NUR2214 Module 4 EAQs

The nurse is teaching a client with multiple sclerosis methods to reduce fatigue. Which statement indicates an understanding of the education?

Rest in an air-conditioned room.

A patient is admitted with a stroke (brain attack). Which tool does the nurse use to facilitate a focused neurologic assessment of the patient?

National Institutes of Health Stroke Scale (NIHSS)

Which hemorrhage results from venous bleeding into the space beneath the dura and above the arachnoid?

Subdural hematoma

Which stroke syndrome includes personality and behavior changes?

anterior cerebral artery

Which patient complication is most commonly associated with dysphagia?

aspiration

Which antiepileptic drug is used to prevent seizures?

phenytoin

Which tumor in the anterior lobe of the cerebellum accounts for up to one fourth of brain tumors?

pituitary tumors

What is the function of periaqueductal gray of the brainstem?

To eliminate pain

What is the most common type of benign brain tumor?

Meningioma

Which terms are related to a closed traumatic brain injury? Select all that apply.

Laceration injury Contusion injury Contrecoup injury

What is the most important variable to assess with any brain injury?

Level of consciousness

Which drug is used to treat a brain tumor in a patient?

Lomustine

Which drug will be most effective for the treatment of cerebral edema and increased intracranial pressure?

Mannitol

A patient arrives at the emergency department after a motor vehicle accident and indirect injury to the head. Upon assessment, it is discovered that the patient's increased intracranial pressure (ICP) is 18 mm Hg. What is the priority nursing action?

Notify the health care provider.

Which describes secondary brain injuries?

Occur after the initial injury

Which statement is true regarding neurologic changes in older adults?

Older adults may need more time to retrieve information.

Which injury is characterized by a fractured skull?

Open traumatic brain injury

A child sitting on a chair in a playroom starts to have a tonic-clonic seizure with a clenched jaw. What is the best initial action by the nurse?

Placing the child on the floor

The nurse assesses a patient who is suffering from dementia and metabolic disorders. Which diagnostic test will be most beneficial to assess the patient's condition?

Positron emission tomography (PET)

During which time frame does an acute subdural hematoma (SDH) present?

Within 48 hours after impact

While performing a neurological assessment, the nurse finds that the patient can be aroused only with painful stimulation. What is the expected level of consciousness?

stuporous

Which antiepileptic drug is used as the first-line treatment for absence seizures?

valproic acid

Which symptoms can be present with a transient ischemic attack (TIA)? Select all that apply.

vertigo aphasia blurred vision

The nurse is teaching a group of older adults about transient ischemic attack (TIA). Which statement made by a participant indicates a need for further teaching regarding TIAs?

"There is a loss of central vision."

The nurse is teaching a patient about preparing for an electroencephalogram (EEG). Which instruction by the nurse is correct?

"Wake at 2:00 the morning of the EEG and remain awake until time for the test."

A caregiver reports that the patient's mild dementia has worsened. The patient demonstrates impaired physical function and lack of self-management. Which condition does the nurse anticipate?

sleep deprivation

The nurse is assessing a patient admitted with a stroke. What assessment finding would indicate that the patient experienced a stroke to the right hemisphere?

Denial of the illness

Which drug is usually administered to control cerebral edema?

Dexamethasone

A client has a tonic-clonic seizure that involves all extremities. The nurse anticipates that the healthcare provider will prescribe the intravenous administration of which drug?

Diazepam

Which may be the largest cistern of the spinal cord?

From the level of the second lumbar vertebra to the second sacral vertebra (L2-S2)

During an annual physical assessment a client reports not being able to smell coffee and most foods. Which cranial nerve function should the nurse assess?

I

A 70-year-old woman brought to the emergency department is diagnosed with acute ischemic stroke with a NIH Stroke Scale score of 20. A family member reports last seeing the patient as normal (LSN) 3.5 hours before evaluation. The patient has an INR of 1.4. The nurse anticipates that the patient will not be eligible for fibrinolytic therapy for which reason?

INR 1.4

A patient is brought to the emergency department with sudden onset of right-sided paralysis and difficulty speaking. A family member is worried that these symptoms will be permanent. Based on the patient's symptoms, the nurse anticipates which outcome?

Improvement over several days

A patient has been admitted with a diagnosis of a stroke (brain attack). The nurse suspects that the patient has had a right hemisphere stroke because the patient exhibits which symptoms?

Impulsiveness and smiling

What helps in distinguishing cerebrospinal fluid from other fluids when it is placed on a white absorbent paper or linen?

halo sign

The nurse is obtaining a history on a patient who has had several transient ischemic attacks. Which risk factor in this patient's history cannot be changed with appropriate management of care?

head trauma

Which lab values may be abnormally low from blood loss during surgery or elevated if the blood was replaced?

hematocrit

Which is the most common benign tumor that arises from the coverings of the brain (the meninges)?

meningiomas

Which cranial nerve (CN) controls the muscles of the face and scalp?

CN VII

Which group is at the highest risk for stroke?

alaskan native men

Which part of the brain contains the aqueduct of Sylvius?

midbrain

A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked with an applicator stick during a neurologic examination. What should the nurse document in the client's medical record?

"Exhibits a positive Babinski sign"

The daughter of a patient who has had a stroke asks the nurse for additional resources. What is the nurse's best response?

"Go to the National Stroke Association website."

A primary healthcare provider diagnoses late-stage (tertiary) syphilis in a client. Which statement made by the client supports this diagnosis?

"I'm having trouble keeping my balance."

A patient is intubated and cannot talk. What is the best possible Glasgow Coma score for this patient?

11t

How many categories are on the National Institutes of Health Stroke Scale (NIHSS)?

11

A patient weighing 165 pounds will begin receiving recombinant tissue plasminogen activator (rtPA) to treat an ischemic stroke. The nurse expects an order to administer how many milligrams of rtPA in the first minute of the infusion? Record your answer using two decimal places. Use a leading zero if applicable. ___ mg

6.75

What is the duration of mild traumatic brain injury symptoms?

72 hrs

What is the most common type of pituitary tumor?

Adenoma

Which statement about subdural hematoma (SDH) is accurate?

It has the highest mortality rate.

Which factors contraindicate administering alteplase more than three hours after stroke onset? Select all that apply.

Age older than 80 years History of both diabetes and stroke Use of warfarin or other anticoagulants Imaging evidence of middle cerebral artery involvement

Which ethnic group has the highest prevalence of stroke?

American Indians and Alaskan Natives

Which assessment strategy does the nurse use to assess the function of cranial nerve VII?

Asks the patient to raise the eyebrows and grimace or puff the cheeks.

Which task does the nurse plan to delegate to the nursing assistant caring for a group of patients in the neurosurgical unit?

Attend to the care needs of a patient who has had a transcranial Doppler study.

A patient is scheduled for an electroencephalogram. What should the nurse teach the patient prior to the test?

Avoid central nervous system depressants.

What does the reticular activating system (RAS) in the brainstem control?

Awareness and alertness

Using a blunt object, the nurse gently scrapes the sole of the patient's foot from the heel to the toe. Which reflex is the nurse assessing?

Babinski's reflex

A client has inflammation of the facial nerve, causing facial paralysis on one side. Which diagnosis will the nurse most likely observe written in the medical record?

Bell palsy

During a follow-up visit, the nurse finds increased intracranial pressure in a client who has undergone nasal hypophysectomy for hyperpituitarism. Which action taken by the client is responsible for this condition?

Blowing the nose and sneezing

Which type of brain tumor is considered malignant?

Chondrosarcoma

Which cranial nerve damage may lead to a decrease in the client's olfactory acuity?

Cranial nerve I

Which therapy must be performed to open the skull and remove the tumor?

Craniotomy

What describes traumatic brain injury (TBI)?

Damage to the brain from an external mechanical force

While assessing a client the nurse observes abnormal rigidity with pronation of the arms. Which condition should the nurse record in the assessment findings?

Decerebration

The nurse is monitoring a patient after supratentorial surgery. Which sign does the nurse report immediately to the provider?

Decorticate positioning

Neurologic changes associated with aging and vision include the need for additional light. What is the pathophysiology underlying this change?

Decrease in pupil size

Which treatment is also known as gamma knife treatment?

Stereotactic radiation therapy

What is inserted to drain cerebrospinal fluid to another area of the body when there is a long-term treatment required for chronic hydrocephalus?

Surgical shunt

What is the major "relay station" of the brain?

Thalamus

During a seizure, a client had sudden loss of muscle tone that lasted for a few seconds followed by confusion. Which statement about this type of seizures is true? Select all that apply.

These seizures increase the risk of injuries due to fall. These seizures are most resistant to drug therapy.

A patient is having difficulty understanding spoken and written words and is saying made-up words and meaningless speech. What would be the possible reason behind the patient's condition?

receptive aphasia

The nurse is providing care to a patient with a skull fracture. The nurse notes leakage of fluid from the patient's nose and ears. The magnetic resonance imaging report indicates hemorrhage and damage to the anterior and middle fossal regions of the brain. Which type of fracture does the nurse suspect?

A basilar skull fracture

A patient has a brain tumor classified as supratentorial. Where is the tumor located?

Above the tentorium

A 50-year-old male client has difficulty communicating because of expressive aphasia after a cerebrovascular accident (CVA, also known as a "brain attack"). When the nurse asks the client how he is feeling, his wife answers for him. How should the nurse address this behavior?

Acknowledge the wife but look at the client for a response.

The nurse reads the patient's health record and sees that the patient's brain is contused. What does the nurse infer from this?

The patient's brain is bruised.

The nurse observes a student nurse care for an adult patient with moderate traumatic brain injury (TBI). Which action made by the student nurse causes the nurse to intervene?

Elevating the head of the bed to 15 degrees

The nurse is using auditory-evoked potentials to assess a patient. What is this technique meant to detect?

High-frequency hearing loss

Which intervention is beneficial in the management of anoxia when it occurs as a result of a witnessed cardiac arrest in a patient?

Performing therapeutic hypothermia

While assessing the airway patency of a client after a bomb blast, the nurse suspects severe brain injury and gives a score of 7 using the Glasgow Coma Scale (GCS). Which intervention is most appropriate for the client?

Preparing for endotracheal intubation and mechanical ventilation

While assessing a patient with a spinal cord injury, the nurse finds that the patient is unable to lift a hand. Which cranial nerve may be damaged?

XI

In assessing a patient using a reflex hammer, the nurse places a thumb in the patient's antecubital space and strikes the thumb with the hammer. The patient's forearm and wrist rise. The nurse notes an appropriate response of which reflex?

biceps

Which brain injury is caused by blunt force?

closed traumatic brain injury

Which is a symptom of increased intracranial pressure?

irritability

Which region of the cerebrum controls voluntary function?

motor cortex

Which words can be used to classify primary brain injuries? Select all that apply.

open closed

A patient is receiving IV administration of recombinant tissue plasminogen activator (rtPA) therapy. Which sign/symptom alerts the nurse that the infusion should be discontinued?

report of HA

A client is taking phenytoin to treat clonic-tonic seizures. The client's phenytoin level is 16 mg/L. Which action should the nurse take?

Administer the next dose of the medication as prescribed.

A patient with a traumatic brain injury from a motor vehicle crash is monitored for signs of increased intracranial pressure (ICP). Which sign does the nurse monitor for?

Changes in breathing pattern

While reviewing a patient's chart from the previous shift, the nurse reads the phrase, "The patient continues to demonstrate decorticate posturing." From this entry, what does the nurse expect the patient to exhibit?

Clenched fists and arms bent in toward the body, with wrists and fingers held on the chest

A family member of a patient who experienced a stroke is anxious and says to the nurse, "Something is the matter with Grandpa. All he does is cry!" Which response by the nurse is best at this time?

"He is emotionally labile and may have this behavior for some time."

The nurse is caring for a patient who has a tumor on the brainstem. Which signs and symptoms may be present with brainstem tumors? Select all that apply.

hoarseness apnea hearing loss bradycardia

Which is caused by an obstruction of the normal cerebrospinal fluid pathway (CSF) from edema?

hydrocephalus

A client has a tonic-clonic seizure at work and is admitted to the emergency department. Which question is most useful when planning nursing care related to the client's seizure?

"Were you aware of anything different or unusual just before your seizure began?"

Which cranial nerve is located in the midbrain?

Trochlear

Which cranial nerve is responsible for eye movement via the superior oblique muscles?

Trochlear

Which diagnostic technique is used to measure the integrity of the cerebral vessels in a patient who sustained a traumatic brain injury?

Ultrasonography

A client experiences a cerebral vascular accident (CVA) and is admitted to the hospital in a coma. What is the priority nursing care for this client?

Maintain an open airway.

What is the first indication that central neurologic function has declined in a patient?

Change in level of consciousness

The nurse is recording the output from a Hemovac drain of a patient one-day postoperative following infratentorial craniotomy. For the past eight hours, the total amount of drainage is 45 mL. What action should the nurse take?

Continue to monitor the output. Following infratentorial surgery, the normal output for an eight-hour shift is 30 to 50 mL; therefore, 45 mL is expected over eight hours, and the nurse should continue to monitor the output.

A patient diagnosed with a stroke is receiving recombinant tissue plasminogen activator (rtPA) through one intravenous line. The nurse discovers that the second line has infiltrated and removes it. The insertion site continues to bleed even after the nurse applies pressure on it. What is the priority nursing action?

Discontinue the rtPA infusion.

A patient is receiving recombinant tissue plasminogen activator (rtPA) for an acute ischemic stroke. What nursing intervention does the nurse perform first to properly take care of the patient?

Ensure that the prescribed follow-up computed tomography (CT) scan is done after treatment is completed and before starting antiplatelet drugs.

How often should the nurse assess the patient's neurologic status and vital signs in the first four to six hours following craniotomy?

Every 15 to 30 minutes

A nurse should plan to maintain a client who has experienced a subarachnoid hemorrhage in what position?

In bed with the head of the bed elevated

Which tumors produce ataxia, autonomic nervous system dysfunction, vomiting, drooling, hearing loss, and vision impairment?

Infratentorial

The nurse suspects a patient has a brain tumor. What noninvasive test is most likely to be ordered to validate the presence of a brain tumor?

Magnetic resonance imaging (MRI) scan

Which device is most invasive for monitoring intracranial pressure?

Intraventricular catheter

Which statement indicates a nurse has a correct understanding about trigeminal autonomic cephalalgia (cluster headaches)?

It is caused by an overactive hypothalamus.

What is the purpose for using magnetic resonance spectroscopy (MRS)?

It is used to detect abnormalities in the brain's biochemical processes.

Which nursing intervention takes priority in a patient with dysphagia?

Keep the patient on strict NPO status until he or she can swallow safely.

Which diagnostic test is done to detect subtle changes in brain tissue and show more specific details of a brain injury?

Magnetic resonance imaging

Impairments of which functions can be the result of traumatic brain injury (TBI)? Select all that apply.

Mobility Cognition Sensory perception Psychosocial function

The nurse provides care to an intubated adult patient with hypocarbia. Which finding does the nurse report immediately to the health care provider?

Nonreactive, dilated pupils

A nurse is listening to family members discuss feelings of guilt and anger over a patient's traumatic brain injury. How does the nurse document this type of assessment?

Psychosocial

The nurse is caring for a patient with a confirmed thrombotic stroke, whose onset of symptoms began 2 hours earlier. The nurse expects the health care provider to prescribe the administration of which drug?

Recombinant tissue plasminogen activator

On the day after surgery for insertion of a ventriculoperitoneal shunt to treat hydrocephalus, an infant's temperature increases to 103.0° F (39.4° C). The nurse immediately notifies the practitioner. What is the next nursing action?

Removing excess clothing from the infant

Which is an alternative surgery to the traditional surgery used for curing brain tumors?

Stereotactic radiosurgery

During the first month in a nursing home, an older client with dementia demonstrates numerous disruptive behaviors related to disorientation and cognitive impairment. What should the nurse take into consideration when planning care?

Stressors that appear to precipitate the client's disruptive behavior

A patient with a brain tumor is prescribed lansoprazole (Prevacid). What is the purpose of lansoprazole for this patient?

To prevent development of stress ulcers

What is the function of the cerebral cortex?

To translate impulses into understandable feelings

Which complication causes a brain tumor to expand and invade, infiltrate, compress, and displace normal brain tissue?

cerebral edema

A nurse uses the Glasgow Coma Scale to assess a client's status after a head injury. When the nurse applies pressure to the nail bed of a finger, which movement of the client's upper arm should cause the most concern?

extending

A patient develops syndrome of inappropriate antidiuretic hormone (SIADH) following a craniotomy with brain tumor removal. What medical management should the nurse expect?

fluid restriction

What brain injury is confined to a specific area of the brain?

focal injury

In what lobe is Broca's area (speech area) located in the brain?

frontal

Which drug is often used as adjunctive therapy to reduce the incidence of rebound from mannitol?

furosemide

Which drug wafers may be placed directly into the cavity created during surgical brain tumor removal?

gliadel

Which potential disorder should be ruled out before a patient's level of consciousness is attributed to stroke?

hypoglycemia

Which medication is used to treat cerebral edema by pulling water out of the extracellular space of the edematous brain tissue?

mannitol

Which signs/symptoms suggest that a patient's intracranial pressure (ICP) is increasing? Select all that apply.

vomiting dilated pupils presence of papilledema

The nurse caring for a 3-year-old child with meningitis should be alert for which signs and symptoms of increased intracranial pressure? Select all that apply.

vomiting headache irritability

Which factors are implicated in the greatest number of injuries associated with traumatic brain injuries (TBIs)? Select all that apply.

weekends alcohol use evenings and nights

Which complication results from changes in capillary endothelial tissue permeability, allowing the plasma to seep into the extracellular spaces?

Cerebral edema

The nurse is about to administer a contrast medium to the patient undergoing diagnostic testing. Which question does the nurse first ask the patient?

"Are you taking ibuprofen daily?"

The registered nurse is teaching a student nurse regarding questions to ask a patient with traumatic brain injury during the assessment. Which statement made by the student nurse indicates ineffective learning?

"I will wait until the patient gains consciousness to answer my questions about the injury."

Which statement made by the student nurse indicates understanding of neurogenic pulmonary edema?

"Most patients with neurogenic pulmonary edema do not survive."

The registered nurse is teaching a student nurse about post-surgery management of a patient who underwent supratentorial surgery. Which statement made by the student nurse indicates ineffective learning?

"The patient should be placed in a supine position."

The nurse is teaching the spouse and patient who has had a brain attack (cerebrovascular accident) about rehabilitation. Which statement by the spouse demonstrates understanding of the nurse's instruction?

"The rehabilitation therapist will help identify changes needed at home."

The nurse assesses a patient and notes partial hemianopia, ataxia in the right limb only, and no auditory comprehension. Painful stimulation is needed for the patient to make movements. Based on the National Institutes of Health Stroke Scale (NIHSS), what is the total score for this patient?______

7

What is the best explanation of an open traumatic brain injury (TBI)?

An injury in which the skull is fractured

A patient with a newly diagnosed high-grade malignant glioma is receiving interstitial chemotherapy. What is the major drug used for this type of treatment?

Carmustine (BCNU)

Which drug is considered an antithrombotic?

Clopidogrel

A patient with a newly diagnosed brain tumor complains of a headache. What medication is likely to be prescribed for this patient?

Codeine and acetaminophen (Tylenol, ACE-Tabs)

The nurse is performing a rapid neurologic assessment on a trauma patient. Which assessment finding is normal?

Constriction of pupils

The nurse is doing a neurological assessment on a patient admitted to the emergency department. The patient reports having had a slight headache, speech deficits, confusion, and blurred vision. What does the nurse suspect is happening to the patient?

Formation of a blood clot

A patient is brought to the emergency department with aphasia and right-sided hemiplegia. The nurse suspects a stroke in which area of the brain?

Left cerebral hemisphere

A patient reports feeling disoriented after having been hit in the head with heavy material from a construction site. Although the patient's MRI results do not show evidence of brain damage and the patient did not lose consciousness, the patient is unable to remember events immediately following the accident, including how the patient ended up at the hospital. The nurse understands that the patient most likely has which condition?

Mild traumatic brain injury

A client who takes four 325-mg tablets of buffered aspirin four times a day for severe arthritis complains of dizziness and ringing in the ears. Which complication does the nurse conclude that the client probably is experiencing?

Salicylate toxicity

A patient has experienced a right-hemisphere stroke. What is an important nursing action while caring for this patient?

Stand on the patient's left side when talking to increase the visual field.

Which treatment beams are widely dispersed over the surface of the head to prevent damage to healthy brain tissue?

Stereotactic radiation therapy

What is the purpose of the Glasgow Coma Scale used by health care personnel?

To assess level of consciousness

The emergency room nurse is assessing a patient who presents with a stroke. The nurse finds that the patient shows perseveration, loss of deep sensation, and decreased touch sensation. What should the nurse infer from these symptoms?

The patient had a posterior cerebral artery stroke.

The laboratory results for a patient who sustained a stroke shows the presence of proteins in the cerebrospinal fluid. What should the nurse infer from the reports?

The patient had a thrombotic stroke.

Which statements about afferent neurons are correct? Select all that apply.

They are also known as sensory neurons. They send impulses toward the central nervous system (CNS).

A patient with a traumatic brain injury underwent monitoring of the intracranial pressure. Suddenly, it resulted in leakage of the cerebrospinal fluid. What would be the possible reason for the leakage?

Use of intraventricular catheter

An injury that is caused by an external force contacting the head, placing the head in sudden motion, is known as what?

acceleration injury

What brain injury will be initially at a microscopic level and not detectable by computerized tomography (CT) scan?

diffuse

The nurse is assessing a patient with a traumatic brain injury (TBI) after a skateboarding accident. Which symptom would concern the nurse the most?

asymmetrical pupils

Which term is used to describe loss of balance in a patient with a brainstem or cerebellar injury?

ataxia

A patient has just returned to the unit after having a cerebral angiography. Which symptom does the patient display that causes the nurse to act immediately?

bleeding

What should be considered if the patient voids large amounts of very dilute urine with an increasing serum osmolarity and electrolyte concentration?

diabetes insipidus

The nurse is assessing a patient with a history of mild traumatic brain injury. The patient reports sleep disturbances. Which findings should the nurse observe for in the patient? Select all that apply.

drowsiness sleeping for long hours

Which is a clinical manifestation of brainstem tumors?

dysphagia

A patient gradually becomes weak, lethargic, and confused following a craniotomy. What electrolyte alteration may be causing the patient's status change?

hyponatremia

Which part of the brain controls the functions of the "master gland"?

hypothalamus

The nurse assesses poor wound healing and worsening cognitive symptoms in a patient with dementia. What does the nurse anticipate may be the causative factor?

insomnia

Which are advantages of stereotactic radiosurgery (SRS)? Select all that apply.

noninvasive decreased cost surgical precision rapid recovery time

Which lobe of the cerebral cortex is located in the area of the brain parallel to the ears?

temporal

A patient's laboratory report shows an intracranial pressure of 12 mmHg. Which events will occur in the patient's body?

the body will function normally