Neuro ATI
A nurse is preparing an older adult client who had a TIA for discharge nurse should teach the patient to monitor which of the following parameters at home
Blood pressure a temporary disturbance of the blood supply to the brain causes a TIA which is a brief alteration in neurological function the most common cause are atherosclerotic plaque in the carotid arteries and hypertension therefore the client should track his BP regularly to prevent hypertension management and reduce the risk of another TIA or CVA
A nurse in the ER has assess a patient's airway breathing and circulation following a head injury from a fall at work which of the following actions is priority for the nurse to perform next
Immobilize the patient's cervical spine the greatest risk to the patient is an injury from a cervical spine dislocation and spinal cord compression following a traumatic head injury therefore the priority action the nurse should take after assessing the clients ABC is immobilizing the patient's neck with a cervical collar a patient who has head trauma may also have damage to the cervical spine this is an essential component of the initial stabilization of a patient who has a head injury
A nurse is assessing a patient who recently experienced ahead injury which of the following findings should the nurse identify as an indication of short term memory impairment
Inability to locate eyeglasses short-term memory loss is manifest by inability to recall events or actions that just occurred such as where a patient recently placed her glasses
A nurse is assessing a patient who has ICP and has received intravenous mannitol which of the following findings indicates a therapeutic effect of this medication
Increased urine output Mannitol is an osmotic diuretic used to reduce intracranial pressure by mobilizing intercranial fluid and inhibiting the reabsorption of water and electrolytes in the kidneys increased urine output and decrease ICP are the therapeutic effects of this medication
A nurse in acute care facility is preparing to admit a patient with myasthenia gravis which of the following supplies should the nurse place at the patient's bedside
Oral nasal suction equipment a patient who has MG is at risk of aspiration due to progressive weakness of the originalpharyngeal muscles MG causes muscle weakness due to auto immune disease that affects the Acetylcholine receptors the nurse supply place oxygen and oral nasal suction equipment at the bedside in the event of aspiration or respiratory distress
A nurse is providing discharge teaching to a family of a client who has a new diagnosis of seizure disorder the nurse should instruct the patient's family to take which of the following actions first in the event of a seizure
Protect the patients head the nurse should apply the safety and risk reduction priority setting framework the client is at greatest risk for injury from hitting his head therefore the first action is to protect clients head from injury
During a neurological assessment the nurse asked patient how they arrived at the appointment and with whom which of the following types of memory is the nurse testing
Recall to test recall a recent memory the nurse should ask the patient to provide details about how he arrived at appointment and with who also asked the patient name any healthcare providers he saw in the last few days
A nurse is assessing a patient who is postop following a craniotomy and has a urine output of 600 ML per hour the nurse suspects the client has manifestations of diabetes insipidus which of the following laboratory values should the nurse plan to use to assess for DIA
Specific gravity diabetes insipidus is caused by damage to the hypothalamus or pituitary gland as a result of cranial surgery and infection or tumor in this condition and an inadequate amount of anti-diuretic hormone is released and results and polyuria a low specific gravity 1.001 to 1.003 is a manifestation of diabetes insipidus
A nurse is caring for a patient who has a cerebral lesion and develops hyperthermia which of the following areas of the brain is affected
The hypothalamus the nurse should identify that the hypothalamus located below the cerebrum of the brain is responsible for the regulation of body temperature
A nurse is caring for a patient who is recovering from a stroke which of the following assessments is the nurses priority
The patient's ability to clear oral secretions the first action the patient or the nurse should take when using the ABC approach is to check the patient's ability to clear secretions in order to protect the airway and reduce the risk of aspiration
A nurse is providing teaching to a patient who has a history of tonic clonic seizures and is scheduled for a standard EEG which of the following instruction should the nurse include in the teaching
Thoroughly shampoo her hair prior to the EEG the nurse should instruct the patient to thoroughly wash her hair prior to the EEG because hairsprays oils and other hair preparations interfere with the recording results of the EEG
A nurse is providing teaching to a patient who has a new diagnosis of multiple sclerosis patient asked the nurse about the usual course of MS which of the following responses should the nurse make
Acute episodes are usually followed by remissions which can vary in duration
A nurse is teaching a patient who has a new diagnosis of simple partial seizures about auras which of the following statements by the patient indicates an understanding of the teaching
An aura is a sensory warning that a seizure is eminent the aura could be similar to a hallucination and involve any of the senses the patient can report hearing bells seeing lights or smelling in odor
A nurse is assessing a client who is unconscious the client has a rhythmic breathing pattern of rapid deep respirations followed by rapid shallow respirations alternating with periods of apnea the nurse should document that the client is experiencing which of the following type of respirations
Cheyenne stokes respirations is a breathing pattern of deep to shallow breaths followed by a period of apnea Cheyne-Stokes respirations can be the result of drug overdose or increased intercranial pressure and can proceed death
A nurse is preparing a patient who has a brain tumor for a CT scan which of the following factors affect the manner in which the nurse will prepare the patient for the scan
Development of hives when eating shrimp an allergy to shellfish is a contra indication for the use of contrast media during a CT scan the nurse should inform the MD and explain to the client that this factor might alter how the technician performs the CT scan
A nurse is assessing a patient who has a head injury with possible skull fracture which of the following findings should the nurse identify as an indication that the client might have a complication involving the eighth cranial nerve
Dizziness and hearing loss this reflects alterations in the vestibular cochlear area which cranial nerve eight innervates
A nurse is performing a neurological assessment for a patient who has a brain tumor which of the following findings should indicate cranial nerve involvement
Dysphasia dysphasia difficulty swallowing can occur as a result to cranial damage to cranial nerves 9 glossopharyngeal or 10 Vegas
A nurse is caring for a patient during the first 72 hours following a CVA which of the following actions should the nurse take
Elevate the head of the bed 25 to 30° with the client in a neutral midline position elevating the bed with the clients in a neutral position helps to prevent an increase in intercranial pressure increased intercranial pressure is a major risk factor for complications within the first 72 hours following the onset of a CVA
A nurse is caring for a patient who has expressive aphasia following a stroke The nurse should identify that the stroke affected which of the following lobes of the patient's brain
Frontal the nurse should identify that the posterior portion of the frontal lobe is responsible for the verbal expression of thoughts
A nurse is assessing a patient who is admitted to a facility for observation following a closed head injury which of the following is priority assessment the nurse should be performed to determine a change in the patient's neurological status
Level of consciousness when applying the urgent versus non-urgent priority setting framework the nurse should consider urgent needs to be the priority because they pose more risk the priority assessment is level consciousness a change in the patient's level of consciousness can be the first indication of a change in neurologic status
A nurse is caring for a patient who has impairment of cranial nerve to which of the following actions should the nurse perform to promote the patient safety
Provide an obstacle free path for ambulation although providing an obstacle for your path is a safety precaution for all patients it is especially important for this patient, as cranial nerve two is the optic nerve therefore the patient has at least some visual challenges and will need obstacle free path for ambulation
An ER nurse is assessing a patient who has a Trumatic brain injury the nurse observes extension of the clients arms and legs pronation of the arms and plantar flexion of the feet which of the following is the nurses priority
Provide supplemental oxygen the first act action the nurse should take when using the ABC method is to provide supplemental oxygenation the client might require an artificial airway and mechanical ventilation because these findings indicate decerebrate positioning which is associated with brain stem injury and can lead to brain herniation and death
A nurse is caring for a patient who has a left intercranial hemorrhage from a stroke which of the following findings should the nurse expect
Right sided hemiplegia
A nurse is caring for a patient who has a close TBI and is experiencing increased intercranial pressure does increase in ICP is due to which of the following
Rigid skull containing cranial content the nurse should identify that the patient's rigid skull prevents expansion and increase in edema and bleeding from the brain injury against the rigid skull results in an increase in ICP
A nurse is providing teaching to a patient who has a new diagnosis of MG which of the following pieces of information should the nurse include
Set an alarm to ensure medication doses are taken at on time the nurse should instruct the patient to take med dosage on time to maintain a therapeutic blood level dosages should not be missed or postponed because this can cause an exasperation of the disease
A nurse is providing teaching to a patient who is scheduled for an EEG in the morning which of the following pieces of information should the nurse share
Shampoo your hair before the procedure and don't use any styling products an EEG is a painless test that records electrical activity of the brain for the test the technician attaches electrodes to the scalp to record tiny electrical changes released by nerve cells in the brain for the electrodes to adhere to the scalp patients the hair has to be clean and free of oil and hair care products
A nurse is reviewing the medical history of a patient who is scheduled for MRI examination of the cervical vertebra which of the following pieces of information in the clients history is contra indicated to this procedure
The patient has a pacemaker an MRI use a strong magnets and radio waves that are evaluated using computer analogy to view a three dimensional image of the body since an MRI is magnetically generated it is not indicated for use in the presence of certain medical implants patients who have cerebral aneurysm clips cardiac pacemaker or internal defibrillator's cannot undergo an MRI because of the strong magnetic force can interfere with these devices and obscure surrounding anatomical structures
A nurse is caring for a patient who has a TBI and assumes a decerebrate posturing in response to noxious stimuli which of the following reaction should the nurse anticipate when drawing a blood sample
The patient rigidly extends his arms A client who exhibits a decerebrate posturing rigidly extends and pronates the four extremities and externally rotates the wrists Decerebrate posturing indicates a severe brain stem injury and late neurological decline
A nurse is assessing a patient with a closed head injury who just received mannitol for manifestations of ICP which of the following findings indicate that the medication is having a therapeutic affect
The patient's serum osmolarity is 310 MOSM/L Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue a serum osmolarity of 310 is desired a decrease in cerebral edema should result in a decrease and ICP
A nurse is providing teaching to a family of a patient who is neural newly diagnosed with ALS which of the following findings is an early manifestation of ALS
Weakness of the distal extremities ALS is a progressive neurodegenerative disease that involves motor nerve cells in the brain and spinal cord causing muscle wasting spasticity and eventually paralysis early manifestations of ALS include increasing muscle weakness especially involving the distal arms and legs hands and feet speech swallowing and breathing
A nurse is assessing a patient who is younger a syndrome what findings should the nurse expect
Weakness of the lower extremities it is an acute inflammatory demyelinating poly neuropathy, an inflammatory disorder of the peripheral nerves and it is characterized by rapid onset of ascending weakness and paralysis starting at the LEs and can advance to the upper extremities
A nurse is providing teaching to a class about TIAs which of the following pieces of information should the nurse include in the teaching
A TIA can proceed in ischemic stroke TIAs are considered a manifestation of advanced atherosclerotic disease and can often perceived an ischemic stroke manifestations include loss of vision in an eye inability to speak transient hemiparesis vertigo diploplia numbness and weakness
A nurse in the ER is caring for a group of patients who have a odor of alcohol on their breath and multiple injuries to the head and other extremities which of the following patients should the nurse assess first
A patient who is difficult to arouse and is unable to respond to questions the nurse should apply the safety risk reduction priority setting framework this framework assigns priority to the factor or situation posing the greatest safety risk to the patient when there are several risks to patient safety the risk posing the greatest threat is the highest priority the nurse should then use Maslow's hierarchy of needs the ABC priority setting framework and or knowledge to identify which poses the greatest threat to the patient a patient who is difficult to arouse and is unable to respond to questions could have a decreased level of consciousness due to an alcohol intoxication level of 401 to 800 mg/dL or TBI the greatest risk to this patient is the neurological sequelae of head trauma or death due to severe alcohol intoxication
A nurse is assessing a patient who has a high thoracic spinal cord injury the nurse should identify which of the following findings and I as a manifestation of autonomic dysreflexia
A report of a headache It is a neurological emergency that can occur in a patient that has a cervical or thoracic spinal cord injury above the level of T6 It can be triggered by a full bladder or distended rectum manifestations include a severe throbbing headache flushing of the face and neck bradycardia and extreme hypertension
A nurse is assessing a patient who sustained a recent head injury which of the following findings should the nurse recognize as a manifestation of increased intercranial pressure
A widened pulse pressure A widening of the pulse pressure which is the difference between systolic and diastolic pressure is a manifestation of increased intercranial pressure other manifestations include pupil changes change in level of consciousness and nausea and vomiting
A nurse is preparing a patient for an EEG when the patient asked the nurse what this test does which of response should the nurse provide
An EEG records electrical activity of your brain cells it measures brain waves via multiple electrodes the technician will apply to the scalp an EEG provides information the provider can use to identify various problems including seizure disorders sleep disorders inflammation bleeding and migraine headaches
A nurse is caring for a patient who has received sedation when the nurse supplies nailbed pressure the client withdraws his hand the nurse should document this response is indicating which of the following
Arousal the patient should document of the patient is demonstrating some degree of arousal withdrawing the hand in response to nailbed pressure indicates responsiveness to sensory stimulation
A nurse is triaging patients throwing a mass casualty event which of the following labels should the nurse assigned to a patient who has a head injury with fixed dilated pupils
Black tag the nurse assign a black tag or a class 4 label to patients who are not expected to live and will be allowed to die naturally dilated pupils that are fixed or non-reactive to life are a poor prognostic sign and indicate severely increased ICP in a mass casualty situation the overall goal is to provide life-saving treatment to the greatest number of people possible
A nurse asked the patient to stand with her feet together in her eyes open after a few seconds the nurse asked the patient to close her eyes if the client begins to fall the nurse should interpret this finding as a positive Rhomberg test indicating which of the following alterations
Cerebellar dysfunction this causes a loss of position sense- proprioception which results in a positive Romberg sign
A nurse response to call from my sister personnel that a patient just had a seizure and is unconscious which of the following assessments is the nurses priority
Check airway patency the nurse should apply the ABC priority setting framework an alteration in any of the ABC's areas can indicate a threat to life it is the nurses priority concern when applying ABC framework airway is the highest priority because it must be clear for oxygen exchange to occur the priority assessment the nurse should make is to check the patient's airway patency the nurse should establish and maintain the airway to prevent respiratory arrest and hypoxia
A nurse in the ER is assessing a patient who sustained a fall off of a roof which of the following findings should the nurse ID as indication of a basilar skull fracture
Clear fluid coming from the nares or ears cerebral spinal fluid manifest as a clear fluid coming from the nares or ears indicating a Basilar skull fracture
A nurse in a rehab center is performing an assessment for a patient who is recovering from a left hemisphere stroke which of the following findings should the nurse expect
Difficulty with speech the left hemisphere of the brain is usually dominant side and responsible for language this is always true for right handed clients and the majority of left-handed clients since this client is recovering from the left hemisphere stroke the nurse should anticipate the patient will have aphasia and require speech therapy to establish communication
A nurse is caring for a patient who has experienced a traumatic brain injury which of the following findings indicate the patient is experiencing increased intracranial pressure
Dilated pupils this can indicate that intracranial pressure is increasing this findings should be reported to the provider immediately
A nurse is pet caring for a patient with a CVA the patient appears alert and engaged during a visit but does not respond verbally to questions the nurse should document this as which of the following alterations
Expressive aphasia A patient who has expressive aphasia understand speech but has difficulty speaking and writing this usually occurs because of a lesion at brocas area of the frontal lobe
A nurse is preparing to test the function of cranial nerve 10 which of the following assessment procedures should the nurse use
Have the patient open his mouth and say ahh the Vagus or 10th nerve has both sensory and motor functions to test the motor function the nurse should have the patient open his mouth and say ahh the palate and uvula should move upward in response the nurse should also assess the patient's voice quality for hoarseness
A nurse named three objects for a client remember asks the patient to repeat them and then tells the patient that he will repeat them again in a few minutes after five minutes the nurse asked the patient to name the objects the nurse is using the strategy to test which type of memory
Immediate the nurse test the clients immediate or new memory by following the three object protocol a client without cognitive decline should be able to recall and name the three objects five minutes later
A nurse is planning for a client following a stroke which of the following intervention should the nurse ID as the priority in the patient's plan of care
Monitor the patient for increased ICP the greatest risk to the patient is an injury from increased ICP which can result in decreased cerebral perfusion and neurological injury therefore the priority intervention the nurse should include in the plan of care is monitoring the patient for increased ICP manifestations of increased ICP include a decreased level of consciousness and a change in pupils
A nurse is providing discharge teaching to a patient who has had a TIA which of the following instructions should the nurse include
Reduce dietary sodium a temporary disturbance of blood supply to the brain causes a TIA which are brief alterations in the neurological function the most common cause or atherosclerotic plaque in the carotid arteries in hypertension therefore the patient should limit sodium intake to help control hypertension and prevent future TIAs
During a neurological assessment a nurse asked the patients name all of his children their ages and the birthdates which of the following types of memory is the nurse testing
Remote the nurse tests remote or long-term memory by asking a question such as where and when the client was born his age when he graduated high school the names ages and birthdates of his children the nurse can later verify this information with patient's family or friends
A nurse is caring for a patient who has had a brain stem injury which of the following functions to the nurse monitor
Respiratory effort the nurse should monitor the respiratory effort of a client who has had a brain stem injury the medulla in the brain stem controls the respiratory center
A nurse is caring for a patient who is post op following a frontal craniotomy the nurse should place the patient in which position
Semi Fowler's to prevent increased intercranial pressure the nurses position the client with his head midline head of the bed elevated 30° this positioning permits blood flow to the clients brain while allowing venous drainage thereby decreasing the postop risk of increased intercranial pressure
A nurse is caring for a patient who begins to have generalized tonic clonic seizure while lying in bed which of the following actions should the nurse take
Turn the patient onto a side the nurse should turn the patient onto a side to protect the patient from aspiration
A nurse is teaching a patient about a CT scan of the brain which of the following teaching points should the nurse include
You'll have to lie very still on a long narrow table during the test the nurse should inform the patient that the test will require the clients to lie still on a long narrow table movement during the test interferes with the quality of the films
A nurse is caring for a patient who is experiencing autonomic dysreflexia due to a C5 spinal cord injury after checking the patient's vital signs which of the following actions should the nurse perform next
place the patient in a high Fowlers position according to the evidence-based practice the nurse should first place the patient in high Fowlers position to decrease the clients blood pressure and reduce the risk of end organ damage from the sudden blood pressure rise
