Med Surg II: Chapter 39 (The Brain), 40 (spinal cord), 41 (Neurologic Emergencies)

The nurse is caring for a client diagnosed with vascular dementia. The nurse recognizes that which health problem is associated with this type of dementia? A. Epilepsy B. Stroke C. Meningitis D. Migraines

B. Stroke Vascular dementia is typically caused by strokes or other cranial vascular disease. The exact cause of Alzheimer disease is not known.

Question 12 of 20 The nurse is planning desired outcomes for rehabilitation of a client with traumatic brain injury (TBI). What is the most important outcome for this client? A. Preventing skin breakdown B. Preventing further injury C. Achieving the highest level of functioning D. Increasing cerebral perfusion

C. Achieving the highest level of functioning The most important nurse's desired or expected outcome for the client having rehabilitation after TBI is to help him or her achieve the highest level of functioning possible. Prevention of injury from falls or skin breakdown, infection, or further impairment of cerebral perfusion is part of ongoing care for this client.

Question 18 of 20 The nurse is planning health teaching for a client who had a transient ischemic attack (TIA) to help prevent a major stroke. What teaching would the nurse include? (Select all that apply.) Select all that apply. A. "Seek a smoking cessation program, if needed." B. "Increase physical activity by exercising regularly." C. "Monitor blood pressure frequently to assess control." D. "Take your prescribed antiplatelet agent as prescribed." E. "If diabetic, work to achieve glucose control as needed." F. "Eat a heart-healthy diet every day if possible."

A. "Seek a smoking cessation program, if needed." B. "Increase physical activity by exercising regularly." C. "Monitor blood pressure frequently to assess control." D. "Take your prescribed antiplatelet agent as prescribed." E. "If diabetic, work to achieve glucose control as needed." F. "Eat a heart-healthy diet every day if possible." All of these instructions are important in helping to prevent a major stroke for a client who had a TIA.

Question 20 of 20 The nurse is caring for a mechanically ventilated client who has an organ donation card and a severe traumatic brain injury. Which assessment findings indicate that the client will be declared as brain dead? (Select all that apply.) Select all that apply. A. Hypothermia B. Absence of brainstem reflexes C. Apnea not due to drugs or diseases D. Irreversible loss of consciousness E. Hypotension

B. Absence of brainstem reflexes C. Apnea not due to drugs or diseases D. Irreversible loss of consciousness These three assessment findings meet the American Academy of Neurology guidelines for brain death. However, ancillary imaging tests may be used to validate these findings.

Question 16 of 20 A client is being discharged home after treatment for a brain attack. What is the mnemonic that the nurse can teach the family and client to help recognize and act on another stroke? A. A-V-P-U B. F-A-S-T C. K-I-N-D D. P-Q-R-S-T

B. F-A-S-T The mnemonic F-A-S-T is utilized to teach the client, family, and community how to recognize and respond to a stroke. The purpose is to observe the Face, Arms, Speech, and then Time of onset and knowing it's Time to call 9-1-1.

Question 15 of 20 The nurse is monitoring a postoperative craniotomy client with increased intracranial pressure (ICP). Which pharmacologic agent does the nurse expect to be requested to maintain the ICP within a specified range? A. Dexamethasone B. Mannitol C. Phenytoin D. Hydrochlorothiazide

B. Mannitol In a postoperative craniotomy client with ICP, the nurse expects Mannitol to be requested to keep the ICP within a certain range. Mannitol is an osmotic diuretic used specifically to treat cerebral edema.Glucocorticoids have no demonstrated benefit in reducing ICP. Hydrochlorothiazide is only a mild diuretic and is not beneficial in maintaining ICP. Dilantin is used to treat seizure activity caused by increased ICP.

Question 9 of 20 A client in the emergency department (ED) has slurred speech, confusion, and visual problems and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The client also has a history of hypertension and atherosclerosis. What would the nurse suspect that the client is most likely experiencing? A. Transient ischemic attack B. Thrombotic stroke C. Embolic stroke D. Hemorrhagic stroke

B. Thrombotic stroke The client's signs and symptoms fit the description of a thrombotic stroke due to its gradual onset.Signs and symptoms of embolic stroke have a sudden onset, unlike this client's symptoms. Hemorrhagic strokes more frequently present with sudden, severe headache. Intermittent episodes of slurred speech, confusion, and visual problems are transient ischemic attacks, which often are warning signs of an impending ischemic stroke.

Question 9 of 18 The nurse is collaborating with the rehabilitation therapist to improve mobility skills for a client with a complete high-level spinal cord injury. Which technique is appropriate for this client? A. Use of a mechanical lift to get the client out of bed B. Use of a sliding board (slider) to transfer from bed to a chair C. Use of parallel bars to facilitate ambulation D. Use of a walker to promote balance and prevent muscle atrophy

B. Use of a sliding board (slider) to transfer from bed to a chair The client who has a complete high-level, or cervical, spinal cord injury is tetraplegic (quadriplegic) meaning that he or she does not have control over any extremity. The client has shoulder movement allowing the client to use a sliding board as a "bridge" between the bed and chair.

Question 10 of 18 Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord injury? A. Special pressure-relief devices B. Frequent ambulation C. Encouraging nutrition D. Regular turning and repositioning

D. Regular turning and repositioning Regular turning and repositioning are the best way to prevent complications of immobility in clients with spinal cord problems.A registered dietitian may be consulted to encourage nutrition to optimize diet for general health and to reduce osteoporosis. Frequent ambulation may not be possible for these clients. Use of special pressure-relief devices is important but is not the best way to prevent immobility complications.

Question 7 of 20 The nurse is teaching assistive personnel (AP) about how to communicate with an older client who has receptive aphasia. Which instruction would the nurse include? A. "Use simple short sentences and one-step commands." B. "Work with the speech-language pathologist for suggestions." C. "Write sentences or words on a white board for the client." D. "Speak loudly to ensure that the client can hear."

A. "Use simple short sentences and one-step commands." Receptive aphasia is an inability to understand words or sentences, whether it is verbal or written. Therefore, using short simple, one-step sentences and commands is the best instruction to provide AP. Unless the client has a heading deficit, there is no need to talk loudly.

Question 3 of 20 The nurse is caring for a client diagnosed with a vertebrobasilar artery stroke. What assessment finding would the nurse expect for this client? A. Ataxia B. Amnesia C. Unilateral neglect D. Aphasia

A. Ataxia Aphasia, amnesia, and unilateral neglect are common assessment findings associated with cerebral strokes. Clients who have vertebrobasilar artery strokes have dysfunctions of the cerebellum, such as ataxia, and possibly the brainstem. Clients with this type of stroke typically have weakness in all four extremities rather than one-sided weakness.

Question 11 of 20 The nurse is monitoring a client admitted with a closed traumatic brain injury for indications of increasing intracranial pressure. Which assessment finding would the nurse report to the primary health care provider immediately? A. Decreased level of consciousness (LOC) B. Blood pressure of 140/88 C. Temperature of 100° F (37.8° C) D. Apical pulse of 90 and regular

A. Decreased level of consciousness (LOC) The first and most important assessment finding associated with increased intracranial pressure that should be reported immediately to the primary health care provider is a decrease in LOC. The vital signs in the choices are near normal and not of great concern.

Question 19 of 20 The nurse is planning discharge teaching for a client after having a carotid angioplasty with stenting. As part of health teaching, what symptoms will the nurse teach the client and family to report to the primary health care provider? (Select all that apply.) Select all that apply. A. Dysphagia B. Severe neck pain C. Neck swelling D. Mild headache E. Hoarseness

A. Dysphagia B. Severe neck pain C. Neck swelling E. Hoarseness The client or family should notify the primary health care provider about complications of the carotid artery surgery, which include all of these choices except they would want to report a severe headache, not a mild one.

Question 18 of 18 The nurse is caring for a client who sustained a complete cervical spinal cord injury and is at risk for autonomic dysreflexia. Which assessment findings would the nurse anticipate if this complication occurs? (Select all that apply.) Select all that apply. A. Goose bumps above and/or below the injury level B. Sudden and severe hypertension C. Severe throbbing headache D. Profuse sweating above the injury level E. Nasal congestion and blurred vision F. Facial and skin flushing

A. Goose bumps above and/or below the injury level B. Sudden and severe hypertension C. Severe throbbing headache D. Profuse sweating above the injury level E. Nasal congestion and blurred vision F. Facial and skin flushing All of these findings commonly occur in clients who experience autonomic dysreflexia.

The nurse is providing medication instructions for a client for whom phenytoin has been ordered for treatment of epilepsy. The nurse instructs the client to avoid which beverage? A. Grape juice B. Grapefruit juice C. Apple juice D. Prune juice

A. Grapefruit juice The nurse instructs the client taking phenytoin for epilepsy to avoid taking grapefruit juice. Some citrus fruits and juices, like grapefruit juice, can interfere with the metabolism of phenytoin potentially leading to an increased blood level and toxicity.Apple, grape, and prune juices are not contraindicated for a client taking phenytoin.

A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first? A. Help the client sit up. B. Check for fecal impaction. C. Loosen the client's clothing. D. Insert a straight catheter.

A. Help the client sit up. The nurse's first action for a T6 spinal cord injury client suddenly developing facial flushing and severe headache is to help the client sit up. The client is experiencing autonomic dysreflexia, which can produce severe and rapidly occurring hypertension. Getting the client to sit upright is the easiest and quickest action to take and has the most immediate chance of lowering blood pressure to the brain. Checking for fecal impaction, inserting a straight catheter, and loosening the clothing are important but will not immediately reduce blood pressure.

Question 14 of 18 The nurse is caring for a client with a spinal cord injury resulting from a diving accident, who has a halo fixator and an indwelling urinary catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the primary health care provider will prescribe which medication? A. Nifedipine B. Dopamine hydrochloride C. Ziconotide D. Methylprednisolone

A. Nifedipine The nurse anticipates that the primary health care provider will prescribe nifedipine or nitrates for a spinal cord injury client who has an elevated blood pressure and severe headache. This client is experiencing autonomic dysreflexia (AD). If AD is not treated, a hemorrhagic stroke can occur.Dopamine hydrochloride is an inotropic agent used to treat severe hypotension. Methylprednisolone is a glucocorticoid and is not indicated because it may further increase blood pressure. Ziconotide is an N-type calcium channel blocker on those nerves that usually transmit pain signals to the brain.

A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is the priority for the client at this time? A. Positioning the client to maximize ventilation potential B. Taking vital signs every 2 hours C. Inserting an indwelling urinary catheter D. Monitoring the client's nutritional status

A. Positioning the client to maximize ventilation potential The priority nursing intervention for a client with a spinal cord injury at the seventh cervical vertebra is to position the client to maximize ventilation potential. Airway management is the priority for the client with a spinal cord injury. The client with a cervical spinal cord injury is at high risk for respiratory compromise because the cervical spinal nerves (C3 to C5) innervate the phrenic nerve, controlling the diaphragm.

The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? A. Positions the client on the side. B. Restrains the client. C. Forces a tongue blade in the mouth. D. Documents the length and time of the seizure.

A. Positions the client on the side. When a newly admitted client with a history of seizures begins to seize, the nurse must turn the client on his/her side. Turning the client on the side during a generalized tonic-clonic or complex partial seizure is indicated because he or she may lose consciousness resulting in potential loss of a patent airway.Documenting the length and time of seizures is important, but not the priority intervention. Both forcing a tongue blade in the mouth and restraining the client can cause injury.

A client has been admitted with new-onset status epilepticus. Which seizure precautions would the nurse implement? (Select all that apply.) Select all that apply. A. Suction equipment at the bedside B. Continuous sedation C. Intravenous (IV) access D. Bite block at the bedside E. Side rails raised

A. Suction equipment at the bedside C. Intravenous (IV) access E. Side rails raised Seizure precautions the nurse institutes for an admitted client with new-onset status epilepticus include IV access, suctioning equipment at the bedside, and raised side rails. IV access is needed to administer medications. Suctioning equipment must be available to suction secretions and facilitate an open airway during a seizure. Raised, padded side rails may be used to protect the client from falling out of bed during a seizure. Bite blocks or padded tongue blades would not be used because the client's jaw may clench, causing teeth to break and possibly obstructing the airway. Continuous sedation is a medical intervention and not a seizure precaution.

Which is the most effective way for a college student to minimize the risk for bacterial meningitis? A. Avoid large crowds. B. Get the meningococcal vaccine. C. Take a high dose vitamin C daily. D. Take prophylactic antibiotics.

B. Get the meningococcal vaccine The most effective way for a college student to minimize the risk for bacterial meningitis is to get the meningococcal vaccine. Individual's ages 16 to 21 years have the highest rates of meningococcal infection and need to be immunized against the virus.Avoiding large crowds is helpful, but is not practical for a college student. Taking a high dose of vitamin C every day does not minimize the risk of bacterial meningitis. However, maintaining a healthy lifestyle, with adequate sleep and nutrition, can improve immunity. Taking prophylactic antibiotics is inappropriate because it leads to antibiotic-resistant strains of microorganisms.

Question 17 of 20 The nurse is teaching a group of older adults about stroke prevention. Which risk factors for stroke would the nurse include? (Select all that apply.) Select all that apply. A. Female gender B. High blood pressure C. Previous stroke or transient ischemic attack (TIA) D. Smoking E. Use of oral contraceptives

B. High blood pressure C. Previous stroke or transient ischemic attack (TIA) D. Smoking E. Use of oral contraceptives Common modifiable risk factors for developing a stroke include smoking and the use of oral contraceptives. Other risk factors include high blood pressure and history of a previous TIA. Gender is not a known risk factor for stroke; however, the female client is at risk for delayed recognition of early stroke symptoms.

Question 6 of 20 A client completed an alteplase infusion following a thrombotic stroke. What nursing action is appropriate? A. Insert an indwelling urinary catheter. B. Perform frequent neurologic assessments. C. Notify Radiology to schedule an MRI. D. Administer an antiplatelet agent.

B. Perform frequent neurologic assessments. After administering an alteplase infusion, the nurse performs a focused neurologic assessment, including vital signs, every 15 to 30 minutes, depending on agency protocol and the client's condition. Antiplatelet therapy is not started for at least 24 hours after infusion. A urinary catheter or other invasive tube can cause bleeding and should be avoided. The client would have a CT angiogram or perfusion scan before antiplatelet therapy is initiated.

The nurse is teaching a client, newly diagnosed with migraines, about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan? A. "I need to use fake sugar in my coffee." B. "I can still eat Chinese food." C. "I should not miss any meals." D. "It is okay to drink a few wine coolers."

C. "I should not miss any meals." The client understands the teaching plan about trigger control for migraines when the client states that he/she must not miss meals. Until triggers are identified, a headache diary would be considered. Missing meals is a trigger for many people suffering from migraines. The client must not skip any meals until the triggers are identified.Chinese food frequently contains monosodium glutamate. Monosodium glutamate-containing foods, alcohol, and artificial sweeteners are triggers for many people suffering from migraines and need to be eliminated until the triggers are identified.

The nurse is providing instructions to a client with a cervical spinal cord injury about caring for the halo fixator device. The nurse plans to include which instructions? A. "Avoid using a pillow under the head while sleeping." B. "Begin driving 1 week after discharge." C. "Keep straws available for drinking fluids." D. "Swimming is recommended to keep active."

C. "Keep straws available for drinking fluids." The instructions the nurse include for a client with a halo device is to keep straws available for drinking fluids. The halo device makes it difficult to bring a cup or a glass to the mouth.The head would be supported with a small pillow when sleeping to prevent unnecessary pressure and discomfort. Driving must be avoided because vision is impaired with the device. Swimming must be avoided to prevent the risk for infection.

The nurse is assessing a client who was diagnosed with Alzheimer disease (AD) and notes the client has difficulty finding the correct words at times during conversation. What communication alteration would the nurse document? A. Aphasia B. Apraxia C. Anomia D. Agnosia

C. Anomia Anomia is the inability to find words for objects, places, and events, and is a common assessment finding in clients with early AD. Aphasia is a general problem with speaking, understanding, to both. Apraxia is the inability to use an object correctly and agnosia, a later AD finding, is a lack of sensory comprehension.

Question 2 of 20 A client hospitalized for hypertension presses the call light and reports "feeling funny." When the nurse gets to the room, the client is slurring words and has right-sided weakness. What would the nurse do first? A. Perform a focused neurologic assessment. B. Position the client in a sitting position. C. Assess airway, breathing, and circulation. D. Call the primary health care provider.

C. Assess airway, breathing, and circulation. When a client reports "feeling funny" and then starts slurring words and has right-sided weakness, the nurse must first assess for airway, breathing, and circulation. The priority is assessment of the "ABCs"—airway, breathing, and circulation.Calling the Rapid Response Team (RRT), not the primary health care provider, after assessing ABCs would be appropriate. The first 10 minutes after onset of symptoms is crucial. A neurologic check will be performed rapidly but is not the top priority. The client would be placed in bed, easily accessible for the RRT to assess and begin treatment. This does not need to be a seated position.

Question 13 of 20 The nurse is assessing a client with a traumatic brain injury after a skateboarding accident. Which sign or symptom would the nurse be most concerned about? A. Head laceration B. Headache C. Asymmetric pupils D. Amnesia

C. Asymmetric pupils The nurse is most concerned about asymmetric pupils in the client with traumatic brain injury. Asymmetric (uneven) pupils are treated as herniation of the brain from increased intracranial pressure (ICP) until proven otherwise. The nurse must report and document any changes in pupil size, shape, and reactivity to the primary health care provider immediately.Amnesia, a headache, and a head laceration can be signs of mild traumatic brain injuries and need to be investigated more thoroughly.

The nurse is caring for a client who has a left middle cerebral artery stroke. During shift assessment, the client begins to cry unexpectedly after laughing. What would the nurse suspect that the client is experiencing? A. Anxiety B. Delirium C. Emotional lability D. Depression

C. Emotional lability Emotional lability is present when the client's emotions change quickly and are not necessarily reflective of the client's mood or a particular situation. This problem is common in clients who have cerebral artery strokes.

Question 1 of 20 The nurse is caring for a client who has a cerebral artery aneurysm. For what complication is the client at risk? A. Traumatic brain injury B. Brain cancer C. Hemorrhagic stroke D. Embolic stroke

C. Hemorrhagic stroke Aneurysms cause the arterial wall to be weak and thin which can lead to blood vessel rupture or hemorrhage. Therefore, an aneurysm in the brain can rupture and cause a hemorrhagic stroke.

Question 14 of 20 A client has had a traumatic brain injury and is mechanically ventilated. Which technique would the nurse use to prevent increasing intracranial pressure (ICP)? A. Place the client in the Trendelenburg position. B. Suction the client frequently and as needed. C. Maintain neutral head position. D. Assess for Grey Turner sign.

C. Maintain neutral head position. To prevent ICP in a client with traumatic brain injury who is being mechanically ventilated, the nurse needs to maintain the patent's head in a neutral position. Maintaining the head in neutral alignments prevents obstruction of blood flow and is an important component of ICP.Grey Turner sign is a bluish gray discoloration in the flank region caused by retroperitoneal hemorrhage. The head of the bed needs to be at 30 degrees. The Trendelenburg position will cause the client's ICP to increase. Although some suctioning is necessary, frequent suctioning would be avoided because it increases ICP.

Question 10 of 20 A client is admitted with a stroke. Which tool does the nurse use to facilitate a focused neurologic assessment of the client? A. Intracranial pressure monitor B. Mini-Mental State Examination (MMSE) C. National Institutes of Health Stroke Scale (NIHSS) D. Glasgow Coma Score (GCS)

C. National Institutes of Health Stroke Scale (NIHSS) The nurse uses the NIHSS tool to perform a focused neurologic assessment. Primary health care providers and nurses at designated stroke centers use a specialized stroke scale such as the NIHSS to assess clients.The Glasgow Coma Score (GCS) provides a nonspecific indication of level of consciousness. An intracranial pressure monitor would be requested by the health care specialist if signs and symptoms indicated increased intracranial pressure. The MMSE is used primarily to differentiate among dementia, psychosis, and affective disorders.

To prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the primary health care team is a nursing priority? A. Nutritional therapy B. Physical therapy C. Respiratory therapy D. Occupational therapy

C. Respiratory therapy To help prevent death for a client with spinal cord injury, collaboration with the respiratory therapy team is a priority. A client with a cervical spinal cord injury is at risk for breathing problems including pneumonia and aspiration, resulting from the interruption of spinal innervation to the respiratory muscles. Collaboration with respiratory therapy is crucial. Collaboration with nutritional therapy, occupational therapy, and physical therapy does not help prevent the leading cause of death in clients with spinal cord injury.

A client receiving propranolol as preventive therapy for migraine headaches is experiencing side effects after taking the drug. Which side effect is of greatest concern to the nurse? A. Warm sensation B. Tingling feelings C. Slow heart rate D. Dry mouth

C. Slow heart rate The side effect that is the greatest concern for a client taking propranolol for migraine headaches is a slow heart rate. Beta blockers such as propranolol may be prescribed as a preventive medication for migraines. Propranolol causes blood vessels to relax and improves blood flow although the exact mechanism of action in migraines is unclear. The client would be taught how to monitor his or her heart rate and appropriately report any deviations to the primary care provider.Dry mouth is typically associated with tricyclic antidepressants such as nortriptyline. Skin flushing, tingling feelings, and a warm sensation are common side effects with triptan medications and are not indications to avoid using this group of drugs. Nortriptyline may be used as a preventive medication. Triptans are utilized as abortive medications after a migraine begins.

Question 8 of 18 A family member of a client with a recent spinal cord injury asks the nurse, "Can you please tell me what the real prognosis for recovery is? I don't feel like I'm getting a straight answer." What would be the appropriate response for the nurse? A. "Only time will tell, but hopefully the client will be able to care for yourself." B. "Every injury is different, and it is too soon to have any real answers right now." C. "The Health Insurance Portability and Accountability Act requires that I obtain the client's permission first." D. "Please request a meeting with the primary health care provider. I can help set that up."

D. "Please request a meeting with the primary health care provider. I can help set that up." Questions concerning prognosis and potential for recovery would be referred to the primary health care provider. The nurse can help facilitate the meeting, however.The timing and extent of recovery are different for each client, but it is not the nurse's role to inform the client and family members of the client's prognosis. Telling the family that "only time will tell" is too vague and minimizes the family's concern. The client was informed of Health Insurance Portability and Accountability Act (HIPAA) rights on admission or when consciousness was established, so permission has already been granted by the client.

A client visits the clinic with a migraine and is lying in a darkened room with a wet cloth on the head after receiving treatment. What action would the nurse take next? A. Turn on the lights for a neurologic assessment. B. Assess the client's vital signs. C. Remove the cloth because it can harbor microorganisms. D. Allow the client to remain undisturbed.

D. Allow the client to remain undisturbed. The next action by the nurse is to allow the client to remain undisturbed. The client may be able to alleviate pain by lying down in a darkened room with a cool cloth on his or her forehead. If the client falls asleep, he or she would remain undisturbed until awakening. Assessing the client's vital signs, although important, will disturb the client unnecessarily. A cool cloth is helpful for the client with a migraine and does not present enough of a risk that it would be removed. Turning on the lights for a neurologic assessment is not appropriate because light can cause the migraine to worsen.

A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client? A. Strict monitoring of hourly intake and output B. Decreasing environmental stimuli C. Managing pain through drug and nondrug methods D. Assessing neurologic status at least every 2 to 4 hours

D. Assessing neurologic status at least every 2 to 4 hours The highest priority nursing intervention for the newly admitted client with bacterial meningitis is to accurately monitor and record the client's neurologic status every 2 to 4 hours. The neurologic status, vital signs, and vascular status must be assessed at least every 4 hours or more often, if clinically indicated, to rapidly determine any deterioration in status.Decreasing environmental stimuli is helpful for the client with bacterial meningitis but is not the highest priority. Clients with bacterial meningitis report severe headaches requiring pain management which may be accomplished through both pharmacologic and nonpharmacologic methods. Assessing fluid balance while preventing overload is not the highest priority; however, intake and output must be monitored.

A client is admitted into the emergency department (ED) with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What health problem does the nurse suspect may be occurring? A. West Nile virus B. Stroke C. Meningitis D. Classic migraine

D. Classic migraine The nurse suspects that a classic migraine could be present when an ED client complains of frontal-temporal pain preceded by a visual disturbance. These symptoms are most typical of a classic migraine.Meningitis may present with a headache and visual disturbance but is usually accompanied by nuchal rigidity (neck stiffness) and fever. The symptoms of stroke will vary depending upon the area affected. Mild cases of West Nile virus may be asymptomatic or present with flulike symptoms, whereas severe cases may lead to loss of consciousness and death.

Question 8 of 20 A client recovering from a stroke reports double vision that is preventing the client from effectively completing activities of daily living. How would the nurse help the client compensate? A. Approach the client on the affected side. B. Place objects in the client's field of vision. C. Encourage turning the head from side to side. D. Cover the affected eye, if possible.

D. Cover the affected eye, if possible. The nurse helps the stroke client compensate with double vision by covering the affected eye. Covering the client's affected eye with a patch may help reduce diplopia.The client who is recovering from a stroke would always be approached on the unaffected side. The nurse may encourage side-to-side head turning for clients with hemianopsia (blindness in half of the visual field). Objects would be placed in the field of vision for the client with a decreased visual field.

The nurse is caring for a client who is diagnosed with bacterial meningitis. Which assessment finding would be an immediate concern for the nurse? A. Severe unrelenting headaches B. Photophobia during the day C. Periodic nystagmus D. Decreased level of consciousness

D. Decreased level of consciousness. Unlike the other assessment findings, decreased level of consciousness is life threatening and would be of greatest concern to the nurse.

A client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What would the nurse do first? A. Administer phenytoin. B. Draw the client's blood. C. Start an intravenous (IV) line. D. Establish an airway.

D. Establish an airway.. When a client admitted with cerebral edema begins to have a seizure, the nurse must first establish an airway. The primary goal is to open and maintain an airway and then assess the client for the need of additional support during the seizure.Phenytoin is administered to prevent the recurrence of seizures, not to treat a seizure already underway. Drawing blood or starting an IV is not the priority in this situation. Remember the ABCs during an emergency situation.

Question 5 of 20 A client has been admitted with a diagnosis of stroke. The nurse suspects that the client has had a right hemisphere stroke because the client exhibits which symptoms? A. Quick to anger and frustration B. Inability to discriminate words C. Aphasia and cautiousness D. Impulsiveness and smiling

D. Impulsiveness and smiling Impulsiveness and smiling are signs and symptoms indicative of a right hemisphere stroke.Aphasia, cautiousness, the inability to discriminate words, quick to anger, and frustration are signs and symptoms indicative of a left hemisphere stroke.