Rationale: The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection. IV mannitol or hypertonic saline will be administered as ordered for increased ICP. Ventilators may be used to maintain oxygenation. CSF leaks may cause inaccurate ICP readings, or CSF may be drained to decrease ICP, but strict aseptic technique to prevent infection is the nurse's priority of care.

The nurse is teaching a senior citizen's group about signs and symptoms of a stroke. Which statement provides the group accurate information? "Take the person to the hospital if a headache lasts for more than 24 hours." "Stroke symptoms usually start when the person is awake and physically active." "A person with a transient ischemic attack has mild symptoms that will go away." "Call 911 immediately if a person develops slurred speech or difficulty speaking."

Correct Answer: "Call 911 immediately if a person develops slurred speech or difficulty speaking." Rationale: Medical assistance should be obtained immediately for someone with signs and symptoms of a stroke such as sudden numbness; weakness; paralysis of the face, arm, or leg (especially on one side of the body); sudden confusion; trouble speaking or understanding; slurred speech; sudden trouble seeing in one or both eyes; sudden trouble walking; dizziness; loss of balance or coordination; or a sudden, severe headache with no known cause. A person with signs and symptoms of a transient ischemic attack should seek medical attention immediately because it is unknown if the symptoms will resolve or persist and progress to a stroke. Onset of signs and symptoms of a stroke vary depending on the type. Onset of an ischemic thrombotic stroke usually occurs at rest. Onset of an ischemic embolic stroke is not related to rest or activity, and onset of a hemorrhagic stroke usually occurs with activity.

A patient who had a long leg cast applied this morning asks to crutch walk before dinner. Which statement explains why the nurse will decline the patient's request? "You must ambulate with a physical therapist for the first few days." "The cast is not dry yet, so it may be damaged while using crutches." "Rest, ice, compression, and elevation are in process to decrease pain." "Excess edema and complications are prevented when the leg is elevated for 24 hours."

Correct Answer: "Excess edema and complications are prevented when the leg is elevated for 24 hours." Rationale: For the first 24 hours after a lower extremity cast is applied, the leg should be elevated on pillows above heart level to avoid excessive edema and compartment syndrome. RICE is used for soft tissue injuries, not with long leg casts.

The nurse provides information to the caregiver of a 68-yr-old man with epilepsy who has tonic-clonic seizures. Which statement by the caregiver indicates a need for further teaching? "The jerking movements may last for 30 to 40 seconds" "It is normal for a person to be sleepy after a seizure." "I should call 911 if breathing stops during the seizure." "Objects should not be placed in the mouth during a seizure."

Correct Answer: "I should call 911 if breathing stops during the seizure." Rationale: Caregivers do not need to call an ambulance or send a person to the hospital after a single seizure unless the seizure is prolonged, another seizure immediately follows, or extensive injury has occurred. Altered breathing is a manifestation of a tonic-clonic seizure. Contact emergency medical services (or call 911) if breathing stops for more than 30 seconds. No objects (e.g., oral airway, padded tongue blade) should be placed in the mouth. Lethargy is common in the postictal phase of a seizure. Jerking of the extremities occurs during the clonic phase of a tonic-clonic seizure. The clonic phase may last 30 to 40 seconds.

When reinforcing health teaching on managing osteoarthritis, which patient statement indicates additional instruction is needed? "I can use a cane to relieve the pressure on my back and hip." "I should take the Naprosyn as prescribed to help control the pain." "I should try to stay standing all day to keep my joints from becoming stiff." "A warm shower in the morning will help relieve the stiffness I have when I get up."

Correct Answer: "I should try to stay standing all day to keep my joints from becoming stiff." Rationale: Maintaining a balance between rest and activity is important to prevent overstressing joints affected by OA. Naproxen may be used for moderate to severe OA pain. Using a cane and warm shower to help relieve pain and morning stiffness are helpful.

A nurse performs discharge teaching for a patient after a left hip arthroplasty using the posterior approach. Which statement indicates teaching is successful? "Leg-raising exercises are necessary for several months." "I should not try to drive a motor vehicle for 2 to 3 weeks." "I will not have any restrictions now on hip and leg movements." "Blood tests will be done weekly while taking enoxaparin (Lovenox)."

Correct Answer: "Leg-raising exercises are necessary for several months." Rationale: Exercises designed to restore strength and muscle tone will be done for months after surgery. The exercises include leg raises in supine and prone positions. Driving a car is not allowed for 4 to 6 weeks. In the posterior approach hip arthroplasties, extremes of internal rotation and 90-degree flexion of the hip must be avoided for 4 to 6 weeks postoperatively. The knees must be kept apart. The patient should never cross the legs or twist to reach behind. To prevent thromboembolism, enoxaparin is administered subcutaneously and can be given at home. Enoxaparin does not require monitoring of the patient's coagulation status.

The nurse teaches a 38-yr-old woman who has migraine headaches about sumatriptan (Imitrex). Which statement by the patient requires clarification by the nurse? "The injection might feel like a bee sting." "This medicine will prevent a migraine headache." "I can take another dose if the first does not work." "This drug for migraine headaches could cause birth defects."

Correct Answer: "This medicine will prevent a migraine headache." Rationale: Sumatriptan is given to abort an ongoing migraine headache and is not used to prevent migraine headaches. When given as a subcutaneous injection, this drug may cause transient pain and redness at the injection site. This drug may be repeated after a specified time period if the first dose is not effective. This drug should be avoided during pregnancy and is classified as a Food and Drug Administration Pregnancy Risk Category C drug.

he nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? A 92-yr-old female patient who takes warfarin for atrial fibrillation A 28-yr-old male patient who uses marijuana after chemotherapy to ease nausea A 72-yr-old male patient who has hypertension and diabetes and smokes tobacco. A 42-yr-old female patient who takes oral contraceptives and has migraine headaches

Correct Answer: A 72-yr-old male patient who has hypertension and diabetes and smokes tobacco. Rationale: Stroke risk increases after 65 years of age. Strokes are more common in men. Hypertension is the single most important modifiable risk factor for stroke. Diabetes is a significant stroke risk factor. Smoking nearly doubles the risk of a stroke. Other risk factors include drug use (especially cocaine), high-dose oral contraception use, migraine headaches, and untreated heart disease, such as atrial fibrillation.

A patient presents to the clinical after tripping on a curb and spraining the right ankle. Which initial care measures are appropriate? (Select all that apply.) Apply ice directly to the skin. Apply heat to the ankle every 2 hours. Administer antiinflammatory medication. Compress ankle using an elastic bandage. Rest and elevate the ankle above the heart. Perform passive and active range of motion.

Correct Answer: Administer antiinflammatory medication. Compress ankle using an elastic bandage. Rest and elevate the ankle above the heart. Rationale: Appropriate care for a sprain is represented with the acronym RICE (rest, ice, compression, and elevation). Antiinflammatory medication should be used to decrease swelling if not contraindicated for the patient. After the injury, the ankle should be immobilized and rested. Prolonged immobilization is not required unless there is significant injury. Ice is indicated but will cause tissue damage if applied directly to the skin. Apply ice to sprains as soon as possible and leave in place for 20 to 30 minutes at a time. Moist heat may be applied 24 to 48 hours after the injury.

A patient has left-sided hemiplegia after an ischemic stroke 4 days earlier. How should the nurse promote skin integrity? Position the patient on her weak side most of the time. Avoid the use of pillows to promote independence in positioning. Alternate the patient's positioning between supine and side-lying. Establish a schedule for the massage of areas where skin breakdown emerges.

Correct Answer: Alternate the patient's positioning between supine and side-lying. Rationale: A position change schedule should be established for stroke patients. An example is side-back-side, with a maximum duration of 2 hours for any position. The patient should be positioned on the weak or paralyzed side for only 30 minutes. Pillows may be used to facilitate positioning. Areas of skin breakdown should never be massaged.

A patient is hospitalized for a frontal skull fracture from a blunt force head injury. Thin bloody fluid is draining from the patient's nose. What action by the nurse is most appropriate? Place packing in the patient's nares. Apply a loose gauze pad under the patient's nose. Place the patient in a modified Trendelenburg position. Ask the patient to gently blow the nose to clear the drainage.

Correct Answer: Apply a loose gauze pad under the patient's nose. Rationale: Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage from the nose) may occur with a frontal skull fracture. A loose collection pad may be placed under the nose, and if thin bloody fluid is present, the blood will coalesce, and a yellow halo will form if CSF is present. If clear drainage is present, testing for glucose would indicate the presence of CSF. Mixed blood and CSF will test positive for glucose because blood contains glucose. If CSF rhinorrhea occurs, the nurse should inform the provider immediately. The head of the bed may be raised to decrease the CSF pressure so that a tear can seal. The nurse should not place packing in the nasal cavity, and the patient should not sneeze or blow the nose.

The provider orders intracranial pressure (ICP) readings every hour for a patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. It is most important for the nurse to take which action? Document the ICP reading in the chart. Determine if the patient has a headache. Assess the patient's level of consciousness. Position the patient with head elevated 60 degrees.

Correct Answer: Assess the patient's level of consciousness. Rationale: The patient has an increased ICP (normal ICP ranges from 5 to 15 mm Hg). The most sensitive and reliable indicator of neurologic status is level of consciousness. The Glasgow Coma Scale may be used to determine the degree of impaired consciousness.

The nurse observes a student nurse assigned to start oral feedings for a patient with an ischemic stroke. Which action by the student will require the nurse to intervene? Giving the patient 1 ounce of water to swallow Telling the patient to perform a chin tuck before swallowing Assisting the patient to sit in a chair before feeding the patient Assessing cranial nerves III, IV, and VI before attempting feeding

Correct Answer: Assessing cranial nerves III, IV, and VI before attempting feeding Rationale: Many patients after a stroke have dysphagia. The gag reflex and swallowing ability (cranial nerves IX and X) should be assessed before the first oral feeding. Cranial nerves III, IV, and VI are responsible for ocular movements. To assess swallowing ability, the nurse should elevate the head of the bed to an upright position (unless contraindicated) and give the patient a small amount of crushed ice or ice water to swallow. The patient should remain in a high Fowler's position, preferably in a chair with the head flexed forward, for the feeding and for 30 minutes following.

The nurse is caring for a patient admitted with a subdural hematoma after a motor vehicle accident. What change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)? Tachypnea Bradycardia Hypotension Narrowing pulse pressure

Correct Answer: Bradycardia Rationale: Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with increased ICP. They consist of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.

A nurse is working with a 73-yr-old patient with osteoarthritis. Which description of the disorder should be included in the teaching plan? Joint destruction caused by an autoimmune process Degeneration of articular cartilage in synovial joints Overproduction of synovial fluid resulting in joint destruction Breakdown of tissue in non-weight-bearing joints by enzymes

Correct Answer: Degeneration of articular cartilage in synovial joints Rationale: OA is a degeneration of the articular cartilage in diarthrodial (synovial) joints from damage to the cartilage. The condition has also been referred to as degenerative joint disease. OA is not an autoimmune disease. There is no overproduction of synovial fluid causing destruction or breakdown of tissue by enzymes.

The nurse observes a 74-yr-old man with Parkinson's disease rocking side to side while sitting in the chair. Which action by the nurse is most appropriate? Provide the patient with diversional activities. Document the activity in the patient's health record. Take the patient's blood pressure sitting and standing. Ask if the patient is feeling either anxious or depressed.

Correct Answer: Document the activity in the patient's health record. Rationale: Patients with Parkinson's disease are taught to rock from side to side to stimulate balance mechanisms and decrease akinesia.

The nurse is caring for a patient with bilateral knee osteoarthritis. Which measure should the nurse recommend to slow progression of the disease? Use a wheelchair to avoid walking as much as possible. Sit in chairs that cause the hips to be lower than the knees. Eat a well-balanced diet to maintain a healthy body weight. Use a walker for ambulation to relieve the pressure on the hips.

Correct Answer: Eat a well-balanced diet to maintain a healthy body weight. Rationale: Because maintaining an appropriate load on the joints is essential to the preservation of articular cartilage integrity, the patient should maintain an optimal overall body weight or lose weight if overweight. Walking is encouraged. The best chairs for this patient have a higher seat and armrests to facilitate sitting and rising from the chair. Relieving pressure on the hips is not important for knee disease.

A patient has a plaster cast applied to the right arm for a Colles' fracture. Which nursing action is most appropriate? Elevate the right arm on 2 pillows for 24 hours. Apply heating pad to reduce muscle spasms and pain. Limit movement of the thumb and fingers on the right hand. Place arm in a sling to prevent movement of the right shoulder.

Correct Answer: Elevate the right arm on 2 pillows for 24 hours. Rationale: The casted extremity should be elevated at or above heart level for 24 hours to reduce swelling or inflammation. The cast should be supported on pillows during the drying period to prevent denting and flattening of the cast. Ice (not heat) should be applied for the first 24 to 36 hours to reduce swelling or inflammation. Active movement of the thumb and fingers should be encouraged to reduce edema and increase venous return. A sling may be used to support and protect the extremity after the cast is completely dry, but the patient should perform active movements of the shoulder to prevent stiffness or contracture.

The nurse determines that an older adult patient recovering from left total knee arthroplasty has impaired physical mobility from decreased muscle strength. What nursing intervention is appropriate? Promote vitamin C and calcium intake in the diet. Provide passive range of motion to all the joints every 4 hours. Keep the left leg in extension and abduction to prevent contractures. Encourage isometric quadriceps-setting exercises at least 4 times a day.

Correct Answer: Encourage isometric quadriceps-setting exercises at least 4 times a day. Rationale: Emphasis is placed on postoperative exercise of the affected leg, with isometric quadriceps setting beginning on the first day after surgery. Vitamin C and calcium do not improve muscle strength, but they will facilitate healing. The patient should be able to perform active range of motion to all joints. Keeping the leg in one position (extension and abduction) may contribute to contractures.

The nurse is caring for a patient admitted to the hospital with a head injury who requires frequent neurologic assessment. Which components are assessed using the Glasgow Coma Scale (GCS)? (Select all that apply.) Judgment Eye opening Abstract reasoning Best motor response Best verbal response Cranial nerve function

Correct Answer: Eye opening Best motor response Best verbal response Rationale: The three dimensions of the GCS are eye opening, best verbal response, and best motor response. Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.

When providing care to the patient with an acute stroke, which duty can be delegated to the LPN/VN? Screen patient for tPA eligibility. Assess the patient's ability to swallow. Give scheduled anticoagulant medications. Place seizure precaution equipment in room.

Correct Answer: Give scheduled anticoagulant medications . Rationale: Assessment and screening are considered part of the registered nurse scope of practice. The LPN/VN can give PO or subcutaneous anticoagulant medications. Anticoagulant medications are considered high risk and should be double-checked with another LPN/VN or RN. The UAP can place equipment needed for seizure precautions in the room

Which modifiable risk factor for stroke would be most important for the nurse to include when planning a community education program? Alcohol use Hypertension Hyperlipidemia Oral contraceptive use

Correct Answer: Hypertension Rationale: Hypertension is the single most important modifiable risk factor, but it is still often undetected and inadequately treated. The public is often more aware of hyperlipidemia and oral contraceptive use as risk factors for stroke. Alcohol is also a modifiable risk factor.

The patient with type 1 diabetes is having a seizure. Which medication should the nurse anticipate will be administered first? IV dextrose solution IV diazepam (Valium) IV phenytoin (Dilantin) Oral carbamazepine (Tegretol)

Correct Answer: IV dextrose solution Rationale: This patient's seizure could be caused by low blood glucose, so IV dextrose solution would be given first to stop the seizure. IV diazepam, IV phenytoin, and oral carbamazepine would be used first to treat seizures from other causes such as head trauma, drugs, and infections. These drugs will be tried if the IV dextrose is ineffective.

The patient brought to the emergency department after a car accident is diagnosed with a femur fracture. What nursing intervention should the nurse implement at this time to decrease risk of a fat embolus?' Administer enoxaparin (Lovenox). Provide range-of-motion exercises. Apply sequential compression boots. Immobilize the fracture preoperatively.

Correct Answer: Immobilize the fracture preoperatively. Rationale: The nurse immobilizes the long bone to reduce movement of the fractured bone ends and decrease the risk of a fat embolus development before surgical reduction. Enoxaparin is used to prevent blood clots, not fat emboli. Range of motion and compression boots will not prevent a fat embolus in this patient.

A patient has a systemic BP of 120/60 mm Hg and an ICP of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? High blood flow to the brain Normal intracranial pressure Impaired blood flow to the brain Adequate autoregulation of blood flow

Correct Answer: Impaired blood flow to the brain Rationale: Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = SBP + 2 (DBP)/ 3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP − ICP: 80 mm Hg − 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24 mm Hg, treatment is required.

The nurse would expect what assessment finding in a patient admitted with a left-sided stroke? Impulsivity Impaired speech Left-side neglect Short attention span

Correct Answer: Impaired speech Rationale: Manifestations of left-sided brain damage include right hemiplegia, impaired speech/language, impaired right/left discrimination, and slow and cautious performance. Impulsivity, left-sided neglect, and short attention span are all manifestations of right-sided brain damage

The nurse is caring for a patient with osteoarthritis scheduled for total left knee arthroplasty. Preoperatively, the nurse assesses for which contraindication to surgery? Pain Left knee stiffness Left knee infection Left knee instability

Correct Answer: Left knee infection Rationale: The patient must be free of infection before total knee arthroplasty. An infection in the joint could lead to even greater pain and joint instability, requiring more extensive surgery. The nurse must assess the patient for signs of infection, such as redness, swelling, fever, and elevated white blood cell count. Pain, knee stiffness, or instability are typical of osteoarthritis.

A CT scan of a patient's head reveals a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? Maintaining the patient's airway Positioning to promote cerebral perfusion Controlling fluid and electrolyte imbalances Administering tissue plasminogen activator (tPA)

Correct Answer: Maintaining the patient's airway Rationale: Maintaining a patent airway is the priority in the acute care of a patient with a hemorrhagic stroke. It supersedes the importance of fluid and electrolyte imbalance and positioning. tPA is contraindicated in hemorrhagic stroke.

The nurse is completing discharge teaching with a patient who is recovering from a right total hip arthroplasty by posterior approach. Which patient action indicates further instruction is needed? Uses an elevated toilet seat. Sits with feet flat on the floor. Maintains hip in adduction and internal rotation. Verifies need to notify future caregivers about the prosthesis.

Correct Answer: Maintains hip in adduction and internal rotation. Rationale: The patient should not force hip into adduction or internal rotation because these movements could dislocate the hip prosthesis. Sitting with feet flat on the floor (avoiding crossing the legs), using an elevated toilet seat, and notifying future caregivers about the prosthesis indicate understanding of discharge teaching.

A patient sustained a diffuse axonal injury from a traumatic brain injury. Why are IV fluids being decreased and enteral feedings started? Free water should be avoided. Sodium restrictions can be managed. Dehydration can be better avoided with feedings. Malnutrition promotes continued cerebral edema.

Correct Answer: Malnutrition promotes continued cerebral edema. Rationale: A patient with diffuse axonal injury is unconscious and, with increased intracranial pressure, is in a hypermetabolic, hypercatabolic state that increases the need for energy to heal. Malnutrition promotes continued cerebral edema, and early feeding may improve outcomes when begun within 3 days after injury. Fluid and electrolytes will be monitored to maintain balance with the enteral nutrition. Excess intravenous fluid administration will also increase cerebral edema.

A female patient reports a throbbing headache. The nurse learns the patient has had photophobia and headaches previously. Which diagnosis should the nurse suspect? Cluster headache Migraine headache Polycythemia vera Hemorrhagic stroke

Correct Answer: Migraine headache Rationale: Although a headache may occur with any of these options, a migraine headache is the only one that has a throbbing headache with an aura (the photophobia). Headache from polycythemia vera is from erythrocytosis. The cluster headache pain is sharp and stabbing. The headache associated with a hemorrhagic stroke has a sudden onset and is not recurrent.

What nursing intervention should be implemented for a patient with increased intracranial pressure (ICP)? Monitor fluid and electrolyte status carefully. Position the patient in a high Fowler's position. Administer vasoconstrictors to maintain cerebral perfusion. Maintain physical restraints to prevent episodes of agitation.

Correct Answer: Monitor fluid and electrolyte status carefully. Rationale: Fluid and electrolyte changes can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically used in the treatment of ICP.

The nurse is caring for a patient placed in Buck's traction before open reduction and internal fixation of a left hip fracture. Which care can be delegated to the LPN/VN? Assess skin integrity around the traction boot. Determine correct body alignment to enhance traction. Remove weights from traction when turning the patient. Monitor pain intensity and administer prescribed analgesics.

Correct Answer: Monitor pain intensity and administer prescribed analgesics. Rationale: The LPN/VN can monitor pain intensity and administer analgesics. Assessment of skin integrity and determining correct alignment to enhance traction are within the RN scope of practice. Removing weights from the traction should not be delegated or done. Removal of weights can cause muscle spasms and bone misalignment and should not be delegated or done.

A patient with a fracture of the proximal left tibia in a long leg cast reports of severe pain and a prickling sensation in the left foot. The toes on the left foot are pale and cool. Which nursing action is a priority? Notify the health care provider immediately. Elevate the left leg above the level of the heart. Administer prescribed morphine sulfate intravenously. Apply ice packs to the left proximal tibia over the cast.

Correct Answer: Notify the health care provider immediately. Rationale: Notify the health care provider immediately of this change in patient's condition, which suggests development of compartment syndrome. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Changes in sensation (tingling) also suggest compartment syndrome. Because elevation of the extremity may lower venous pressure and slow arterial perfusion, the extremity should not be elevated above heart level. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome. Administration of morphine may be warranted, but it is not the first priority.

A patient has been receiving scheduled doses of phenytoin (Dilantin) and begins develops diplopia. Which additional findings should the nurse expect? Nystagmus or confusion An aura or focal seizure Abdominal pain or cramping Irregular pulse or palpitations

Correct Answer: Nystagmus or confusion Rationale: Diplopia is a sign of phenytoin toxicity. The nurse should assess for other signs of toxicity, which include neurologic changes, such as nystagmus, ataxia, confusion, dizziness, or slurred speech. An aura, focal seizure, abdominal pain or cramping, irregular pulse, or palpitations are not associated with phenytoin toxicity.

The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis. Which finding should the nurse expect when examining the patient's knees? Ulnar drift Pain with joint movement Reddened, swollen affected joints Stiffness that increases with movement

Correct Answer: Pain with joint movement Rationale: Osteoarthritis is characterized predominantly by joint pain upon movement and is a classic feature of the disease. Ulnar drift occurs with rheumatoid arthritis, not osteoarthritis. Local inflammation (red, swollen joints) is unlikely with osteoarthritis. Stiffness decreases with movement.

The nurse is caring for a patient who had a left total knee arthroplasty to relieve the pain of severe osteoarthritis. What care would be expected postoperatively? Progressive leg exercises to obtain 90-degree flexion Early ambulation with full weight bearing on the left leg Bed rest for 3 days with the left leg immobilized in extension Immobilization of the left knee in 30-degree flexion to prevent dislocation

Correct Answer: Progressive leg exercises to obtain 90-degree flexion Rationale: The patient is encouraged to engage in progressive leg exercises until 90-degree flexion is possible; continuous passive motion also may be used based on surgeon preference. Early ambulation is implemented, sometimes the day of surgery, but orders are likely to indicate weight bearing as tolerated rather than full weight bearing. Immobilization and bed rest are not indicated. The patient's knee is unlikely to dislocate.

A 74-yr-old man who has right-sided extremity paralysis related to a thrombotic stroke develops constipation. Which action should the nurse take first? Assist the patient to the bathroom every 2 hours. Provide incontinence briefs to wear during the day. Give a bisacodyl (Dulcolax) rectal suppository every day. Provide several servings daily of cooked fruits and vegetables.

Correct Answer: Provide several servings daily of cooked fruits and vegetables. Rationale: Patients after a stroke often have constipation. Dietary management includes the following: fluid intake of 2500 to 3000 mL daily, prune juice (120 mL) or stewed prunes daily, cooked fruit 3 times daily, cooked vegetables 3 times daily, and whole-grain cereal or bread 3 to 5 times daily. Patients with urinary incontinence should be assisted to the bathroom every 2 hours. Suppositories may be ordered for short-term management if the patient does not respond to increased fluid and fiber. Incontinence briefs are indicated as a short-term intervention for urinary incontinence.

A patient with a diagnosis of Parkinson's disease (PD) is admitted to a long-term care facility. Which action should the health care team take to promote adequate nutrition for this patient? Administer multivitamins every morning and with each meal. Provide a diet that is low in complex carbohydrates and high in protein. Give the patient with a pureed diet that is high in potassium and low in sodium. Provide small, frequent meals throughout the day that are easy to chew and swallow.

Correct Answer: Provide small, frequent meals throughout the day that are easy to chew and swallow. Rationale: Nutritional support is a priority in the care of persons with PD. Patients may benefit from smaller, more frequent meals that are easy to chew and swallow. Multivitamins are not necessary at each meal. Vitamin and protein intake must be monitored to prevent interactions with medications. Introducing a minced or pureed diet is likely premature, and a low carbohydrate diet is not indicated.

A nurse is assessing the recent health history of a 63-yr-old patient with osteoarthritis. Which activity pattern should the nurse recommend? Bed rest with bathroom privileges Daily high-impact aerobic exercise Regular exercise program of walking Frequent rest periods with minimal exercise

Correct Answer: Regular exercise program of walking Rationale: A regular low-impact exercise, such as walking, is important in helping to maintain joint mobility in patients with osteoarthritis. A balance of rest and activity is needed. High-impact aerobic exercises would cause stress to affected joints and further damage.

A patient with intracranial pressure monitoring has a pressure of 12 mm Hg. The nurse understands that this pressure reflects a. a severe decrease in cerebral perfusion pressure. b. an alteration in the production of cerebrospinal fluid. c. the loss of autoregulatory control of intracranial pressure. d. a normal balance among brain tissue, blood, and cerebrospinal fluid.

d. a normal balance among brain tissue, blood, and cerebrospinal fluid. Rationale: Normal intracranial pressure (ICP) is 5 to 15 mm Hg. A sustained pressure above the upper limit is considered abnormal.

A patient is scheduled for total ankle replacement. The nurse should tell the patient that after surgery he should avoid a. lifting heavy objects. b. sleeping on the back. c. abduction exercises of the affected ankle. d. bearing weight on the affected leg for 6 weeks.

d. bearing weight on the affected leg for 6 weeks. Rationale: After total ankle arthroplasty (TAA), the patient may not bear weight for 6 weeks and must elevate the extremity to reduce edema. The patient must follow strategies to prevent postoperative infection and maintain immobilization as directed by the provider.

The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the a. O2 content of the blood. b. amount of cardiac output. c. level of CO2 in the blood. d. degree of collateral circulation

d. degree of collateral circulation Rationale: The extent of the stroke depends on the rapidity of onset, size of the lesion, and presence of collateral circulation.

A patient with a stable, closed humeral fracture has a temporary splint with bulky padding applied with an elastic bandage. The nurse notifies the provider of possible early compartment syndrome when the patient has a. increasing edema of the limb. b. muscle spasms of the lower arm. c. bounding pulse at the fracture site. d. pain when passively extending the fingers.

d. pain when passively extending the fingers. Rationale: One or more of these characteristics occur with early compartment syndrome: (1) paresthesia (e.g., numbness and tingling sensation); (2) pain distal to the injury that is not relieved by opioid analgesics and is increased on passive stretch of muscle; (3) increased pressure in the compartment; and (4) pallor, coolness, and loss of normal color of the extremity. Paralysis (or loss of function) and pulselessness (or decreased or absent peripheral pulses) are late signs of compartment syndrome. The examination also includes assessment of peripheral edema, especially pitting edema, which may occur with severe injury.

Information provided by the patient that would help distinguish a hemorrhagic stroke from a thrombotic stroke includes a. sensory changes. b. a history of hypertension. c. presence of motor weakness. d. sudden onset of severe headache.

d. sudden onset of severe headache. Rationale: A hemorrhagic stroke usually causes a sudden onset of symptoms, which include neurologic deficits, headache, nausea, vomiting, decreased level of consciousness, and hypertension. Ischemic stroke symptoms may progress in the first 72 hours as infarction and cerebral edema increase

The nurse suspects an ankle sprain when a patient at the urgent care center describes a. being hit by another soccer player during a game. b. having ankle pain after sprinting around the track. c. dropping a 10-lb weight on his lower leg at the health club. d. twisting his ankle while running bases during a baseball game.

d. twisting his ankle while running bases during a baseball game. Rationale: A sprain is an injury to the ligaments surrounding a joint. It is usually caused by a wrenching or twisting motion. Most sprains occur in the ankle and knee joints.

A 50-yr-old man reports recurring headaches. He describes them as sharp, stabbing, and around his left eye. He says his left eye seems to swell and get teary when these headaches occur. Based on this history, you suspect he has a. cluster headaches. b. tension headaches. c. migraine headaches. d. medication overuse headaches.

a. cluster headaches. Rationale: Cluster headaches involve repeated headaches that can occur for weeks to months, followed by periods of remission. The pain of cluster headache is sharp and stabbing. It lasts a few minutes to 3 hours. Cluster headaches can occur every other day and as often as 8 times a day. The clusters occur with regularity, usually at the same time each day and during the same seasons of the year. The pain usually is around the eye and radiates to the temple, forehead, cheek, nose, or gums. Other manifestations may include swelling around the eye, lacrimation (tearing), facial flushing or pallor, nasal congestion, and constriction of the pupil.

Common psychosocial problems a patient may have post stroke include (select all that apply) a. depression. b. disassociation. c. sleep problems. d. intellectualization e. denial of severity of stroke.

a. depression. c. sleep problems. e. denial of severity of stroke. Rationale: The patient with a stroke may have many losses, including sensory, intellectual, communicative, functional, role behavior, emotional, social, and vocational. Some patients have long-term depression, manifesting symptoms, including anxiety, weight loss, fatigue, poor appetite, and sleep problems. The time and energy needed to perform previously simple tasks can result in anger and frustration. Reactions vary considerably but may involve fear, apprehension, denial of the severity of stroke, depression, anger, and sorrow.

A patient with a humeral fracture is returning for a 4-week checkup. The nurse explains that initial evidence of healing on x-ray is indicated by a. formation of callus. b. complete bony union. c. hematoma at the fracture site. d. presence of granulation tissue.

a. formation of callus. Rationale: Bone goes through a remarkable healing process (e.g., union) that occurs in stages. The third stage is callus formation. As minerals (e.g., calcium, phosphorus, and magnesium) and new bone matrix are deposited in the osteoid, an unorganized network of bone is formed that is woven about the fracture parts. Callus is composed primarily of cartilage, osteoblasts, calcium, and phosphorus. It usually appears by the end of the second week after injury. Evidence of callus formation can be verified on x-rays

During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for a. patency of airway. b. presence of a neck injury. c. neurologic status with the Glasgow Coma Scale. d. cerebrospinal fluid leakage from the ears or nose.

a. patency of airway. Rationale: The nurse's initial priority in the emergency management of a patient with a severe head injury is to ensure that the patient has a patent airway.

Possible social effects of a chronic neurologic disease include (select all that apply) a. divorce. b. job loss. c. depression. d. role changes. e. loss of self-esteem.

all of the above Rationale: Problems related to chronic neurologic disease that may have social effects include changes in roles and relationships (e.g., divorce, job loss, role changes) and other psychologic problems (e.g., depression, loss of self-esteem).

A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to a. keep the head of the bed flat. b. elevate the head of the bed to 30 degrees. c. maintain patient on the left side with the head supported on a pillow. d. use a continuous-rotation bed to continuously change patient position.

b. elevate the head of the bed to 30 degrees. Rationale: The nurse should maintain the patient with abnormal ICP in the head-up position. Elevation of the head of the bed to 30 degrees enhances respiratory exchange and aids in decreasing cerebral edema. The nurse should position the patient to prevent extreme neck flexion, which can cause venous obstruction and contribute to elevation in ICP. Elevating the head of the bed reduces sagittal sinus pressure, promotes drainage from the head through the venous system and jugular veins, and decreases the vascular congestion that can cause cerebral edema. However, raising the head of the bed above 30 degrees may decrease the cerebral perfusion pressure (CPP) by lowering systemic BP. The effects of elevation of the head of the bed on the ICP and CPP must be evaluated carefully.

Bladder training in a male patient who has urinary incontinence after a stroke includes a. limiting fluid intake. b. helping the patient to stand to void. c. keeping a urinal in place at all times. d. catheterizing the patient every 4 hours.

b. helping the patient to stand to void. Rationale: In the acute stage of stroke, the primary urinary problem is poor bladder control and incontinence. A bladder retraining program consists of (1) adequate fluid intake, with the greatest fluid intake between 7:00 AM and 7:00 PM; and (2) scheduled toileting every 2 hours with the use of a urinal, commode, or bathroom, (3) assisting with clothing and mobility; and (4) encouraging the usual position for urinating.

In assessing the joints of a patient with osteoarthritis, the nurse understands that Bouchard's nodes a. are often red, swollen, and tender. b. indicate osteophyte formation at the PIP joints. c. are the result of pannus formation at the DIP joints. d. occur from deterioration of cartilage by proteolytic enzymes.

b. indicate osteophyte formation at the PIP joints. Rationale: Bouchard's nodes are bony deformities of the proximal interphalangeal joints that indicate osteophyte formation and loss of joint space in osteoarthritis.

A patient with osteoarthritis is scheduled for total hip arthroplasty. The nurse explains the purpose of this procedure is to (select all that apply) a. fuse the joint. b. replace the joint. c. prevent further damage. d. improve or maintain ROM. e. decrease the amount of destruction in the joint.

b. replace the joint. d. improve or maintain ROM. Rationale: Arthroplasty is the reconstruction or replacement of a joint. This surgical procedure is done to relieve pain, improve or maintain range of motion, and correct deformity. Total hip arthroplasty (THA) provides significant pain relief and improved function for a patient with osteoarthritis (OA).

For a patient who is suspected of having a stroke, the most important piece of information that the nurse can obtain is a. time of the patient's last meal. b. time at which stroke symptoms first appeared. c. patient's hypertension history and management. d. family history of stroke and other cardiovascular diseases.

b. time at which stroke symptoms first appeared. Rationale: During initial evaluation, the most crucial point in the patient's history is the time since onset of stroke symptoms. If the stroke is ischemic, recombinant tissue plasminogen activator (tPA) must be given within 3 to 4½ hours of the onset of signs of ischemic stroke; tPA reestablishes blood flow through a blocked artery and prevents brain cell death in patients with acute onset of ischemic stroke.

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first? a. Patient with a skull fracture whose nose is bleeding b. An older patient with a stroke who is confused and whose daughter is present c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0- to 10 scale d. Patient 2 days postoperative after a craniotomy for a brain tumor who has had continued vomiting

c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0- to 10 scale Rationale: The patient with meningitis should be seen first. Patients with meningitis must be observed closely for manifestations of increased ICP, which is thought to result from swelling around the dura and increased cerebrospinal fluid (CSF) volume. Sudden change in the level of consciousness or change in behavior along with a sudden severe headache may indicate an acute elevation of ICP. The patient who has undergone cranial surgery should be seen second. Although nausea and vomiting are common after cranial surgery, it can result in elevations of ICP. Nausea and vomiting should be treated with antiemetics. The patient with a skull fracture needs to be evaluated for CSF leakage occurring with the nosebleed and should be seen third. Confusion after a stroke may be expected; the patient should have a family member present.

The nurse suspects a neurovascular problem based on assessment of a. exaggerated strength with movement. b. increased redness and heat below the injury. c. decreased sensation distal to the fracture site. d. purulent drainage at the site of an open fracture.

c. decreased sensation distal to the fracture site. Rationale: Musculoskeletal injuries can cause changes in the neurovascular condition of an injured extremity. The neurovascular assessment consists of peripheral vascular evaluation (e.g., color, temperature, capillary refill, peripheral pulses, and edema) and peripheral neurologic evaluation (e.g., sensation and motor function). Paresthesia and partial or full loss of sensation (paresis or paralysis) may be a sign of neurovascular damage. Pallor, a cool-to-cold extremity, or a delay in capillary refill time below the injury occur with arterial insufficiency. A decreased or absent pulse distal to the injury can indicate vascular dysfunction and insufficiency.

The nurse is alerted to a possible acute subdural hematoma in the patient who a. has a linear skull fracture crossing a major artery. b. has focal symptoms of brain damage with no recollection of a head injury. c. develops decreased level of consciousness and a headache within 48 hours of a head injury. d. has an immediate loss of consciousness with a brief lucid interval followed by decreasing level of consciousness.

c. develops decreased level of consciousness and a headache within 48 hours of a head injury. Rationale: An acute subdural hematoma manifests within 24 to 48 hours of the injury. The signs and symptoms are similar to those associated with brain tissue compression in increased ICP. They include decreasing level of consciousness and headache.

A patient is having word finding difficulty and weakness in his right arm. What area of the brain is most likely involved? a. brainstem. b. vertebral artery. c. left middle cerebral artery. d. right middle cerebral artery.

c. left middle cerebral artery. Rationale: If the middle cerebral artery is involved in a stroke, the expected manifestations include aphasia, motor and sensory deficit, and hemianopsia on the dominant side and include neglect, motor and sensory deficit, and hemianopsia on the nondominant side.

A patient with a comminuted fracture of the tibia is to have an open reduction with internal fixation (ORIF) of the fracture. The nurse explains that ORIF is indicated when a. the patient is unable to tolerate prolonged immobilization. b. the patient cannot tolerate the surgery for a closed reduction. c. other nonsurgical methods cannot achieve adequate alignment. d. a temporary cast would be too unstable to provide normal mobility.

c. other nonsurgical methods cannot achieve adequate alignment. Rationale: A comminuted fracture has more than 2 bone fragments. Open reduction with internal fixation (ORIF) is indicated for a comminuted fracture. It is used to realign and maintain bony fragments. Other nonsurgical methods can fail to obtain satisfactory reduction. Internal fixation reduces the hospital stay and complications associated with prolonged bed rest.

The nurse explains to the patient with a stroke who is scheduled for angiography that this test is used to determine the a. presence of increased ICP. b. site and size of the infarction. c. patency of the cerebral blood vessels. d. presence of blood in the cerebrospinal fluid.

c. patency of the cerebral blood vessels. Rationale: Angiography provides visualization of cerebral blood vessels and can help estimate perfusion and detect filling defects in the cerebral arteries.

A patient having TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to a. decrease cerebral edema. b. reduce the brain damage that occurs during a stroke in evolution. c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow. d. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation.

c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow. Rationale: In a carotid endarterectomy, the atheromatous lesion is removed from the carotid artery to improve blood flow

A 65-yr-old woman was just diagnosed with Parkinson's disease. The priority nursing intervention is a. searching the Internet for educational videos. b. helping the caregiver explore respite care options. c. promoting physical exercise and a well-balanced diet. d. teaching about the benefits and risks of ablation surgery.

c. promoting physical exercise and a well-balanced diet. Rationale: Promoting physical exercise and a well-balanced diet are major concerns of nursing care for patients newly diagnosed with Parkinson's disease. Diet is of major concern as malnutrition and constipation can result from poor nutrition. Exercise can limit the effects of decreased mobility, such as muscle atrophy, contractures, and constipation. Helping the patient and caregiver explore respite care options may be appropriate later in the course of PD.