Stroke

A pt with right sided Hemiplegia and aphasia resulting from a stroke most likely has involvement of the A. Brain stem B. Vertebral artery C left middle cerebral artery D. Right middle cerebral artery

C

during the first 24 hrs after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's a. pulse b. respirations c. bp d. temp

c

a client with MS ask whats the most beneficial thing she can do when she gets home? a. psychotherapy b. regular exercise

b

the nurse is assessing a client in the post ictal phase of generalized tonic clonic seizure. the nurse should determine if the client has a. drowsiness b. inability to move c. paresthia d. hypotension

a

the nurse is monitoring a client with increase ICP . what indicators are the most critical for the nurse to monitor? a. systolic blood pressure b. UO c. breath sounds d. cerebral perfusion pressure e. level of pain

a d

which of the following nursing interventions is appropriate for a client with an ICP of 20mmHg? a. give the client a warm blanket b. administer low dose barbituates c. encourage the client to hyperventilate d.restrict fluids

c.

which of the following is not a realistic outcome to establish with a client who has multiple sclerosis. the client will develop a. joint mobility b. muscle strength c. cognition d. mood elevation

c. does not affect cognition

the client will have an EEG in the morning . the nurse should instruct the client to have which of the following for breakfast ? a. no food or drinks b. only coffee or tea if needed c. a full breakfast as desired without coffee or energy drinks d. a liquid diet of fruit juice, oatmeal, or smoothie

c. due to stimulating effects of caffiene on brain waves

The home health nurse concluded that more teaching may be necessary after making which observation during the first home visit to a client discharged after a stroke. Select all that apply A. A commode is observed at the bedside B. A fluid restriction chart is on the refrigerator C. Metamucil is on the kitchen counter D. Hand weights are next to the couch E. There is a small scatter rug at the side of the bed

2,5 Rugs increase risk for falls

A patients eye jerk while the patient looks to the left. You will record this finding as A. Nystagmus B. CN VI palsy C. Oculixephilia D. Ophthalmic dyskinesia

A

Which assessment finding in a 35 yr old client with an intracranial hematoma should concern the nurse? A. Hamstring pain when the hip and knee are forced and then extended B. Curling of the ties whine the bottom of the foot is stroked in upward motion C muscle aches and cranking especially at night D. Cogwheel and lead pip rigidity

A. Positive Kernigs sign B is wrong because that is a negative not positive babinski sign (doseiflexion of the toes in an adult)

For a pt who is suspected of having a stroke one of the most important pieces of info that the nurse can obtain is A. Time of the pts last meal B. Time at which symptoms first appeared C. PTS hypertension Hx and management D. Family Hx of stroke and other cardiovascular diseases

B

A client calls the telephone triage nurse to report fever nausea chills and malaise. The nurse instructs the client to come immediately to the ER after the client shares which additional data? A. A bad headache. B stiff sore neck C. HR 106 D. A roommate with the same symptoms

B. Sign of menigeal irritation. Other signs just seem like flu

A pt experiencing TIAs is scheduled for a carotid endarterectomy . The nurse is explains that this procedure is done to A. Decrease cerebral edema B. Reduce the brain damage that occurs during a stroke in evolution C prevent a stroke by removing atherosclerotic plaque blocking cerebral blood flow D. Provide a circulatory bypass around a thrombotic plaques obstructing cranial circulation

C

Info provided by the pt that would help differentiate a hemorraghic stroke from a thrombotic stroke is the A. Sensory disturbance B Hx of hypertension C. Presence of motor weakness D. Sudden onset of severe headache

D

Of the following pts the nurse recognizes that the one with the highest risk of stroke is an A. Obese 45 yr old Native American B. 35yr old Asian American C. 32 yes old white woman taking COC D. 65 yr old black man with hypertension

D

a 22 yr old who hit his head while playing football has a tonic clonic seizure upon awakening from the seizure the client asks " what caused me to have a seziure, ive never had one before? the nurses best response is a. head trauma b. electrolye imbalance c. congenital defect d. epilepsy

a

an unconscious client with multiple injuries in the ED . which nursing interventions receives the highest priority? a. establishing an airway b. replacing bllood flow c. stopping bleeding from open wounds d. checking for a neck fracture

a

in planning care for teh lcient who has had a stroke, the nurse should obtain a hx of teh clients functional status before the stroke because a. the rehab plan will be guiided by it b. functional status before the stroke will help predict outcomes c. it wil help the client recognize physical limitations d. the client can be expected to regain most functional status

a

the client has sustained a increased ICP of 20mm Hg. which client position would be most appropriate? a. the HOB 30-45 degrees b. trendelengburgs position c. Left sim's position d. the head elevated on two pillows.

a

the nurse is instructing the client who has been in the hospital with bacterial menegitis and will be going home soon. which of the following will be of the highest priority ? a. take all of the antibiotics as directed until completely gone b. eat a high protein, high calorie diet c. exercise daily, beginning with active ROM d. get a least 8 hrs of sleep per night with freq rest periods

a

which of the following respiratory patterns indicates increasing intracranial pressure in the brain stem ? a. slow irregular respiration b. rapid shallow respiration c. asymmetric chest excursion d. nasal flaring

a

when communicating with a client with aphasia, which of the following are helpful ? select all that apply a. present one thought at a time b. avoid writing messages c. speak with normal volume d. make use of gestures e. encouarge pointing to the needed object

a, c,d,e

the nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. which of the following strategies should the nurse include in the teaching plan a. maintain an upright position while eating b. restrict the diet to liquids until swallowing improves c. introducing foods on the unaffected side of the mouth d. keeping distractions to a minimum e. cutting food into large pieces of finger foods

a,c,d

the office nurse should direct a client on the phone to seek care at the hospital ER based on which statement ? a. my legs are weak and now im having trouble getting a good breath b. my shaky hand is no better than last visit . in fact, i think its getting worse c. the double vision went away when i put my eye patch on d. my headache doesnt seem any better even though I gave up coffee

a. gullian barre syndrome

a client is at risk for increased intracranial pressire. which of the following would be the priorirty for the nurse to monitor? a. unequal pupil size b. decreased systolic BP c. tacycardia d. decreased body temp

a. shows increased pressure on CN III

in providing safety of the client during a grandmal seizure, the nurse peforms which of the following interventions? select all that apply a. position the client on his back b. gently place a padded tongue blade between the teeth c. remove nearby objects that could lead to client injury d. apply oxygen immediately via mask e. note the length and progression of seizure

c e

which of the following is the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis? a, place the clients feet against a firm footboard b. reposition the client q2hr c. have the client wear ankle high tennis shoes at interval throughout the day d. massage the clients feet and ankles regularly

c prevents foot drop

When assessing the client with meningitis, the nurse looks for which manifestations as a frequent first sign of increased intracranial pressure a. rising systolic blood pressure b. change in mood or attention level c. irregular respiratory rate and depth d. a bounding radial pulse

b

a client has had multiple sclerosis for 15 yrs and has received various drug therapies. what is the priority reason why the nurse has found it difficult to evaluate the effectiveness of the drugs that the client has used? a. the cleint exhibits intolerance to many drugs b. the client experiences sponataneous remissions from time to time c. the client requires multiple drugs simultaneously d. the client endures long periods of exacerbation before the illness responds to a particular drug

b

a client receving vent assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. the nurse should a. count the rate to be sure that ventilations are deep enough to be sufficient b. notify the physician of the clients breathing pattern c. increase the rate of ventilation d. increase the tidal volume on the ventilator

b

a client who is regaining consciousness after a craniotomy becomes restless and attepmts to pull out the IV line. which nursing intervention protects the client without increasing the intracranial pressure (ICP)? a. place in a jacket restraint b. wrap the hands in soft "mitten" restraints c. tuck the arms/hands under the drawsheet d. apply a wrist restriant to each arm

b

for the client who is experiencing expressive aphasia which nursing intervention is most helpful in promoting communication ? a. speaking loudly and slowly b. using a picture board for the client to point to pictures c. writing directions so client can read them d. speaking in short sentences

b

the client recently diagnosed with Gullian barre syndrome is drooling and having difficulty swallowing secretions. when the family asks why this occurs the nurse indicate that which of the following is the cause? a. obstructed blood flow to the midbrain b. demyelination of cranial nerves responsible for swallow and gag reflex c. enlargment of the parotid and salivary glands d. deficiency in thiamine and pyridoxine in the central nervous system

b

the nurse administers mannitol (osmitrol) to the client with increased ICP . which parameter requires close monitoring ? a. muscle relaxation b. I &O c. widening of the pulse pressure d. pupil dilation

b

the nurse is assisting a client with a stoke who has homonymous hemianopia. the nurse should understand that the client will a. have a preference for food high in salt b. eat food on only half of the plate c. forget the names of foods d. not be able to swallow liquids

b

the nurse is preparing a clientt with MS for discharge from the hospital to home. the nurse should tell the client a. you will need to accept the necessity for a quiet and inactive lifestyle b. keep active use stress reduction strategies, and avoid fatigue c. follow good health habits to change the coursse of the disease d. practice using the mechanical aids that you will need when future disabilities arise

b

which of the following is not a typical clincal manifestation of MS? a. double vision b. sudden bursts of energy c. weakness in the extremeties d. muscle tremors

b

the nurse has established a goal to maintain intracranial pressure within the normal range for a client who had a craniotomy 12hrs ago. what should the nurse do ? select all that apply a. encourage the client to cough to expectorate secretions b.. elevate HOB 15-30 degrees c. contact doctor if ICP is >20mmHg d. monitor neurologic status using the glasgow coma scale e. stimulate the client with active ROM exercises

b,c,d

what is the priority nursing assessment in the first 24 hrs afte admission of the client with a thrombotic stroke ? a. cholesterol level b. pupil size and pupillary response c. bowel sounds d. echocardiogram

b. to if changes to cranial nerves

a client is experiencing mood swings after a stroke and often has episodes of tear-fullness that are distressing to the family. which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? a. sit quietly with the client until the episode is over b. ignore the behavior c. attempt to divert the clients attention d. tell the client that this behavior is unacceptable

c

what is the expected outcome of thrombolytic drug therapy for stroke? a. increased vascular permeability b. vasconstriction c. dissolved emoboli d. prevention of hemorrhage

c

what is the priority nursing intervention in the postictal phase of a seizure? a. reorient the client to time, place, and person b. determine the clients level of sleepiness c. assess the client breathing patterns d. position the client comfortably

c

which activity should the nurse encourage the client to avoid when there is a risk for increased ICP ? a. deep breathing b. turning c. coughing d. passive ROM

c

which intervention should the nurse suggest to help a client with MS avoid episodes of urinary incontinenece? a. limit fluid intake to 1,000 mL day b. insert an indwelling urinary catheter c. establish a regular voiding schedule d. adminster prophalyactic antibiotics as prescribed

c

a client with MS is experiencing bowel incontinence and is starting a bowel regimen program. which strategy is not appropriate? a. eating a diet high in fiber b. setting a regular time for elimination c. using an elevated toliet seat d. limiting fluid intake to 1,000mL /day

d

the nurse anticipates that the client presenting with increased intracranial pressure would most likely exhibit which set of vital signs? a. BP 190/84 HR 150 , and irregular respiratory system b. 80/50, HR 50, and Kussmaul respirations c. BP 80/50 HR 150 and cheyne-stroke respirations d. BP 190/84, HR 50, and irregular respiartory pattern

d

what nursing assessments should be documented at the beginnnig of teh ictal phase of a seizure? a. HR, BP, RR, pulse ox b. last dose of antivconvuslant and circumstances at the time c. type fo visual, auditory, and olfactory aura teh client experienced d. movement of the head and eyes and muscle rigidity

d

which instructions would the nurse give to a client with multiple sclerosis who has urinary retention? a. Run water whenever you experience difficulty initiating urination b. decrease your fluid intake to prevent urgency c. drink a caffinated beverage to promote the ability to form urine d. catheterize your bladders according to the schedule we discussed

d

which intervention is most effective in minimizing the risk of seizure activity in a client who is undergoing diagnostic studies after having experienced several episodes of seizures ? a. maintain the client on bed rest b. administer butabarbital sodium 30mg PO three times per day c. close the door to the room to minimize stimulation d. administer carbamazepine 200mg PO, twice per day

d

which of the following describe deceberate posturing ? a. internal rotation and adduction of arms with flexion of elbows, wrists, and fingers b. back hunched over, rigid flexion of all 4 extremeties with supination of arms and plantar flexion of feet c. supination of arms, dorsiflexion of the feet d. back arched, rigid extension of all 4 extremeties

d

which of the following will the nurse observe in the client in the ictal phase of a generalized tonic clonic seizure? a. jerking in one extremity that spreads gradually to adjacent areas b. vacant staring and abruptly ceasing all activity c. facial grimaces, patting motions and lip smacking d. loss of consciousness, body stiffening and violent muslcles contractions

d

a nurse is teaching a client who had a stroke about ways to adapt to a visual diability. which does the nurse identify as the primary safety precaution to use? a. wear a patch over one eye b. place personal items on the sighted side c. lie in bed with the unaffected side toward the door d. turn the head from side to side when walking

d. increases visual field

the nurse is assessing a client with increased ICP. the nurse should notify the health care provider about which of the following changes in the clients conditon? a. widening pulse pressure b. decreased pulse rate c. dilated fixed pupils d. decreased LOC

d. most sensitize and reliable indicator