Nclex- neuro questions
Listen to breath sounds. Because compromise of respiration is a leading cause of death in cervical cord injury, respiratory assessment is the highest priority. Assessment of temperature and strength can be done after adequate oxygenation is ensured. Because dyskinesias occur in cerebellar disorders, this is not as important a concern as in cord-injured clients unless head injury is suspected.
A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action? Take the temperature. Listen to breath sounds. Observe for dyskinesias. Assess extremity muscle strength.
It will cause vasodilation of blood vessels in the brain. CO2 is one of the metabolic end products that can alter the tone of the blood vessels in the brain. High CO2 levels cause vasodilation, which may cause headache, whereas low CO2 levels cause vasoconstriction, which may cause lightheadedness. The statements included in the other options are incorrect effects.
A client has a high level of carbon dioxide (CO2) in the bloodstream, as measured by arterial blood gases. The nurse anticipates that which underlying pathophysiology can occur as a result of this elevated CO2? It will cause arteriovenous shunting. It will cause vasodilation of blood vessels in the brain. It will cause blood vessels in the circle of Willis to collapse. It will cause hyperresponsiveness of blood vessels in the brain.
Fluid separates into concentric rings and tests positive for glucose. Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.
A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? Fluid is clear and tests negative for glucose. Fluid is grossly bloody in appearance and has a pH of 6. Fluid clumps together on the dressing and has a pH of 7. Fluid separates into concentric rings and tests positive for glucose.
A hearing aid The cochlear division of cranial nerve VIII is responsible for hearing. Clients with hearing difficulty may benefit from the use of a hearing aid. The vestibular portion of this nerve controls equilibrium; difficulty with balance caused by dysfunction of this division could be addressed with use of a walker. Eyeglasses would correct visual problems (cranial nerve II); a bath thermometer would be of use to clients with sensory deficits of peripheral nerves, such as with diabetic neuropathy.
A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item? A walker Eyeglasses A hearing aid A bath thermometer
Vision The occipital lobe is responsible for reception of vision and contains visual association areas. This area of the brain helps the individual to visually recognize and understand the surroundings. The other senses listed are not a function of the occipital lobe.
A client has suffered a head injury affecting the occipital lobe of the brain. What is the focus of the nurse's immediate assessment? Taste Smell Vision Hearing
Problem with understanding language Wernicke's area consists of a small group of cells in the temporal lobe whose function is the understanding of language. Damage to Broca's area is responsible for aphasia. The motor cortex in the precentral gyrus controls voluntary motor activity. The hippocampus is responsible for the storage of memory.
A client has sustained damage to Wernicke's area from a stroke (brain attack). On assessment of the client, which sign or symptom would be noted? Difficulty speaking Problem with understanding language Difficulty controlling voluntary motor activity Problem with articulating events from the remote past
Sympathetic nervous system The sympathetic nervous system is responsible for the so-called fight or flight response, which is characterized by dilated pupils, increases in heart rate and cardiac output, and increases in respiratory rate and blood pressure. The sympathetic nervous system response affects some type of change in most systems of the body. The responses stated in the other options do not produce these effects.
A client is anxious about an upcoming diagnostic procedure. The client's pupils are dilated, and the respiratory rate, heart rate, and blood pressure are increased from baseline. The nurse determines that the client's clinical manifestations are due to what type of physiologic response? Vagal Peripheral nervous system Sympathetic nervous system Parasympathetic nervous system
Exhaling during repositioning Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.
A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? Blowing the nose Isometric exercises Coughing vigorously Exhaling during repositioning
Autonomic dysreflexia (hyperreflexia) Autonomic dysreflexia (hyperreflexia) results from sudden strong discharge of the sympathetic nervous system in response to a noxious stimulus. Signs and symptoms include pounding headache, nausea, nasal stuffiness, flushed skin, piloerection, and diaphoresis. Severe hypertension can occur, with a systolic BP rising potentially as high as 300 mm Hg. It often is triggered by thermal or mechanical events such as a kinking of catheter tubing, constipation, urinary tract infection, or any variety of cutaneous stimuli. The nurse must recognize this situation immediately and take corrective action to remove the stimulus. If untreated, this medical emergency could result in stroke, status epilepticus, or possibly death.
A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What should the nurse immediately suspect? Return of spinal shock Malignant hypertension Impending brain attack (stroke) Autonomic dysreflexia (hyperreflexia)
Vagus (CN X) The vagus nerve is responsible for sensations in the thoracic and abdominal viscera. It also is responsible for the decrease in heart rate because approximately 75% of all parasympathetic stimulation is carried by the vagus nerve. CN XII is responsible for tongue movement. CN XI is responsible for neck and shoulder movement. CN IX is responsible for taste in the posterior two thirds of the tongue, pharyngeal sensation, and swallowing.
A client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the range of 50 to 56 beats/minute. The client also is complaining of nausea. On the basis of these findings, the nurse determines that the client is experiencing parasympathetic stimulation of which cranial nerve? Vagus (CN X) Hypoglossal (CN XII) Spinal accessory (CN XI) Glossopharyngeal (CN IX)
Altered breathing pattern Altered breathing pattern indicates that the respiratory rate, depth, rhythm, timing, or chest wall movements are insufficient for optimal ventilation of the client. This is a risk for clients with spinal cord injury in the lower cervical area. Ineffective oxygen consumption occurs when oxygenation or carbon dioxide elimination is altered at the alveolar-capillary membrane. Increased susceptibility to aspiration and increased likelihood of injury are unrelated to the subject of the question.
A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem? Altered breathing pattern Increased likelihood of injury Ineffective oxygen consumption Increased susceptibility to aspiration
Keeping the linens wrinkle-free under the client Preventing unnecessary pressure on the lower limbs Turning and repositioning the client at least every 2 hours The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and urinary catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement once a week is much too infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. Keeping the linens wrinkle-free under the client Preventing unnecessary pressure on the lower limbs Limiting bladder catheterization to once every 12 hours Turning and repositioning the client at least every 2 hours Ensuring that the client has a bowel movement at least once a week
Parietal The ability to distinguish an object by touch is called stereognosis, which is a function of the right parietal area. The parietal lobe of the brain is responsible for spatial orientation and awareness of sizes and shapes. The left parietal area is responsible for mathematics and right-left orientation. The other lobes of the brain are not responsible for this function.
A client with a traumatic brain injury is able, with eyes closed, to identify a set of keys placed in his or her hands. On the basis of this assessment finding, the nurse determines that there is appropriate function of which lobe of the brain? Frontal Parietal Occipital Temporal
PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 35 to 38 mm Hg (35 to 38 mm Hg) The goal is to maintain the partial pressure of arterial carbon dioxide (PaCo2) at 35 to 38 mm Hg (35 to 38 mm Hg). Carbon dioxide is a very potent vasodilator that can contribute to increases in ICP. The PaO2 is not allowed to fall below 80 mm Hg (80 mm Hg), to prevent cerebral vasodilation from hypoxemia, which can also result in an increase in ICP. Therefore, the remaining options are incorrect.
A client with a traumatic brain injury is on mechanical ventilation. The nurse promotes normal intracranial pressure (ICP) by ensuring that the client's arterial blood gas (ABG) results are within which ranges? PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCo2 25 to 30 mm Hg (25 to 30 mm Hg) PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCo2 30 to 35 mm Hg (30 to 35 mm Hg) PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 25 to 30 mm Hg (25 to 30 mm Hg) PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 35 to 38 mm Hg (35 to 38 mm Hg)
Call the health care provider (HCP). The important nursing action is to call the HCP. The deterioration in neurological status, decreasing pulse, and increasing blood pressure with a widening pulse pressure all indicate that the client is experiencing increased intracranial pressure, which requires immediate treatment to prevent further complications and possible death. The nurse should retake the vital signs and reorient the client to surroundings. If the client's blood pressure falls within parameters for PRN antihypertensive medication, the medication also should be administered. However, options 1, 2, and 4 are secondary nursing actions.
At 8:00 a.m., A client who has had a stroke (brain attack) was awake and alert with vital signs of temperature 98°F (37.2°C) orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure 138/80 mm Hg. At noon, the client is confused and only responsive to tactile stimuli, and vital signs are temperature 99°F (36.7°C) orally, pulse 62 beats/min, respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse should take which action? Reorient the client. Retake the vital signs. Call the health care provider (HCP). Administer an antihypertensive PRN (as needed).
Using a RotoRest bed Ensuring that weights hang freely Assessing the integrity of the weights and pulleys Comparing the amount of prescribed traction with the amount in use Cervical tongs are applied after drilling holes in the client's skull under local anesthesia. Weights are attached to the tongs, which exert pulling pressure on the longitudinal axis of the cervical spine. Serial x-rays of the cervical spine are taken, with weights being added gradually until the x-ray reveals that the vertebral column is realigned. After that, weights may be reduced gradually to a point that maintains alignment. The client with cervical tongs is placed on a Stryker frame or RotoRest bed. The nurse ensures that weights hang freely and the amount of weight matches the current prescription. The nurse also inspects the integrity and position of the ropes and pulleys. The nurse does not remove the weights to administer care.
The client with a cervical spine injury has cervical tongs applied in the emergency department. What should the nurse include when planning care for this client? Select all that apply. Using a RotoRest bed Ensuring that weights hang freely Removing the weights to reposition the client Assessing the integrity of the weights and pulleys Comparing the amount of prescribed traction with the amount in use
Leaving the client in an unchilled area of the room The most common cause of autonomic dysreflexia is visceral stimuli, such as with blockage of urinary drainage or with constipation. Barring these, other causes include noxious mechanical and thermal stimuli, particularly pressure and overchilling. For this reason, the nurse ensures that the client is positioned with no pinching or pressure on paralyzed body parts and that the client will be sufficiently warm.
The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)? Updating the home safety sheet Leaving the client in an unchilled area of the room Noting a bowel movement on the client progress note Recording the amount of urine obtained with catheterization
Damage to the auditory association areas Auditory association and storage areas are located in the temporal lobe and relate to understanding spoken language. The occipital lobe contains areas related to vision. The frontal lobe controls voluntary muscle activity, including speech, and an impairment can result in expressive aphasia. The parietal lobe contains association areas for concept formation, abstraction, spatial orientation, body and object size and shape, and tactile sensation.
The nurse assesses a client who is diagnosed with a stroke (brain attack). On assessment, the client is unable to understand the nurse's commands. Which condition should the nurse document? Occipital lobe impairment Damage to the auditory association areas Frontal lobe and optic nerve tracts damage Difficulty with concept formation and abstraction areas
"I will drive only during the daytime." The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the use of powder or lotions. The liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client cannot drive at all because the device impairs the range of vision.
The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions? "I will use a straw for drinking." "I will drive only during the daytime." "I will be careful because the device alters balance." "I will wash the skin daily under the lamb's wool liner of the vest."
Keep suction equipment at the bedside. Elevate the head of the bed 30 degrees. Keep the head and neck in good alignment. Administer prescribed respiratory treatments as needed. The nurse maintains a patent airway for the client with difficulty breathing by keeping the head and neck in good alignment and elevating the head of the bed 30 degrees unless contraindicated. Suction equipment is kept at the bedside if secretions need to be cleared. The client should be kept in a side-lying position whenever possible to minimize the risk of aspiration.
The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which activities would be appropriate components of the care plan for this client? Select all that apply. Keep suction equipment at the bedside. Elevate the head of the bed 30 degrees. Keep the client lying in a supine position. Keep the head and neck in good alignment. Administer prescribed respiratory treatments as needed.
"We need to remind him to turn his head to scan the lost visual field." Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.
The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? "We need to discourage him from wearing eyeglasses." "We need to place objects in his impaired field of vision." "We need to approach him from the impaired field of vision." "We need to remind him to turn his head to scan the lost visual field."
Head midline Neck in neutral position Head of bed elevated 30 to 45 degrees Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure from elevating. The head of the client at risk for or with increased intracranial pressure should be positioned so that it is in a neutral, midline position. The head of the bed should be raised to 30 to 45 degrees. The nurse should avoid flexing or extending the client's neck or turning the client's head from side to side.
The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. Head midline Neck in neutral position Head of bed elevated 30 to 45 degrees Head turned to the side when flat in bed Neck and jaw flexed forward when opening the mouth
Liver function studies Divalproex sodium, an anticonvulsant, can cause fatal hepatotoxicity. The nurse should instruct the client about the importance of monitoring the results of liver function studies and ammonia level determinations. The studies in the remaining options are not required with the use of this medication.
The nurse in the health care clinic is providing medication instructions to a client with a seizure disorder who will be taking divalproex sodium. The nurse should instruct the client about the importance of returning to the clinic for monitoring of which laboratory study? Electrolyte panel Liver function studies Renal function studies Blood glucose level determination
Blood pressure Cushing's reflex is a late sign of increased ICP and consists of a widening pulse pressure (systolic pressure rises faster than diastolic pressure) and bradycardia. The remaining options are unrelated to monitoring for Cushing's reflex.
The nurse in the neurological unit is monitoring a client for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by assessing which item? Blood pressure Motor response Pupillary response Level of consciousness
Position the client on his or her side. Brush the teeth with a small, soft toothbrush. Cleanse the mucous membranes with soft sponges. The unconscious client is positioned on the side during mouth care to prevent aspiration. The teeth are brushed at least twice daily with a small toothbrush. The gums, tongue, roof of the mouth, and oral mucous membranes are cleansed with soft sponges to avoid encrustation and infection. The lips are coated with water-soluble lubricant to prevent drying, cracking, and encrustation. The use of products with alcohol and lemon glycerin swabs should be avoided because they have a drying effect.
The nurse is administering mouth care to an unconscious client. The nurse should perform which actions in the care of this person? Select all that apply. Use products that contain alcohol. Position the client on his or her side. Brush the teeth with a small, soft toothbrush. Cleanse the mucous membranes with soft sponges. Use lemon glycerin swabs when performing mouth care.
Postictal status Duration of the seizure Changes in pupil size or eye deviation Seizure progression and type of movements Typically seizure assessment includes the time the seizure began, parts of the body affected, type of movements and progression of the seizure, change in pupil size or eye deviation or nystagmus, client condition during the seizure, and postictal status. Determining what the client ate 2 hours prior to the seizure is not a component of seizure assessment.
The nurse is assessing a client who is experiencing seizure activity. The nurse understands that it is necessary to determine information about which items as part of routine assessment of seizures? Select all that apply Postictal status Duration of the seizure Changes in pupil size or eye deviation Seizure progression and type of movements What the client ate in the 2 hours preceding seizure activity
Ataxic An ataxic gait is characterized by unsteadiness and staggering. A spastic gait is characterized by stiff, short steps with the legs held together, hip and knees flexed, and toes that catch and drag. A festinating gait is best described as walking on the toes with an accelerating pace. A dystrophic or broad-based gait is seen as waddling, with the weight shifting from side to side and the legs far apart.
The nurse is assessing the client's gait and notes it is unsteady and staggering. Which description should the nurse use when documenting the assessment finding? Spastic Ataxic Festinating Dystrophic or broad-based
Nail bed pressure Nail bed pressure tests a basic motor and sensory peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain? Sternal rub Nail bed pressure Pressure on the orbital rim Squeezing of the sternocleidomastoid muscle
The client is aphasic. The client has weakness on the right side of the body. The client has weakness on the right side of the face and tongue. Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. The client is aphasic. The client has weakness on the right side of the body. The client has complete bilateral paralysis of the arms and legs. The client has weakness on the right side of the face and tongue. The client has lost the ability to move the right arm but is able to walk independently. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance.
A cervical cord injury In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll's eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as that for the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem. Contraindications to performing this test include cervical-level spinal cord injuries and severely increased intracranial pressure.
The nurse is assisting the neurologist in performing an assessment on a client who is unconscious after sustaining a head injury. The nurse understands that the neurologist would avoid performing the oculocephalic response (doll's eyes maneuver) if which condition is present in the client? Dilated pupils Lumbar trauma A cervical cord injury Altered level of consciousness
Confusion Early manifestations of increased ICP are subtle and often may be transient, lasting for only a few minutes in some cases. These early clinical manifestations include episodes of confusion, drowsiness, and slight pupillary and breathing changes. Later manifestations include a further decrease in the level of consciousness, a widened pulse pressure, and bradycardia. Cheyne-Stokes respiratory pattern, or a hyperventilation respiratory pattern, and pupillary sluggishness and dilatation appear in the late stages.
The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP? Confusion Bradycardia Sluggish pupils A widened pulse pressure
Loosening restrictive clothing Removing the pillow and raising padded side rails Positioning the client to the side, if possible, with the head flexed forward Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head from injury; and moves furniture that may injure the client.
The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. Loosening restrictive clothing Restraining the client's limbs Removing the pillow and raising padded side rails Positioning the client to the side, if possible, with the head flexed forward Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist
Placing the client on a bed that provides spinal immobilization Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible, the client is placed on a special bed, such as a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board under it should be used. The remaining options are incorrect and potentially harmful interventions.
The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord injury. The nurse minimizes the risk of compounding the injury by performing which action? Keeping the client on a stretcher Logrolling the client onto a soft mattress Logrolling the client onto a firm mattress Placing the client on a bed that provides spinal immobilization
Elevate the head of the bed. Autonomic dysreflexia is a serious complication that can occur in the spinal cord-injured client. Once the syndrome is identified, the nurse elevates the head of the client's bed and then examines the client for the source of noxious stimuli. The nurse also assesses the client's blood pressure, but the initial action would be to elevate the head of the bed. The client would not be placed in the prone position; lying flat will increase the client's blood pressure.
The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action should the nurse take? Elevate the head of the bed. Examine the rectum digitally. Assess the client's blood pressure. Place the client in the prone position.
Is likely to have perceptual and spatial disabilities The client with a right (nondominant) hemispheric stroke may be alert and oriented to time and place. These signs of apparent wellness often suggest that the client is less disabled than is the case. However, impulsivity and confusion in carrying out activities may be very real problems for these clients as a result of perceptual and spatial disabilities. The right hemisphere is considered specialized in sensory-perceptual and visual-spatial processing and awareness of body space. The left hemisphere is dominant for language abilities.
The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric stroke. The nurse notes that the client is alert and oriented to time and place. On the basis of these assessment findings, the nurse should make which interpretation? Had a very mild stroke Most likely suffered a transient ischemic attack May have difficulty with language abilities only Is likely to have perceptual and spatial disabilities
The intracranial pressure reading is normal. The normal intracranial pressure is 5 to 15 mm Hg. A pressure of 8 mm Hg is within normal range.
The nurse is caring for a client with a head injury. The client's intracranial pressure reading is 8 mm Hg. Which condition should the nurse document? The intracranial pressure reading is normal. The intracranial pressure reading is elevated. The intracranial pressure reading is borderline. An intracranial pressure reading of 8 mm Hg is low.
Cannot recall what was eaten for breakfast today Recall of recent events and the storage of memories are controlled by the hippocampus, which is a limbic system structure. The cerebral hemispheres, with specific regional functions, control orientation. The limbic system, overall, is responsible for feelings, affect, and emotions. Calculation ability and knowledge of current events are under the control of the frontal lobes of the cerebrum.
The nurse is caring for a client with a neurological deficit involving the hippocampus. On assessment of the client, which signs and symptoms would most likely be noted? Disoriented to client, place, and time Affect flat, with periods of emotional lability Cannot recall what was eaten for breakfast today Unable to add and subtract; does not know who is president
22 mm Hg Normal ICP readings range from 5 to 15 mm Hg pressure. Pressures greater than 20 mm Hg are considered to represent increased ICP, which seriously impairs cerebral perfusion.
The nurse is caring for a client with an intracranial pressure (ICP) monitoring device. The nurse should become most concerned if the ICP readings drifted to and stayed in the vicinity of which finding? 5 mm Hg 2.8 mm Hg 14 mm Hg 22 mm Hg
Use strict aseptic technique when touching the monitoring system. Because there is a foreign body embedded in the client's brain, vigilant aseptic technique should be implemented. Sims' is a side-lying, flat position. With a client who has increased ICP, the head of the bed should be elevated at least 30 degrees to improve jugular outflow. The drainage tubing should not be routinely changed. It should remain for the duration of the monitoring. To obtain accurate ICP pressure readings, the transducer is zeroed at the level of the foramen of Monro, which is approximated by placing the transducer 1 inch above the level of the ear. Serial ICP readings should be done with the client's head in the same position.
The nurse is caring for a client with intracranial pressure (ICP) monitoring. Which intervention is appropriate to include in the plan of care? Place the client in Sims' position. Change the drainage tubing every 48 hours. Level the transducer at the lowest point of the ear. Use strict aseptic technique when touching the monitoring system.
Hypothalamus Hypothalamic damage causes persistent hyperthermia, which also may be called central fever. It is characterized by a persistent high fever with no diurnal variation. Another characteristic feature is absence of sweating. Hyperthermia would not result from damage to the cerebrum, cerebellum, or hippocampus.
The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs of infection. On the basis of these findings the nurse suspects dysfunction in which area of the brain? Cerebrum Cerebellum Hippocampus Hypothalamus
Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.
The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
The client will exhibit neglect of the affected side. In anosognosia, the client neglects the affected side of the body. The client either may ignore the presence of the affected side (often creating a safety hazard as a result of potential injuries) or may state that the involved arm or leg belongs to someone else. The remaining options are not associated with anosognosia.
The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack). On reviewing the client's record, the nurse notes an assessment finding of anosognosia. The nursing care plan should address which manifestation related to this finding? The client will be easily fatigued. The client will have difficulty speaking. The client will have difficulty swallowing. The client will exhibit neglect of the affected side.
Associated with poor comprehension Global aphasia is a condition in which the affected person has few language skills as a result of extensive damage to the left hemisphere. The speech is nonfluent and is associated with poor comprehension and limited ability to name objects or repeat words. The client with conduction aphasia has difficulty repeating words spoken by another, and speech is characterized by literal paraphasia with intact comprehension. The client with Wernicke's aphasia may exhibit a rambling type of speech.
The nurse is creating a plan of care for a client with a stroke (brain attack) who has global aphasia. The nurse should incorporate communication strategies into the plan of care because of which expected characteristic of the client's speech? Intact Rambling Characterized by literal paraphasia Associated with poor comprehension
Thicken liquids. Assist the client with eating. Assess for the presence of a swallow reflex. Provide ample time for the client to chew and swallow. Liquids are thickened to prevent aspiration. The nurse should assist the client with eating and place food on the unaffected side of the mouth. The nurse should assess for gag and swallowing reflexes before the client with dysphagia is started on a diet. The client should be allowed ample time to chew and swallow to prevent choking.
The nurse is creating a plan of care for a client with dysphagia following a stroke (brain attack). Which should the nurse include in the plan? Select all that apply. Thicken liquids. Assist the client with eating. Assess for the presence of a swallow reflex. Place the food on the affected side of the mouth. Provide ample time for the client to chew and swallow.
Spasms of the entire body The clonic phase of a seizure is characterized by alternating spasms and momentary muscular relaxation of the entire body, accompanied by strenuous hyperventilation. The face is contorted and the eyes roll. Excessive salivation results in frothing from the mouth. The tongue may be bitten, the client sweats profusely, and the pulse is rapid. The clonic jerking subsides by slowing in frequency and losing strength of contractions over a period of 30 seconds. Body stiffening, sudden loss of consciousness, and brief flexion of the extremities are associated with the tonic phase of a seizure.
The nurse is documenting nursing observations in the record of a client who experienced a tonic-clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of the seizure? Body stiffening Spasms of the entire body Sudden loss of consciousness Brief flexion of the extremities
Flaccid paralysis Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.
The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? Hyperreflexia Positive reflexes Flaccid paralysis Reflex emptying of the bladder
Padding the side rails of the bed Placing an airway at the bedside Placing oxygen and suction equipment at the bedside Flushing the intravenous catheter to ensure that the site is patent Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure medications must be administered, and as part of the routine assessment the nurse should be checking patency of the catheter. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.
The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. Padding the side rails of the bed Placing an airway at the bedside Placing the bed in the high position Putting a padded tongue blade at the head of the bed Placing oxygen and suction equipment at the bedside Flushing the intravenous catheter to ensure that the site is patent
Eye movements Eye movements are under the control of cranial nerves III, IV, and VI. Level of consciousness (response to verbal stimuli) is controlled by the reticular activating system and both cerebral hemispheres. Feelings are part of the role of the limbic system and involve both hemispheres. Insight, judgment, and planning are part of the function of the frontal lobe in conjunction with association fibers that connect to other areas of the cerebrum.
The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function will yield the best information about these cranial nerves? Eye movements Response to verbal stimuli Affect, feelings, or emotions Insight, judgment, and planning
"Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?" Cerebral thrombosis (thrombotic stroke) does not occur suddenly. In the few days or hours preceding the thrombotic stroke, the client may experience a transient loss of speech, hemiparesis, or paresthesias on 1 side of the body. Signs and symptoms of this type of stroke vary but may also include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage. The client does not complain of difficulty with night vision as part of this clinical problem. In addition, most clients do not have repeated episodes of loss of consciousness.
The nurse is performing an assessment on a client with a diagnosis of thrombotic stroke (brain attack). Which assessment question would elicit data specific to this type of stroke? "Have you had any headaches in the past few days?" "Have you recently been having difficulty with seeing at nighttime?" "Have you had any sudden episodes of passing out in the past few days?" "Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?"
Ipsilateral paralysis and loss of touch and vibration Brown-Séquard syndrome results from hemisection of the spinal cord, resulting in ipsilateral paralysis and loss of touch, pressure, vibration, and proprioception. Contralaterally, pain and temperature sensation are lost because these fibers decussate after entering the cord. The remaining options are not assessment findings in this syndrome.
The nurse is performing an assessment on a client with the diagnosis of Brown-Séquard syndrome. The nurse would expect to note which assessment finding? Bilateral loss of pain and temperature sensation Ipsilateral paralysis and loss of touch and vibration Contralateral paralysis and loss of touch, pressure, and vibration Complete paraplegia or quadriplegia, depending on the level of injury
Provide physical aspects of care. Prevent pushing or straining activities. Maintain the head of the bed at 15 degrees. Aneurysm precautions include placing the client on bed rest (as prescribed) in a quiet setting. Stimulants such as caffeine and nicotine are prohibited; decaffeinated coffee or tea may be used. Lights are kept dim to minimize environmental stimulation. Any activity that increases the blood pressure or impedes venous return from the brain is prohibited, such as pushing, pulling, sneezing, coughing, or straining. The nurse provides physical care to minimize increases in blood pressure. For the same reason, visitors, radio, television, and reading materials are prohibited or limited.
The nurse is planning to put aneurysm precautions in place for a client with a cerebral aneurysm. Which nursing measures would be implemented? Select all that apply. Provide physical aspects of care. Prevent pushing or straining activities. Limit caffeinated coffee to 1 cup per day. Keeping the lights on in the client's room. Maintain the head of the bed at 15 degrees.
"I need to perform good oral hygiene, including flossing and brushing my teeth." Phenytoin is an anticonvulsant used to treat seizure disorders. The client also should see a dentist at regularly scheduled times because gingival hyperplasia is a side effect of this medication. The client should perform good oral hygiene, including flossing and brushing the teeth. The client should avoid alcohol while taking this medication. The client should also be instructed that follow-up serum blood levels are important and that, on the day of the scheduled laboratory test, the client should avoid taking the medication before the specimen is drawn. The client should not adjust medication dosages.
The nurse is providing instructions to a client who will be taking phenytoin. Which statement, if made by the client, would indicate an understanding of the information about this medication? "I need to perform good oral hygiene, including flossing and brushing my teeth." "I should try to avoid alcohol, but if I'm not able to, I can drink alcohol in moderation." "I should take my medication before coming to the laboratory to have a blood level drawn." "I should monitor for side effects and adjust my medication dose depending on how severe the side effects are."
The client experienced paresthesias a few days before admission to the hospital. Cerebral thrombosis does not occur suddenly. In the few hours or days preceding a thrombotic brain attack (stroke), the client may experience a transient loss of speech, hemiplegia, or paresthesias on 1 side of the body. Signs and symptoms of thrombotic brain attack (stroke) vary but may include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke (brain attack) experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage.
The nurse is reviewing the medical records of a client admitted to the nursing unit with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note that which is documented in the assessment data section of the record? Sudden loss of consciousness occurred. Signs and symptoms occurred suddenly. The client experienced paresthesias a few days before admission to the hospital. The client complained of a severe headache, which was followed by sudden onset of paralysis.
Shift weight every 2 hours while in a wheelchair. To maintain skin integrity, the client should shift weight in the wheelchair every 2 hours and use a pressure relief pad. A pillow is not sufficient to relieve the pressure. While the client is in bed, the bottom sheet should be free of wrinkles and wetness. Sheets should be changed as needed and more frequently than every other week. The client should use a mirror to inspect the skin twice daily (morning and evening) to assess for redness, edema, and breakdown. General additional measures include a nutritious diet and meticulous skin care.
The nurse is teaching a client with paraplegia measures to maintain skin integrity. Which instruction will be most helpful to the client? Shift weight every 2 hours while in a wheelchair. Change bed sheets every other week to maintain cleanliness. Place a pillow on the seat of the wheelchair to provide extra comfort. Use a mirror to inspect for redness and skin breakdown twice a week.
Hypothalamus The hypothalamus is responsible for autonomic nervous system functions, such as heart rate, blood pressure, temperature, and fluid and electrolyte balance (among others). The thalamus acts as a relay station for sensory and motor information. The limbic system is responsible for emotions. The reticular activating system is responsible for the sleep-wake cycle.
The nurse notes that a client who has suffered a brain injury has an adequate heart rate, blood pressure, fluid balance, and body temperature. Based on these clinical findings, the nurse determines that which brain area is functioning properly? Thalamus Hypothalamus Limbic system Reticular activating system
Anterior cerebral artery Internal carotid arteries Posterior cerebral artery The circle of Willis is a ring of blood vessels located at the base of the brain. It is referred to as the anterior circulation to the brain and is composed of the anterior and middle cerebral arteries, posterior cerebral arteries, posterior communicating arteries, internal carotid arteries, and anterior communicating branches. The basilar artery and vertebral artery are not part of the circle of Willis. Rather, they are part of the vertebral-basilar system, which is known as the posterior circulation to the brain. Other parts of the posterior circulation are the posterior inferior cerebellar artery and the spinal arteries.
The nurse overhears a neurologist saying that a client has an aneurysm located in the circle of Willis. The nurse understands that which blood vessels are part of the circle of Willis? Select all that apply. Basilar artery Vertebral artery Anterior cerebral artery Internal carotid arteries Posterior cerebral artery
Dysfunction of trigeminal nerve (cranial nerve V) The motor branch of cranial nerve V is responsible for the ability to chew food. The vagus nerve is active in parasympathetic functions of the autonomic nervous system. The hypoglossal nerve aids in swallowing. The spinal accessory nerve is responsible for shoulder movement, among other things.
Which assessment finding should the nurse expect to note in the client hospitalized with a diagnosis of stroke who has difficulty chewing food? Dysfunction of vagus nerve (cranial nerve X) Dysfunction of trigeminal nerve (cranial nerve V) Dysfunction of hypoglossal nerve (cranial nerve XII) Dysfunction of spinal accessory nerve (cranial nerve XI)
