Neuro NCLEX Study questions
The answer is B. If a patient is in uncontrolled a-fib they are at risk for clot formation within the heart chambers. This clot can leave the heart and travel to the brain. Hence, an ischemic embolism type stroke can occur. An ischemic thrombosis type stroke is where a clot forms within the artery wall of the neck or brain.
GOOD A patient is admitted with uncontrolled atrial fibrillation. The patient's medication history includes vitamin D supplements and calcium. What type of stroke is this patient at MOST risk for? A. Ischemic thrombosis B. Ischemic embolism C. Hemorrhagic D. Ischemic stenosis
B. A patient whose blood pressure is 200/110. D. A patient who received Heparin 24 hours ago. The answers are B and D. Patients who are experiencing signs and symptoms of a hemorrhagic stroke, who have a BP for >185/110, and has received heparin or any other anticoagulants etc. are NOT a candidate for tPA. tPA is only for an ischemic stroke.
GOOD Which patients are NOT a candidate for tissue plasminogen activator (tPA) for the treatment of stroke? A. A patient with a CT scan that is negative. B. A patient whose blood pressure is 200/110. C. A patient who is showing signs and symptoms of ischemic stroke. D. A patient who received Heparin 24 hours ago.
Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? Hemorrhagic skin rash Edema Cyanosis Dyspnea on exertion
Hemorrhagic skin rash- DIC is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the condition.
The answer is C. tPA dissolves the clot causing the blockage in stroke by activating the protein that causes fibrinolysis. It should be given within 3 hours after the onset of stroke symptoms. It can be given 3 to 4.5 hours after onset IF the patient meets strict criteria. It is used for acute ischemia stroke, NOT hemorrhagic!!
In order for tissue plasminogen activator (tPA) to be most effective in the treatment of stroke, it must be administered? A. 6 hours after the onset of stroke symptoms B. 3 hours before the onset of stroke symptoms C. 3 hours after the onset of stroke symptoms D. 12 hours before the onset of stroke symptoms
GOOD A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? Vomiting continues Intracranial pressure (ICP) is increased The client needs mechanical ventilation Blood is anticipated in the cerebralspinal fluid (CSF)
Intracranial pressure (ICP) is increased
GOOD Meningitis occurs as an extension of a variety of bacterial infections due to which of the following conditions? Congenital anatomic abnormality of the meninges Lack of acquired resistance to the various etiologic organisms Occlusion or narrowing of the CSF pathway Natural affinity of the CNS to certain pathogens
Lack of acquired resistance to the various etiologic organisms Septic Meningitis - Bacterial • Streptococcus pneumoniae • Neisseria meningitidis • Peaks Winter & Early Spring • Factors that increase risk • Tobacco Use • Viral upper respiratory infection d/t increase in droplet production Aseptic Meningitis - Viral • Secondary to cancer • Immunosuppressed - HIV • Caused by enterovirus • Occurs Summer and Early Fall PATHOPHYSIOLOGY • Originates in 2 ways • Bloodstream as a consequence of other infections • Direct Spread - Traumatic injury
When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis? Bladder infection Middle ear infection Fractured clavicle Septic arthritis
Middle ear infection
The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure? Side-lying, with legs pulled up and head bent down onto the chest Side-lying, with a pillow under the hip Prone, in a slight Trendelenburg's position Prone, with a pillow under the abdomen.
Side-lying, with legs pulled up and head bent down onto the chest
GOOD A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? To reduce intraocular pressure To prevent acute tubular necrosis To promote osmotic diuresis to decrease ICP To draw water into the vascular system to increase blood pressure
To promote osmotic diuresis to decrease ICP
GOOD A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? Urine output increases Pupils are 8 mm and nonreactive Systolic blood pressure remains at 150 mm Hg BUN and creatinine levels return to normal
Urine output increases
The answer is C. A hemorrhagic stroke occurs when bleeding in the brain happens due to a break in a blood vessel. Risk factors for a hemorrhagic stroke is uncontrolled hypertension, history of brain aneurysm, old age (due to aging blood vessels.) All the other options are at risk for an ischemic type of stroke.
Which patient below is at most risk for a hemorrhagic stroke? A. A 65 year old male patient with carotid stenosis. B. A 89 year old female with atherosclerosis. C. A 88 year old male with uncontrolled hypertension and a history of brain aneurysm repair 2 years ago. D. A 55 year old female with atrial flutter.
The answers are B and D. Options A and C are CORRECT statements about TIAs. However, option B is wrong because TIAs produce signs and symptoms that can last a few minutes to hours and resolve (NOT several weeks to months). Option D is wrong be TIAs do require medical treatment.
You're educating a patient about transient ischemic attacks (TIAs). Select all the options that are incorrect about this condition: A. TIAs are caused by a temporary decrease in blood flow to the brain. B. TIAs produce signs and symptoms that can last for several weeks to months. C. A TIAs is a warning sign that an impending stroke may occur. D. TIAs don't require medical treatment.
The nurse is preparing to discharge a client who is stable following a head injury. Which statement by the client indicates a need for further discharge instructions? a. "I have a leftover prescription at home I can use if I have pain" b. "I will cancel the wine tasting I have planned for this weekend" c. "I will have someone drive me home and will take a couple of days off work" d. "I will have someone stay with me and sure I am okay"
a. "I have a leftover prescription at home I can use if I have pain"
A hospitalized client develops acute hemorrhagic stroke and is transferred to the intensive care unit. Which nursing interventions should be included in the plan of care? Select all that apply. a. Administer PRN stool softeners daily b. Administer scheduled enoxaparin injection c. Implement seizure precautions d. Keep client NPO until swallow screen is performed e. Perform frequent neurological assessments
a. Administer PRN stool softeners daily c. Implement seizure precautions d. Keep client NPO until swallow screen is performed e. Perform frequent neurological assessments Not B. May need to give TPA- and this cant be given if any anticogulats are given
Assessment of a client with a history of stroke reveals that the client understands and follows commands but answers questions with incorrect word choices. The nurse documents the presence of which communication deficit? a. Aphasia b. Apraxia c. Dysarthria d. Dysphagia
a. Aphasia TEAACH SAID DONT WORRY?
A client with massive trauma and possible spinal cord injury is admitted to the emergency department following a dirt bike accident. Which clinical manifestation does the nurse assess to help best confirm a diagnosis of neurogenic shock? a. Apical heart rate 48/min b. Blood pressure 186/92 mm Hg c. Cool, clammy skin d. Temperature 100 F (37.7 C) tympanic
a. Apical heart rate 48/min
A client with blunt head injury is admitted for observation, including hourly neurologic checks. At 01:00 AM, the client reports a headache; the nurse obtains a normal neurologic assessment and administers the PRN acetaminophen. At 02:00 AM, the client appears to be sleeping. Which action should the nurse take? a. Arouse the client and ask what the current month is b. Document "relief apparently obtained" and recheck at 03:00 AM c. Let the client sleep but verify respiratory rate d. Wake the client up and check for paresthesia
a. Arouse the client and ask what the current month is Part of ICP check ups is neuro checks every hour to access compensation vs decompensation
The nurse is caring for a client who had a stroke 2 weeks ago and has moderate receptive aphasia. The nurse is trying to get the client to follow simple commands regarding activities of daily living (ADL). Which nursing interventions should be included in the plan of care? Select all that apply. a. Ask simple questions that require "yes" or "no" answers b. If the client becomes frustrated, seek a different care provider to complete ADL c. Perform ADL for the client until the goal of each activity is understood d. Show the client gestures or pictures of ADL (shower, toilet, and toothbrush) e. Speak slowly but loudly while looking directly at the client
a. Ask simple questions that require "yes" or "no" answers d. Show the client gestures or pictures of ADL (shower, toilet, and toothbrush)
Good The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring? a. Auscultate breath sounds to assess for crackles b. Monitor for >50 mL/hr urine output c. Monitor Glasgow Coma Scale increasing from 8/15 to 9/15 d. Press over the tibia to assess for pitting edema
a. Auscultate breath sounds to assess for crackles Mannitol can cause peripheral edema and pulmonary edema- watch fore signs of heart failure= crackles in lungs
GOOD The nurse is assessing a newly admitted client on a neurological inpatient unit. Which assessment findings are abnormal and require follow-up by the nurse? Select all that apply. a. Cannot touch chin to chest b. Eyes roll in opposite direction when turning head side to side c. Muscle strength of lower extremities is 3/5 d. Pupils are 8 mm in diameter e. Toes point downward when noxious stimuli are applied to the sole
a. Cannot touch chin to chest c. Muscle strength of lower extremities is 3/5 d. Pupils are 8 mm in diameter all signs of increasing ICP
A client sustained a concussion after falling off a ladder. What are essential instructions for the nurse to provide when the client is discharged from the hospital? Select all that apply. a. Client should abstain from alcohol b. Client should remain awake all night c. Client should return if having difficulty d. Responsible adult should be taught neurological examination e. Responsible adult should stay with the client
a. Client should abstain from alcohol c. Client should return if having difficulty e. Responsible adult should stay with the client
The nurse receives the change of shift report for assigned clients at 7 AM. Which client should the nurse assess first? a. Client with change in level of consciousness who fell in the nursing home b. Client with chronic headaches who is scheduled for an MRI at 9 AM c. Client with chronic obstructive pulmonary disease (COPD) and pulse oximeter reading of 90% d. Client with heart failure and 3+ pitting edema of the lower extremities
a. Client with change in level of consciousness who fell in the nursing home
The nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which of the following as expected neurological changes for the client with a concussion? Select all that apply. a. Asymmetrical pupillary constriction b. Brief loss of consciousness c. Headache d. Loss of vision e. Retrograde amnesia
b. Brief loss of consciousness c. Headache e. Retrograde amnesia
A client is brought to the emergency department with stroke symptoms that began 7 hours ago. A CT scan confirms the presence of an ischemic stroke. The client's current blood pressure is 202/108 mm Hg. Which nursing action is most appropriate? a. Anticipate IV labetalol to keep blood pressure <140/90 mm Hg b. Document the current findings in the client's chart c. Prepare to administer thrombolytic therapy d. Request a prescription for IV antiseizure medication
b. Document the current findings in the client's chart
The nurse is caring for a client with a history of headaches. The client has talked to the nurse, smiled at guests, and maintained stable vital signs. The nurse notes the following changes in the client's status. Which assessment finding is critical to report to the health care provider (HCP)? a. Blood pressure 136/88 mm Hg b. Flat affect and drowsiness c. Poor appetite d. Respiratory rate 12/min
b. Flat affect and drowsiness Early sign of ICP
A client was struck on the head by a baseball bat during a robbery attempt. The nurse gives this report to the oncoming nurse at shift change and conveys that the client's current Glasgow Coma Scale (GCS) score is a "10." Which client assessment is most important for the reporting nurse to include? a. Belief that the current surrounding are a racetrack b. GCS score was "11" one hour ago c. Recent vital signs show blood pressure of 120/80 mm d. Hg and pulse of 82/min e. Reported allergy to penicillin and vancomycin
b. GCS score was "11" one hour ago decreasing GSC indicates ICP is increasing
GOOD The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid? a. Head mildline b. Head turned to the side c. Neck in neutral position d. Head of bed elevated 30 to 45 degrees
b. Head turned to the side Answer B. The head of the client with increased intracranial pressure should be positioned so the head is in a neutral midline position. The nurse should avoid flexing or extending the client's neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.
An adult client with altered mental status and fever has suspected bacterial meningitis with sepsis. Blood pressure is 80/60 mm Hg. Which prescribed intervention should the nurse implement first? a. Administer IV antibiotics b. Infuse bolus of IV normal saline c. Prepare to assist with lumbar puncture d. Transport client for head CT scan
b. Infuse bolus of IV normal saline
The nurse is caring for a client with an acute ischemic stroke who has a blood pressure of 178/95 mm Hg. The health care provider prescribes as-needed antihypertensives to be given if the systolic pressure is >200 mm Hg. Which action by the nurse is most appropriate? a. Give the antihypertensive medication b. Monitor the blood pressure c. Notify the health care provider d. Question the prescription
b. Monitor the blood pressure
The nurse is caring for the male client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated? a. Loosening restrictive clothing b. Restraining the client's limbs c. Removing the pillow and raising padded side rails d. Positioning the client to side, if possible, with the head flexed forward
b. Restraining the client's limbs Answer B. Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising 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. Other aspects of care are as described for the client who is in bed.
A client is receiving several adjunctive professional therapies while rehabilitating after a stroke. Which client statements indicate an understanding of the services? Select all that apply. a. "Occupational therapy will help me learn how to properly use my walker." b. "Physical therapy will help me learn how to dress myself again." c. "Social services can help me find resources for affording my medications." d. "Speech therapy will teach me how to eat my meals properly." e. "Wound care will teach me how to properly dress this wound on my knee."
c. "Social services can help me find resources for affording my medications." d. "Speech therapy will teach me how to eat my meals properly." e. "Wound care will teach me how to properly dress this wound on my knee."
The nurse receives the assigned clients for today on a neurology unit. The nurse should check on which client first? a. Client with history if head injury whose Glasgow Coma Scale (GCS) changes from 13 to 14 b. Client with history of myasthenia gravis who has ptosis in the evening c. Client with history of T2 spinal injury who has diaphoresis, pulse 54/min, and hypertension d. Client with history of transverse myelitis with 2+ bilateral lower extremity muscle strength
c. Client with history of T2 spinal injury who has diaphoresis, pulse 54/min, and hypertension
A highly intoxicated client was brought to the emergency department after found lying on the sidewalk. On admission, the client is awake with a pulse of 70/min and blood pressure of 160/80 mm Hg. An hour later, the client is lethargic, pulse is 48/min, and blood pressure is 200/80 mm Hg. Which action does the nurse anticipate taking next? a. Administer atropine for bradycardia b. Administer nifedipine for hypertension c. Have CT scan performed to rule out an intracranial bleed d. Perform hourly neurologic checks with Glasgow coma scale (GCS)
c. Have CT scan performed to rule out an intracranial bleed
A client is brought to the emergency department by emergency medical services with a flaccid right arm and leg and lack of verbal response. The stroke alert team is initiated. The nurse takes which priority action? a. Determine onset of symptoms b. Ensure that the client has 2 large-bore intravenous (IV) lines c. Maintain patent airway d. Prepare for head CT scan
c. Maintain patent airway
A client is admitted to the hospital for severe headaches. The client has a history of increased intracranial pressure (ICP), which has required lumbar punctures to relieve the pressure by draining cerebrospinal fluid. The client suddenly vomits and states, "That's weird, I didn't even feel nauseated." Which action by the nurse is the most appropriate? a. Document the amount of emesis b. Lower the head of the bed c. Notify the health care provider (HCP) d. Offer anti-nausea medication
c. Notify the health care provider (HCP)
GOOD For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: a. prevent respiratory alkalosis. b. lower arterial pH. c. promote carbon dioxide elimination. d. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg
c. promote carbon dioxide elimination. Answer C. The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this case. It isn't necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients.
A client comes to the emergency department with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency? a. "I am very tired, and it's hard to for me to keep my eyes open" b. "I don't feel good, and I want to be seen" c. "I have not taken my blood pressure medicine in over a week" d. "I have the worst headache I've ever had in my life"
d. "I have the worst headache I've ever had in my life"
GOOD The nurse is caring for a client with increased intracranial pressure (ICP). Which statement by the unlicensed assistive personnel would require immediate intervention by the nurse? a. "I will raise the head of the bed so it is easier to see the television" b. "I will turn down the lights when I leave" c. "Let me move your belongings closer so you can reach them" d. "You should do deep breathing and coughing exercises"
d. "You should do deep breathing and coughing exercises" No coughing baring down sneezing blowing nose holding breath- nothing to elevate pressure
GOOD A client with stroke symptoms has a blood pressure of 240/124 mm Hg. The nurse prepares the prescribed nicardipine intravenous (IV) infusion solution correctly to yield 0.1 mg/mL. The nurse then administers the initial prescription to infuse at 5 mg/hr by setting the infusion pump at 50 mL/hr. What is the nurse's priority action at this time? a. Assess hourly urinary output b. Increase pump setting to correct administration rate to 100 mL/hr d. Keep systolic blood pressure above 170 mm Hg e. Monitor for a widening QT interval
d. Keep systolic blood pressure above 170 mm Hg A client with an acute stroke presentation (brain attack) requires "permissive hypertension" during the first 24-48 hours to allow for adequate perfusion through the damaged cerebral tissues. blood-brain barrier is no longer intact once the blood pressure is >220/120 mm Hg. Therefore, "mild" lowering is required, usually to a systolic pressure that is not below 170 mm Hg 170 mm Hg
The nurse is caring for a client who has homonymous hemianopsia following an acute stroke. Which nursing diagnosis is the most appropriate for this client? a. Risk for ineffective airway maintenance b. Risk for knowledge deficit c. Risk for poor fluid intake d. Risk for self-neglect
d. Risk for self-neglect
GOOD The emergency department nurse is triaging clients. Which neurologic presentation is most concerning for a serious etiology and should be given priority for definitive treatment? a. History of bell's palsy wit unilateral facial droop and drooling b. History of multiple sclerosis and reporting recent blurred vision c. Reports unilateral facial pain when consuming hot foods d. Temple region hit by ball, loss of consciousness, but Glasgow score is now 14
d. Temple region hit by ball, loss of consciousness, but Glasgow score is now 14 EPIDURAL BLEED Brief loss of consciousness, followed by intact neuro exam, followed by rapid clinical deterioration § Frequently associated with skull fracture
The nurse is caring for a client with left-sided weakness from a stroke. When assisting the client to a chair, what should the nurse do? a. Bend at the wrist b. Keep the feet close together c. Pivot on the foot proximal to the chair d. Use a transfer belt
d. Use a transfer belt
Which of the following values is considered normal for ICP? 5 to 15 mm Hg 25 mm Hg 35 to 45 mm Hg 120/80 mm Hg
5 to 15 mm Hg
The answer is D. The occipital lobe is responsible for vision and color perception.
A patient is demonstrating signs and symptoms of stroke. The patient reports loss of vision. What area of the brain do you suspect is affected based on this finding? A. Brain stem B. Hippocampus C. Parietal lobe D. Occipital lobe
The answer is D. The temporal lobe is responsible for hearing, learning, and feelings/emotions.
A patient who suffered a stroke one month ago is experiencing hearing problems along with issues learning and showing emotion. On the MRI what lobe in the brain do you expect to be affected? A. Frontal lobe B. Occipital lobe C. Parietal lobe D. Temporal
The answer is B. The cerebellum is important for coordination and balance.
A patient's MRI imaging shows damage to the cerebellum a week after the patient suffered a stroke. What assessment findings would correlate with this MRI finding? A. Vision problems B. Balance impairment C. Language difficulty D. Impaired short-term memory
The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following? a. Giving the client thin liquids b. Thickening liquids to the consistency of oatmeal c. Placing food on the unaffected side of the mouth d. Allowing plenty of time for chewing and swallowing
Answer A. Before the client with dysphagia is started on a diet, the gag and swallow reflexes must have returned. The client is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration.
The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to: a. take a hot bath. b. rest in an air-conditioned room c. increase the dose of muscle relaxants. d. avoid naps during the day
Answer B. Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with multiple sclerosis include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.
The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to use which of the following to test the client's peripheral response to pain? a. Sternal rub b. Nail bed pressure c. Pressure on the orbital rim d. Squeezing of the sternocleidomastoid muscle
Answer B. Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA? a. Caucasian race b. Female sex c. Obesity d. Bronchial asthma
Answer C. Obesity is a risk factor for CVA. Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, oral contraceptive use, emotional stress, family history of CVA, and advancing age. The client's race, sex, and bronchial asthma aren't risk factors for CVA.
A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority in this client's plan of care? a. Disturbed sensory perception (visual) b. Self-care deficient: Dressing/grooming c. Impaired verbal communication d. Risk for injury
Answer D. Because the client is disoriented and restless, the most important nursing diagnosis is risk for injury. Although the other options may be appropriate, they're secondary because they don't immediately affect the client's health or safety.
A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid: a. Is clear and tests negative for glucose b. Is grossly bloody in appearance and has a pH of 6 c. Clumps together on the dressing and has a pH of 7 d. Separates into concentric rings and test positive of glucose
Answer D. 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 male client is having a tonic-clonic seizures. What should the nurse do first? a. Elevate the head of the bed. b. Restrain the client's arms and legs. c. Place a tongue blade in the client's mouth. d. Take measures to prevent injury.
Answer D. Protecting the client from injury is the immediate priority during a seizure. Elevating the head of the bed would have no effect on the client's condition or safety. Restraining the client's arms and legs could cause injury. Placing a tongue blade or other object in the client's mouth could damage the teeth.
Which of the following symptoms may occur with a phenytoin level of 32 mg/dl? Ataxia and confusion Sodium depletion Tonic-clonic seizure Urinary incontinence
Ataxia and confusion. A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 32 mg/dl indicates toxicity. Symptoms of toxicity include confusion and ataxia. Phenytoin doesn't cause hyponatremia, seizure, or urinary incontinence. Incontinence may occur during or after a seizure.
A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the patient's care will be best to delegate to an LPN/LVN whom you are supervising? (Choose all that apply). A Document the onset time, nature of seizure activity, and postictal behaviors for all seizures. B Administer phenytoin (Dilantin) 200 mg PO daily. C Teach patient about the need for good oral hygiene. D Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation.
B
GOOD The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? A Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. B Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. C Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. D Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.
B Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.
GOOD Which of the following pathologic processes is often associated with aseptic meningitis? Ischemic infarction of cerebral tissue Childhood diseases of viral causation such as mumps Brain abscesses caused by a variety of pyogenic organisms Cerebral ventricular irritation from a traumatic brain injury
Childhood diseases of viral causation such as mumps Septic Meningitis - Bacterial • Streptococcus pneumoniae • Neisseria meningitidis • Peaks Winter & Early Spring • Factors that increase risk • Tobacco Use • Viral upper respiratory infection d/t increase in droplet production Aseptic Meningitis - Viral • Secondary to cancer • Immunosuppressed - HIV • Caused by enterovirus • Occurs Summer and Early Fall PATHOPHYSIOLOGY • Originates in 2 ways • Bloodstream as a consequence of other infections • Direct Spread - Traumatic injury
The answers are A, D, and E. These risk factors are modifiable in that the patient can attempt to change them to prevent another stroke in the future. The other risk factors are NOT modifiable.
During discharge teaching for a patient who experienced a mild stroke, you are providing details on how to eliminate risk factors for experiencing another stroke. Which risk factors below for stroke are modifiable? A. Smoking B. Family history C. Advanced age D. Obesity E. Sedentary lifestyle
