Test 1 Practice Test

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The nurse is enjoying a day at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health-care provider to respond to the accident. Which intervention should be implemented first? 1. Assess the client's level of consciousness. 2. Organize onlookers to remove the client from the lake. 3. Perform a head-to-toe assessment to determine injuries. 4. Stabilize the client's cervical spine.

The nurse is performing a Glascow Coma Scale (GCS) assessment on a client with a problem with intracranial regulation. The client's GCS one (1) hour ago was scored at 10. Which datum indicates the client is improving? 1. The current GSC rating is 3. 2. The current GSC rating is 9. 3. The current GSC rating is 10. 4. The current GSC rating is 12.

The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care? 1. Observe the client swallowing for possible aspiration. 2. Position the client in a semi-Fowler's position when sleeping. 3. Place a suction setup at the client's bedside during meals. 4. Refer the client to an occupational therapist for evaluation.

Which type of precautions should the nurse implement for the client diagnosed with septic meningitis? 1. Standard Precautions. 2. Airborne Precautions. 3. Contact Precautions. 4. Droplet Precautions.

A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a) Encourage family members to remain at the bedside. b) Apply soft restraints to protect the patient from injury. c) Keep the room well-lighted to improve patient orientation. d) Minimize contact with the patient to decrease sensory input.

The nurse is caring for a client with increased intracranial pressure (ICP) who has secretions pooled in the throat. Which intervention should the nurse implement first? 1. Set the ventilator to hyperventilate the client in preparation for suctioning. 2. Assess the client's lung sounds and check for peripheral cyanosis. 3. Turn the client to the side to allow the secretions to drain from the mouth. 4. Suction the client using the in-line suction, wait 30 seconds, and repeat.

The nurse is caring for the client diagnosed with West Nile virus. Which assessment data would require immediate intervention from the nurse? 1. The vital signs are documented as T 100.2°F, P 80, R 18, and BP 136/78. 2. The client complains of generalized body aches and pains. 3. Positive results are reported from the enzyme-linked immunosorbent assay (ELISA). 4. The client becomes lethargic and is difficult to arouse using verbal stimuli.

A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? 1. Administer a stool softener bid. 2. Encourage the client to cough hourly. 3. Monitor neurological status every shift. 4. Maintain the dopamine drip to keep BP at 160/90.

The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained three (3) hours later would indicate the client is improving? 1. Purposeless movement in response to painful stimuli. 2. Flaccid paralysis in all four extremities. 3. Decerebrate posturing when painful stimuli are applied. 4. Pupils that are 6 mm in size and nonreactive on painful stimuli.

The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client's significant other? 1. Awaken the client every two (2) hours. 2. Monitor for increased intracranial pressure (ICP). 3. Observe frequently for hypervigilance. 4. Offer the client food every three (3) to four (4) hours.

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? 1. An oral anticoagulant medication. 2. A beta blocker medication. 3. An anti-hyperuricemic medication. 4. A thrombolytic medication.

The client diagnosed with septic meningitis is admitted to the medical floor at noon. Which health-care provider's order would have the highest priority? 1. Administer an intravenous antibiotic. 2. Obtain the client's lunch tray. 3. Provide a quiet, calm, and dark room. 4. Weigh the client in hospital attire.

The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as "high risk for immobility complications." Which intervention would be included in the plan of care? 1. Position the client with the head of the bed elevated at intervals. 2. Perform active range-of-motion (ROM) exercises every four (4) hours. 3. Turn the client every shift and massage bony prominences. 4. Explain all procedures to the client before performing them.

The nurse is assessing the client diagnosed with meningococcal meningitis. Which assessment data would warrant notifying the HCP? 1. Purpuric lesions on the face. 2. Complaints of light hurting the eyes. 3. Dull, aching, frontal headache. 4. Not remembering the day of the week.

The nurse is caring for a client diagnosed with encephalitis. Which is an expected outcome for the client? 1. The client will regain as much neurological function as possible. 2. The client will have no short-term memory loss. 3. The client will have improved renal function. 4. The client will apply hydrocortisone cream daily.

The nurse is caring for a client diagnosed with meningitis. Which collaborative intervention should be included in the plan of care? 1. Administer antibiotics. 2. Obtain a sputum culture. 3. Monitor the pulse oximeter. 4. Assess intake and output.

The public health department nurse is preparing a lecture on prevention of West Nile virus. Which information should the nurse include? 1. Change water daily in pet dishes and birdbaths. 2. Wear thick, dark clothing when outside to avoid bites. 3. Apply insect repellent over face and arms only. 4. Explain that mosquitoes are more prevalent in the morning.

Which client would the nurse identify as being most at risk for experiencing a cerebrovascular accident (CVA)? 1. A 55-year-old African American male. 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female.

Which collaborative intervention should the nurse implement when caring for the client with West Nile virus? 1. Complete neurovascular examinations every eight (8) hours. 2. Maintain accurate intake and output at the end of each shift. 3. Assess the client's symptoms to determine if there is improvement. 4. Administer intravenous fluids while assessing for overload.

Which intervention has the highest priority for the client in the emergency department who has been in a motorcycle collision with an automobile and has a fractured left leg? 1. Assessing the neurological status. 2. Immobilizing the fractured leg. 3. Monitoring the client's output. 4. Starting an 18-gauge saline lock.

Which problem is the highest priority for the client diagnosed with West Nile virus? 1. Alteration in body temperature. 2. Altered tissue perfusion. 3. Fluid volume excess. 4. Altered skin integrity.

The nurse is developing a plan of care for a client diagnosed with West Nile virus. Which intervention should the nurse include in this plan? 1. Monitor the client's respirations frequently. 2. Refer to a dermatologist for treatment of maculopapular rash. 3. Treat hypothermia by using ice packs under the client's arms. 4. Teach the client to report any swollen lymph glands.

The nurse is developing a plan of care for a client diagnosed with aseptic meningitis secondary to a brain tumor. Which nursing goal would be most appropriate for the client problem "altered cerebral tissue perfusion"? 1. The client will be able to complete activities of daily living. 2. The client will be protected from injury if seizure activity occurs. 3. The client will be afebrile for 48 hours prior to discharge. 4. The client will have elastic tissue turgor with ready recoil.

The nurse writes the nursing diagnosis "altered body temperature related to damaged temperature regulating mechanism" for a client with a head injury. Which would be the most appropriate goal? 1. Administer acetaminophen (Tylenol) for elevated temperature. 2. The client's temperature will remain less than 100°F. 3. Maintain the hypothermia blanket at 99°F for 24 hours. 4. The basal metabolic temperature will fluctuate no more than two (2) degrees.

The public health nurse is giving a lecture on potential outbreaks of infectious meningitis. Which population is most at risk for an outbreak? 1. Clients recently discharged from the hospital. 2. Residents of a college dormitory. 3. Individuals who visit a third world country. 4. Employees in a high-rise office building.

The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with steristrips. Which signs/symptoms would warrant transferring the resident to the emergency department? 1. A 4-cm area of bright red drainage on the dressing. 2. A weak pulse, shallow respirations, and cool pale skin. 3. Pupils that are equal, react to light, and accommodate. 4. Complaints of a headache that resolves with medication.

The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke? A. Impulsivity B. Impaired speech C. Left-side neglect D. Short attention span

The patellar tendon is struck and the leg extends with contraction of the quadriceps. What grade should this response be given? a. 1/5 b. 2/5 c. 3/5 d. 4/5

The patient has just had a myelogram. What should be included in the nursing care for this patient? a. Restrict fluids until the patient is ambulatory. b. Keep the patient positioned flat in bed for several hours. c. Position the patient with the head of the bed elevated 30 degrees. d. Provide mild analgesics for pain associated with the insertion of needles.

The patient is being monitored long term with a brain tissue oxygenation catheter. What range for the pressure of oxygen in brain tissue (PbtO2) will maintain cerebral oxygen supply and demand? a. 55% to 75% b. 20 to 40 mm Hg c. 70 to 150 mm Hg d. 80 to 100 mm Hg

The priority nursing assessment for a patient being admitted with a brainstem infarction is a) pupil reaction. b) respiratory rate. c) reflex reaction time. d) level of consciousness.

The public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is most likely to be effective? a) Emphasize the importance of hand washing. b) Immunize adolescents and college freshman. c) Support serving healthy nutritional options in the college cafeteria. d) Encourage adolescents and young adults to avoid crowds in the winter.

Vasogenic cerebral edema increases intracranial pressure by a. shifting fluid in the gray matter. b. altering the endothelial lining of cerebral capillaries. c. leaking molecules from the intracellular fluid to the capillaries. d. altering the osmotic gradient flow into the intravascular component.

Vigorous control of fever in the patient with meningitis is required to prevent complications of increased cerebral edema, seizure frequency, neurologic damage, and fluid loss. What nursing care should be included? a. Administer analgesics as ordered. b. Monitor LOC related to increased brain metabolism. c. Rapidly decrease temperature with a cooling blanket. d. Assess for peripheral edema from rapid fluid infusion.

What are the key manifestations of bacterial meningitis? a. Papilledema and psychomotor seizures b. High fever, nuchal rigidity, and severe headache c. Behavioral changes with memory loss and lethargy d. Jerky eye movements, loss of corneal reflex, and hemiparesis

What is the best explanation of stereotactic radiosurgery? a. Radioactive seeds are implanted in the brain. b. Very precisely focused radiation destroys tumor cells. c. Tubes are placed to redirect CSF from one area to another. d. The cranium is opened with removal of a bone flap to open the dura.

What is the neurologic diagnostic test that has the highest risk of complications and requires frequent monitoring of neurologic and vital signs following the procedure? a. Electromyelogram b. Cerebral angiography c. Electroencephalogram d. Transcranial Doppler sonography

What is the normal response to striking the triceps tendon with a reflex hammer? a. Forearm pronation b. Extension of the arm c. Flexion of the arm at the elbow d. Flexion and supination of the elbow

What is the purpose of the dendrite? a. Provides gap in peripheral nerve axons b. Carries impulses to the nerve cell body c. Carries impulses from the nerve cell body d. Helps to repair damage to peripheral axons

When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis a) to monitor and record the blood pressure daily. b) to call the health care provider if stools are tarry. c) that clopidogrel will dissolve clots in the cerebral arteries. d) that clopidogrel will reduce cerebral artery plaque formation.

When using intraventricular ICP monitoring, what should the nurse be aware of to prevent inaccurate readings? a. The P2 wave is higher than the P1 wave. b. CSF is leaking around the monitoring device. c. The stopcock of the drainage device is open to drain the CSF fluid. d. The transducer of the ventriculostomy monitor is at the level of the upper ear.

When using the heel-to-shin test, for what abnormality is the nurse assessing the patient? a. Hypertonia b. Lack of coordination c. Extension of the toes d. Loss of proprioception

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness? a) Coordinate the transfer of the patient to the operating room. b) Provide discharge instructions about monitoring neurologic status. c) Transport the patient to radiology for magnetic resonance imaging (MRI). d) Arrange to admit the patient to the neurologic unit for 24 hours of observation.

Which action will the nurse include in the plan of care for a patient with impaired functioning of the left glossopharyngeal nerve (CN IX) and vagus nerve (CN X)? a) Assist to stand and ambulate. b) Withhold oral fluids and food. c) Insert an oropharyngeal airway. d) Apply artificial tears every hour.

Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community? a) Teach about prophylactic antibiotics after exposure to encephalitis. b) Encourage the use of effective insect repellent during mosquito season. c) Remind patients that most cases of viral encephalitis can be cared for at home. d) Arrange to screen school-age children for West Nile virus during the school year.

Which cerebrospinal fluid analysis result should the nurse recognize as abnormal and communicate to the health care provider? a) Specific gravity of 1.007 b) Protein of 65 mg/dL (0.65 g/L) c) Glucose of 45 mg/dL (1.7 mmol/L) d) White blood cell (WBC) count of 4 cells/mL

Which equipment will the nurse obtain to assess vibration sense in a patient with diabetes who has peripheral nerve dysfunction? a) Sharp pin b) Tuning fork c) Reflex hammer d) Calibrated compass

Which finding would the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion? a) Spasticity b) Flaccidity c) Impaired sensation d) Hyperactive reflexes

Which information about a 76-yr-old patient should the nurse report as uncharacteristic of normal aging? a) Triceps reflex response graded at 1/5 b) Unintended weight loss of 15 pounds c) 10 mm Hg orthostatic drop in systolic blood pressure d) Patient complaint of chronic difficulty in falling asleep

Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? a) The patient complains of having a stiff neck. b) The patient's blood pressure (BP) is 90/50 mm Hg. c) The patient reports a severe and unrelenting headache. d) The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

Which problem can the nurse expect for a patient who has a positive Romberg test result? a. Pain b. Falls c. Aphasia d. Confusion

Which question will the nurse ask a patient who has been admitted with a benign occipital lobe tumor to assess for functional deficits? a) "Do you have difficulty in hearing?" b) "Are you experiencing visual problems?" c) "Are you having any trouble with your balance?" d) "Have you developed any weakness on one side?"

Which statement by patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse? a) "I will return if I feel dizzy or nauseated." b) "I am going to drive home and go to bed." c) "I do not even remember being in an accident." d) "I can take acetaminophen (Tylenol) for my headache."

The nurse is completing a health assessment for a newly admitted patient. Which assessment should the nurse perform to determine the cognitive function of the patient? a) Ask the patient a question such as, "Who were the last three presidents?" b) Determine the level of consciousness, body posture, and facial expressions. c) Observe for signs of agitation, anger, or depression during the health check. d) Request that the patient mimic rapid alternating movements with both hands.

The patient is admitted to the emergency department having difficulty with respiratory, vasomotor, and cardiac function. Which portion of the brain is affected to cause these manifestations? a. Medulla b. Cerebellum c. Parietal lobe d. Wernicke's area

The patient with diabetes mellitus had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient? A. Safety measures B. Patience with communication C. Mobility assistance on the right side D. Place food in the left side of patient's mouth.

The patient's magnetic resonance imaging revealed the presence of a brain tumor. The nurse anticipates which treatment modality? A. Surgery B. Chemotherapy C. Radiation therapy D. Biologic drug therapy

The significant other of a client diagnosed with a brain tumor asks the nurse for help identifying resources. Which would be the most appropriate referral for the nurse to make? a. Social worker. b. Chaplain. c. Health-care provider. d. Occupational therapist.

What is an appropriate nursing intervention to promote communication during rehabilitation of the patient with aphasia? a. Allow time for the individual to complete his/her thoughts. b. Use gestures, pictures, and music to stimulate patient responses. c. Structure statements so that the patient does not have to respond verbally. d. Use flashcards with simple words and pictures to promote recall of language.

What is different when a lesion occurs in a lower motor neuron compared to in an upper motor neuron? a. Causes hyporeflexia and flaccidity b. Affects motor control of the lower body c. Arises in structures above the spinal cord d. Interferes with reflex arcs in the spinal cord

What nursing intervention should be implemented for a patient experiencing increased intracranial pressure (ICP)? A. Monitor fluid and electrolyte status carefully. B. Position the patient in a high Fowler's position. C. Administer vasoconstrictors to maintain cerebral perfusion. D. Maintain physical restraints to prevent episodes of agitation.

When admitting an acutely confused patient with a head injury, which action should the nurse take? a) Ask family members about the patient's health history. b) Ask leading questions to assist in obtaining health data. c) Wait until the patient is better oriented to ask questions. d) Obtain only the physiologic neurologic assessment data.

When assessing a patient with a traumatic brain injury, the nurse notes uncoordinated movement of the extremities. How should the nurse document this assessment? a) Ataxia b) Apraxia c) Anisocoria d) Anosognosia

Which modifiable risk factor for stroke would be most important for the nurse to include when planning a community education program? A. Hypertension B. Hyperlipidemia C. Alcohol consumption D. Oral contraceptive use

Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit? a) A 45-yr-old patient receiving IV antibiotics for meningococcal meningitis b) A 35-yr-old patient with intracranial pressure (ICP) monitoring after a head injury c) A 25-yr-old patient admitted with a skull fracture and craniotomy the previous day d) A 55-yr-old patient who has increased intracranial pressure (ICP) and is receiving hyperventilation therapy

Which type of stroke is associated with endocardial disorders, has a rapid onset, and is likely to occur during activity? a. Embolic b. Thrombotic c. Intracerebral hemorrhage d. Subarachnoid hemorrhage

While admitting a 42-yr-old patient with a possible brain injury after a car accident to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider? a) The patient takes warfarin (Coumadin) daily. b) The patient's blood pressure is 162/94 mm Hg. c) The patient is unable to remember the accident. d) The patient complains of a severe dull headache.

Why is the Glasgow Coma Scale (GCS) used? a. To quickly assess the LOC b. To assess the patient's ability to communicate c. To assess the patient's ability to respond to commands d. To assess the patient's coordination with motor responses

The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. Which complications will the nurse monitor for (select all that apply.)? A. Seizures B. Vision loss C. Cerebral edema D. Pituitary dysfunction E. Parathyroid dysfunction F. Focal neurologic deficits

A, B, C, D, F

Which conditions can lead to the development of a brain abscess (select all that apply.)? A. Endocarditis B. Ear infection C. Tooth abscess D. Skull fracture E. Scalp laceration F. Sinus infection

A, B, C, D, F

Stimulation of the parasympathetic nervous system results in (select all that apply) a. constriction of the bronchi. b. dilation of skin blood vessels. c. increased secretion of insulin. d. increased blood glucose levels. e. relaxation of the urinary sphincters.

A, B, C, E

The client is being discharged following a transsphenoidal hypophysectomy. Which discharge instructions should the nurse teach the client? Select all that apply. a. Sleep with the head of the bed elevated. b. Keep a humidifier in the room. c. Use caution when performing oral care. d. Stay on a full liquid diet until seen by the HCP. e. Notify the HCP if developing a cold or fever.

A, B, C, E

What are characteristics of a stroke caused by an intracerebral hemorrhage (select all that apply)? a. Carries a poor prognosis b. Caused by rupture of a vessel c. Strong association with hypertension d. Commonly occurs during or after sleep e. Creates a mass that compresses the brain

A, B, C, E

Which events cause increased ICP (select all that apply)? a. Vasodilation b. Necrotic cerebral tissue c. Blood vessel compression d. Edema from initial brain insult e. Brainstem compression and herniation

A, B, D

After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first? a) Document the increase in intracranial pressure. b) Ensure that the patient's neck is in neutral position. c) Notify the health care provider about the change in pressure. d) Increase the rate of the prescribed propofol (Diprivan) infusion.

After evacuation of an epidural hematoma, a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider? a) Pulse of 102 beats/min b) Temperature of 101.6° F c) Intracranial pressure of 15 mm Hg d) Mean arterial pressure of 90 mm Hg

After talking with the HCP, the patient asks what the blood-brain barrier does. What is the best description that the nurse can give the patient? a. Protects the brain from external trauma b. Protects against harmful blood-borne agents c. Provides for flexibility while protecting the spinal cord d. Forms the outer layer of protective membranes around the brain and spinal cord

An unconscious male patient has just arrived in the emergency department with a head injury caused by a motorcycle crash. Which order should the nurse question? a) Obtain x-rays of the skull and spine. b) Prepare the patient for lumbar puncture. c) Send for computed tomography (CT) scan. d) Perform neurologic checks every 15 minutes.

Assisting the family to understand what is happening to the patient is an especially important role of the nurse when the patient has a tumor in which part of the brain? a. Ventricles b. Frontal lobe c. Parietal lobe d. Occipital lobe

Decerebrate posture is documented in the chart of the patient that the nurse will be caring for. The nurse should know that the patient may have elevated intracranial pressure (ICP), causing serious disruption of motor fibers in the midbrain and brainstem and will expect the patient's posture to look like which posture represented below? A. B. C. D.

During the admitting neurologic examination, the nurse determines the patient has speech difficulties as well as weakness of the right arm and lower face. The nurse would expect a CT scan to show pathology in the distribution of the a. basilar artery. b. left middle cerebral artery. c. right anterior cerebral artery. d. left posterior communicating artery.

The nurse is performing a neurologic assessment for a patient. When assessing the accessory nerve, what action should the nurse take? a) Assess the gag reflex by stroking the posterior pharynx. b) Ask the patient to shrug the shoulders against resistance. c) Ask the patient to push the tongue to either side against resistance. d) Have the patient say "ah" while visualizing elevation of soft palate.

The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? a) The staff nurse assesses neurologic status every hour. b) The staff nurse elevates the head of the bed to 30 degrees. c) The staff nurse suctions the patient routinely every 2 hours. d) The staff nurse administers an analgesic before turning the patient.

The client diagnosed with breast cancer has developed metastasis to the brain. Which prophylactic measure should the nurse implement? a) Institute aspiration precautions. b) Refer the client to Reach to Recovery. c) Initiate seizure precautions. d) Teach the client about mastectomy care.

The client is diagnosed with a pituitary tumor and is scheduled for a transsphenoidal hypophysectomy. Which preoperative instruction is important for the nurse to teach? a. There will be a large turban dressing around the skull after surgery. b. The client will not be able to eat for four (4) or five (5) days postop. c. The client should not blow the nose for two (2) weeks after surgery. d. The client will have to lie flat for 24 hours following the surgery.

The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the a. amount of cardiac output. b. O2 content of the blood. c. degree of collateral circulation. d. level of CO2 in the blood.

The home health nurse is caring for an 81-yr-old who had a stroke 2 months ago. Based on information shown in the accompanying figure from the history, physical assessment, and physical and occupational therapy, which problem is the highest priority? a) Risk for hypoglycemia b) Impaired transfer ability c) Risk for caregiver role strain d) Ineffective health maintenance

The nurse explains to the patient with a stroke who is scheduled for angiography that this test is used to determine the a. presence of increased ICP. b. site and size of the infarction. c. patency of the cerebral blood vessels. d. presence of blood in the cerebrospinal fluid.

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness? a) Blood pressure b) Oxygen saturation c) Intracranial pressure d) Hemoglobin and hematocrit

The nurse has written a care plan for a client diagnosed with a brain tumor. Which is an important goal regarding self-care deficit? a. The client will maintain body weight within two (2) pounds. b. The client will execute an advance directive. c. The client will be able to perform three (3) ADLs with assistance. d. The client will verbalize feeling of loss by the end of the shift.

The nurse is admitting a patient with a diagnosis of frontal lobe dementia. What functional difficulties should the nurse expect in this patient? a) Lack of reflexes b) Endocrine problems c) Higher cognitive function abnormalities d) Respiratory, vasomotor, and cardiac dysfunction

The nurse is alerted to a possible acute subdural hematoma in the patient who a. has a linear skull fracture crossing a major artery. b. has focal symptoms of brain damage with no recollection of a head injury. c. develops decreased level of consciousness and a headache within 48 hours of a head injury. d. has an immediate loss of consciousness with a brief lucid interval followed by decreasing level of consciousness.

The nurse is caring for a group of healthy older adults at a community day center. Which neurologic finding associated with aging would the nurse expect to note in older adults? a) Quicker reaction time b) Improved sense of taste c) Orthostatic hypotension d) Hyperactive deep tendon reflexes

The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires rapid action by the nurse? a) The apical pulse is slightly irregular. b) The patient complains of a headache. c) The patient is more difficult to arouse. d) The blood pressure (BP) increases to 140/62 mm Hg.

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a) Assess the patient's gag and cough reflexes. b) Determine when the stroke symptoms began. c) Administer the prescribed short-acting insulin. d) Infuse the prescribed IV metoprolol (Lopressor).

The nurse is planning psychosocial support for the family of the patient who suffered a stroke. What factor will have the greatest impact on family coping? A. Specific patient neurologic deficits B. The patient's ability to communicate C. Rehabilitation potential of the patient D. Presence of complications of a stroke

The nurse is preparing the patient for an electromyogram (EMG). What should the nurse include in teaching the patient before the test? a) The patient will be tilted on a table during the test. b) It is noninvasive, and there is no risk of electric shock. c) The pain that occurs is from the insertion of the needles. d) The passive sensor does not make contact with the patient.

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first? a. Patient with a skull fracture whose nose is bleeding b. Older patient with a stroke who is confused and whose daughter is present c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-to-10 scale d. Patient who had a craniotomy for a brain tumor and who is now 3 days postoperative and has had continued vomiting

The nurse performing a focused assessment of left posterior temporal lobe functions will assess the patient for a) sensation on the left side of the body. b) reasoning and problem-solving ability. c) ability to understand written and oral language. d) voluntary movements on the right side of the body.

The nurse prepares to administer temozolomide (Temodar) to a 59-yr-old white male patient with a glioblastoma multiforme (GBM) brain tumor. What should the nurse assess before giving the medication? A. Serum potassium and serum sodium levels B. Urine osmolality and urine specific gravity C. Absolute neutrophil count and platelet count D. Cerebrospinal fluid pressure and cell count

The nurse recognizes the presence of Cushing's triad in the patient with which vital sign changes? a. Increased pulse, irregular respiration, increased BP b. Decreased pulse, increased respiration, decreased systolic BP c. Decreased pulse, irregular respiration, widened pulse pressure d. Increased pulse, decreased respiration, widened pulse pressure

The patient comes to the emergency department (ED) with cortical blindness and visual field defects. Which type of head injury does the nurse suspect? a. Cerebral contusion b. Orbital skull fracture c. Posterior fossa fracture d. Frontal lobe skull fracture

The patient has a depressed skull fracture and scalp lacerations with communication to the intracranial cavity. Which type of injury should the nurse record? a. Linear skull fracture b. Depressed skull fracture c. Compound skull fracture d. Comminuted skull fracture

The patient has a lack of comprehension of both verbal and written language. Which type of communication difficulty does this patient have? a. Dysarthria b. Fluent dysphasia c. Receptive aphasia d. Expressive aphasia

The patient with a brain tumor is being monitored for increased intracranial pressure (ICP) with a ventriculostomy. What nursing intervention is priority? A. Administer IV mannitol B. Ventilator use to hyperoxygenate the patient C. Use strict aseptic technique with dressing changes. D. Be aware of changes in ICP related to leaking cerebrospinal fluid (CSF).

The physician orders intracranial pressure (ICP) readings every hour for a 23-yr-old male patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. It is most important for the nurse to take which action? A. Document the ICP reading in the chart. B. Determine if the patient has a headache. C. Assess the patient's level of consciousness. D. Position the patient with head elevated 60 degrees.

To assess the functions of the trigeminal and facial nerves (CNs V and VII), the nurse should a) check for unilateral eyelid droop. b) shine a light into the patient's pupil. c) touch a cotton wisp strand to the cornea. d) have the patient read a magazine or book.

What functions does the thalamus have? a. Registers auditory input b. Integrates past experiences c. Relays sensory and motor input to and from the cerebrum d. Controls and facilitates learned and automatic movements

What happens at the synapse? a. The synapse physically joins two neurons. b. The nerve impulse is transmitted only from one neuron to another neuron. c. The presynaptic terminal submits a nerve impulse through the synaptic cleft to the receptor site on the postsynaptic cell. d. When a presynaptic cell releases excitatory neurotransmitters, the postsynaptic cell depolarizes enough to generate an action potential.

What is an appropriate food for a patient with a stroke who has mild dysphagia? a. Fruit juices b. Pureed meat c. Scrambled eggs d. Fortified milkshakes

What is demonstrated when the patient stands with the feet close together and eyes closed and the patient sways or falls? a. Pronator drift b. Absent patellar reflex c. Positive Romberg test d. Absence of two-point discrimination

What primarily determines the neurologic functions that are affected by a stroke? a. The amount of tissue area involved b. The rapidity of the onset of symptoms c. The brain area perfused by the affected artery d. The presence or absence of collateral circulation

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as a) flexion withdrawal. b) localization of pain. c) decorticate posturing. d) decerebrate posturing.

When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? a) Apply an eye patch to the right eye. b) Approach the patient from the right side. c) Place needed objects on the patient's left side. d) Teach the patient that the left visual deficit will resolve.

When providing care to the patient with an acute stroke, which duty can be delegated to the LPN/LVN? A. Screen patient for tPA eligibility. B. Assess the patient's ability to swallow. C. Administer scheduled anticoagulant medications. D. Place equipment needed for seizure precautions in room.

Which CN is tested with tongue protrusion? a. Vagus (CN X) b. Olfactory (CN I) c. Hypoglossal (CN XII) d. Glossopharyngeal (CN IX)

Which area of the brain regulates functions of the endocrine system and autonomic nervous system (ANS)? a. Basal ganglia b. Temporal lobe c. Hypothalamus d. Reticular activating system

Which information about a 30-yr-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? a) Intracranial pressure of 15 mm Hg b) Cerebrospinal fluid (CSF) drainage of 25 mL/hr c) Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg d) Cardiac monitor shows sinus tachycardia at 120 beats/minute

Which nursing action will be included in the plan of care for a patient who has had cerebral angiography? a) Monitor for headache and photophobia. b) Keep patient NPO until gag reflex returns. c) Check pulse and blood pressure frequently. d) Assess orientation to person, place, and time.

Which of the following CNs responds to the corneal reflex test? a. Optic (CN II) b. Vagus (CN X) c. Trigeminal (CN V) d. Spinal accessory (CN XI)

Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? A. Overestimation of physical abilities B. Difficulty judging position and distance C. Slow and possibly fearful performance of tasks D. Impulsivity and impatience at performing tasks

Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to address? a) The patient is 25 lb above the ideal weight. b) The patient drinks a glass of red wine with dinner daily. c) The patient's usual blood pressure (BP) is 170/94 mm Hg. d) The patient works at a desk and relaxes by watching television.

Which type of macroglial cells myelinate peripheral nerve fibers? a. Neurons b. Astrocytes c. Schwann cells d. Ependymal cells

A thrombus that develops in a cerebral artery does not always cause a loss of neurologic function because a. the body can dissolve atherosclerotic plaques as they form. b. some tissues of the brain do not require constant blood supply to prevent damage. c. circulation via the Circle of Willis may provide blood supply to the affected area of the brain. d. neurologic deficits occur only when major arteries are occluded by thrombus formation around atherosclerotic plaque.

After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about a) cerebral aneurysm clipping. b) heparin intravenous infusion. c) oral low-dose aspirin therapy. d) tissue plasminogen activator (tPA).

An early sign of increased ICP that the nurse should assess for is a. Cushing's triad. b. unexpected vomiting. c. decreasing level of consciousness (LOC). d. dilated pupil with sluggish response to light.

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient? a) Impaired physical mobility related to weakness b) Disturbed sensory perception related to brain injury c) Risk for impaired skin integrity related to immobility d) Risk for aspiration related to inability to protect airway

Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is a(n) a. obese 45-yr-old Native American. b. 35-yr-old Asian American woman who smokes. c. 32-yr-old white woman taking oral contraceptives. d. 65-yr-old African American man with hypertension.

The nurse is teaching a senior citizen's group about signs and symptoms of a stroke. Which statement by the nurse would provide accurate information? A. "Take the person to the hospital if a headache lasts for more than 24 hours." B. "Stroke symptoms usually start when the person is awake and physically active." C. "A person with a transient ischemic attack has mild symptoms that will go away." D. "Call 911 immediately if a person develops slurred speech or difficulty speaking."

The nurse observes a student nurse assigned to initiate oral feedings for a 68-yr-old woman with an ischemic stroke. Which action by the student will require the nurse to intervene? A. Giving the patient 1 oz of water to swallow B. Telling the patient to perform a chin tuck before swallowing C. Assisting the patient to sit in a chair before feeding the patient D. Assessing cranial nerves III, IV, and VI before attempting feeding

The nurse suspects the presence of an arterial epidural hematoma in the patient who experiences a. failure to regain consciousness following a head injury. b. a rapid deterioration of neurologic function within 24 to 48 hours following a head injury. c. nonspecific, nonlocalizing progression of alteration in LOC occurring over weeks or months. d. unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC.

The nurse will anticipate teaching a patient with a possible seizure disorder about which test? a) Cerebral angiography b) Evoked potential studies c) Electromyography (EMG) d) Electroencephalography (EEG)

The patient has been diagnosed with a cerebral concussion. What should the nurse expect to see in this patient? a. Deafness, loss of taste, and CSF otorrhea b. CSF otorrhea, vertigo, and Battle's sign with a dural tear c. Boggy temporal muscle because of extravasation of blood d. Headache, retrograde amnesia, and transient reduction in LOC

The patient is suspected of having a new brain tumor. Which test will the nurse expect to be ordered to detect a small tumor? a. CT scan b. Angiography c. Electroencephalography (EEG) d. Positron emission tomography (PET) scan

What is a nursing intervention that is indicated for the patient with hemiplegia? a. The use of a footboard to prevent plantar flexion b. Immobilization of the affected arm against the chest with a sling c. Positioning the patient in bed with each joint lower than the joint proximal to it d. Having the patient perform passive range of motion (ROM) of the affected limb with the unaffected limb

What is the protective fluid of the central nervous system (CNS)? a. Synaptic cleft b. Limbic system c. Myelin sheath d. Cerebrospinal fluid (CSF)

What method is used to assess for extinction? a. Cotton wisp b. Sharp and dull end of a pin c. Tuning fork to bony prominences d. Simultaneously touching both sides of the body

What should the nurse do to prepare a patient for a lumbar puncture? a. Sedate the patient with medication before the test. b. Withhold beverages containing caffeine for 8 hours. c. Assess the patient for a stroke before the procedure for baseline data

What would best indicate successful achievement of outcomes for the patient with cranial surgery? a. Ability to return home in 6 days b. Ability to meet all self-care needs c. Acceptance of residual neurologic deficits d. Absence of signs and symptoms of increased ICP

When assessing a 53-yr-old patient with bacterial meningitis, the nurse obtains the following data. Which finding requires the most immediate intervention? a) The patient exhibits nuchal rigidity. b) The patient has a positive Kernig's sign. c) The patient's temperature is 101° F (38.3° C). d) The patient's blood pressure is 88/42 mm Hg.

When assessing motor function of a patient admitted with a stroke, the nurse notes mild weakness of the arm. The patient also is unable to hold the arm level. How should the nurse most accurately document this finding? a) Athetosis b) Hypotonia c) Hemiparesis d) Pronator drift

Which cranial surgery would require the patient to learn how to protect the surgical area from trauma? a. Burr holes b. Craniotomy c. Cranioplasty d. Craniectomy

Which drug treatment helps to decrease ICP by expanding plasma and the osmotic effect to move fluid? a. Dexamethasone b. Oxygen administration c. Pentobarbital (Nembutal) d. Mannitol (Osmitrol) (25%)

Which intervention is most appropriate when communicating with a patient with aphasia after a stroke? A. Present several thoughts at once so that the patient can connect the ideas. B. Ask open-ended questions to provide the patient the opportunity to speak. C. Finish the patient's sentences to minimize frustration associated with slow speech. D. Use simple, short sentences accompanied by visual cues to enhance comprehension.

Which is the correct point on the accompanying figure where the nurse will assess for ecchymosis when admitting a patient with a basilar skull fracture? A B C D

Which intervention should the nurse implement to decrease increased intracranial pressure (ICP) for a client on a ventilator? Select all that apply. 1. Position the client with the head of the bed up 30 degrees. 2. Cluster activities of care. 3. Suction the client every three (3) hours. 4. Administer soapsuds enemas until clear. 5. Place the client in Trendelenburg position.

1, 2

The nurse is admitting the client for rule-out encephalitis. Which interventions should the nurse assess to support the diagnosis of encephalitis? Select all that apply. 1. Determine if the client has recently received any immunizations. 2. Ask the client if he or she has had a cold in the last week. 3. Check to see if the client has active herpes simplex 1. 4. Find out if the client has traveled to the Great Lakes region. 5. Assess for exposure to soil with fungal spores.

1, 2, 3

The nurse is preparing a client diagnosed with rule-out meningitis for a lumbar puncture. Which interventions should the nurse implement? Select all that apply. 1. Obtain an informed consent from the client or significant other. 2. Have the client empty the bladder prior to the procedure. 3. Place the client in a side-lying position with the back arched. 4. Instruct the client to breathe rapidly and deeply during the procedure. 5. Explain to the client what to expect during the procedure.

1, 2, 3, 5

Which intervention should the nurse implement when caring for the client diagnosed with encephalitis? Select all that apply. 1. Turn the client every two (2) hours. 2. Encourage the client to increase fluids. 3. Keep the client in the supine position. 4. Assess for deep vein thrombosis (DVT). 5. Assess for any alterations in elimination.

1, 2, 4, 5

The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestation would the nurse document? 1. Hemiparesis of the client's left arm and apraxia. 2. Paralysis of the right side of the body and ataxia. 3. Homonymous hemianopsia and diplopia. 4. Impulsive behavior and hostility toward family.

The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. 1. Position the client to prevent shoulder adduction. 2. Turn and reposition the client every shift. 3. Encourage the client to move the affected side. 4. Perform quadriceps exercises three (3) times a day. 5. Instruct the client to hold the fingers in a fist.

1, 3

The male client is admitted to the emergency department following a motorcycle accident. The client was not wearing a helmet and struck his head on the pavement. The nurse identifies the concept as impaired intracranial regulation. Which interventions should the emergency department nurse implement in the first five (5) minutes? Select all that apply. 1. Stabilize the client's neck and spine. 2. Contact the organ procurement organization to speak with the family. 3. Elevate the head of the bed to 70 degrees. 4. Perform a Glasgow Coma Scale assessment. 5. Ensure the client has a patent peripheral venous catheter in place. 6. Check the client's driver's license to see if he will accept blood.

1, 4, 5

The nurse is caring for the client with encephalitis. Which intervention should the nurse implement first if the client is experiencing a complication? 1. Examine pupil reactions to light. 2. Assess level of consciousness. 3. Observe for seizure activity. 4. Monitor vital signs every shift.

The 29-year-old client who was employed as a forklift operator sustains a traumatic brain injury (TBI) secondary to a motor-vehicle accident. The client is being discharged from the rehabilitation unit after three (3) months and has cognitive deficits. Which goal would be most realistic for this client? 1. The client will return to work within six (6) months. 2. The client is able to focus and stay on task for 10 minutes. 3. The client will be able to dress self without assistance. 4. The client will regain bowel and bladder control.

The ambulance brings the client with a head injury to the emergency department. The client responds to painful stimuli by opening the eyes, muttering, and pulling away from the nurse. How would the nurse rate this client on the Glasgow Coma Scale? 1. 3 2. 8 3. 10 4. 15

The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question? 1. A subcutaneous anticoagulant. 2. An intravenous osmotic diuretic. 3. An oral anticonvulsant. 4. An oral proton pump inhibitor.

The client diagnosed with atrial fibrillation complains of numbness and tingling of her left arm and leg. The nurse assesses facial drooping on the left side and slight slurring of speech. Which nursing interventions should the nurse implement first? 1. Schedule a STAT Magnetic Resonance Imaging of the brain. 2. Call a Code STROKE. 3. Notify the health-care provider (HCP). 4. Have the client swallow a glass of water.

The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? 1. Potential for injury. 2. Powerlessness. 3. Disturbed thought processes. 4. Sexual dysfunction.

The client is diagnosed with meningococcal meningitis. Which preventive measure would the nurse expect the health-care provider to order for the significant others in the home? 1. The Haemophilus influenzae vaccine. 2. Antimicrobial chemoprophylaxis. 3. A 10-day dose pack of corticosteroids. 4. A gamma globulin injection.

Which statement best describes the scientific rationale for alternating a nonnarcotic antipyretic and a nonsteroidal anti-inflammatory drug (NSAID) every two (2) hours to a female client diagnosed with bacterial meningitis? 1. This regimen helps to decrease the purulent exudate surrounding the meninges. 2. These medications will decrease intracranial pressure and brain metabolism. 3. These medications will increase the client's memory and orientation. 4. This will help prevent a yeast infection secondary to antibiotic therapy.

Which diagnostic evaluation tool would the nurse use to assess the client's cognitive functioning? Select all that apply. 1. The Geriatric Depression Scale (GDS). 2. The St. Louis University Mental Status (SLUMS) scale. 3. The Mini-Mental Status Examination (MMSE) scale. 4. The Manic Depression vs Elderly Depression (MDED) scale. 5. The Functional Independence Measurement Scale (FIMS).

2, 3

The 28-year-old client is on the rehabilitation unit post spinal cord injury at level T10. Which collaborative team members should participate with the nurse at the case conference? Select all that apply. 1. Occupational Therapist (OT). 2. Physical therapist (PT). 3. Registered dietitian (RD). 4. Rehabilitation physician. 5. Social Worker (SW). 6. Patient care tech (PCT).

2, 3, 4, 5

The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply. 1. Maintain the head of the bed at 60 degrees of elevation. 2. Administer stool softeners daily. 3. Ensure the pulse oximeter reading is higher than 93%. 4. Perform deep nasal suction every two (2) hours. 5. Administer mild sedatives.

2, 3, 5

A 78-year-old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for a STAT computed tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult.

The client admitted to the hospital to rule out encephalitis is being prepared for a lumbar puncture. Which instructions should the nurse teach the client regarding care postprocedure? 1. Instruct that all invasive procedures require a written permission. 2. Explain that this allows analysis of a sample of the cerebrospinal fluid. 3. Tell the client to increase fluid intake to 300 mL for the next 48 hours. 4. Discuss that lying supine with the head flat will prevent all hematomas.

The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is "brain dead." Which data support that the client is brain dead? 1. When the client's head is turned to the right, the eyes turn to the right. 2. The electroencephalogram (EEG) has identifiable waveforms. 3. No eye activity is observed when the cold caloric test is performed. 4. The client assumes decorticate posturing when painful stimuli are applied.

The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first? 1. Notify the health-care provider immediately. 2. Prepare to administer an antihistamine. 3. Test the drainage for presence of glucose. 4. Place a 2 × 2 gauze under the nose to collect drainage.

The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The assistant places a gait belt around the client's waist prior to ambulating. 2. The assistant places the client on the back with the client's head to the side. 3. The assistant places a hand under the client's right axilla to move up in bed. 4. The assistant praises the client for attempting to perform ADLs independently.

The nurse is assessing the client diagnosed with bacterial meningitis. Which clinical manifestations would support the diagnosis of bacterial meningitis? 1. Positive Babinski's sign and peripheral paresthesia. 2. Negative Chvostek's sign and facial tingling. 3. Positive Kernig's sign and nuchal rigidity. 4. Negative Trousseau's sign and nystagmus.

The nurse is caring for several clients. Which client would the nurse assess first after receiving the shift report? 1. The 22-year-old male client diagnosed with a concussion who is complaining someone is waking him up every two (2) hours. 2. The 36-year-old female client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan. 3. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale (GCS) score of 6. 4. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia.

The wife of the client diagnosed with septic meningitis asks the nurse, "I am so scared. What is meningitis?" Which statement would be the most appropriate response by the nurse? 1. "There is bleeding into his brain causing irritation of the meninges." 2. "A virus has infected the brain and meninges, causing inflammation." 3. "It is a bacterial infection of the tissues that cover the brain and spinal cord." 4. "It is an inflammation of the brain parenchyma caused by a mosquito bite."

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? 1. A blood glucose level of 480 mg/dL. 2. A right-sided carotid bruit. 3. A blood pressure (BP) of 220/120 mm Hg. 4. The presence of bronchogenic carcinoma.

Which potential pituitary complication should the nurse assess for in the client diagnosed with a traumatic brain injury (TBI)? 1. Diabetes mellitus type 2 (DM 2). 2. Seizure activity. 3. Syndrome of inappropriate antidiuretic hormone (SIADH). 4. Cushing's disease.

Which rationale explains the transmission of the West Nile virus? 1. Transmission occurs through exchange of body fluids when sneezing and coughing. 2. Transmission occurs only through mosquito bites and not between humans. 3. Transmission can occur from human to human in blood products and breast milk. 4. Transmission occurs with direct contact from the maculopapular rash drainage.

The nurse is assessing the client admitted with encephalitis. Which data require immediate nursing intervention? The client has bilateral facial palsies. 1. The client has bilateral facial palsies. 2. The client has a recurrent temperature of 100.6°F. 3. The client has a decreased complaint of headache. 4. The client comments that the meal has no taste.

The 29-year-old client is admitted to the medical floor diagnosed with meningitis. Which assessment by the nurse has priority? 1. Assess lung sounds. 2. Assess the six cardinal fields of gaze. 3. Assess apical pulse. 4. Assess level of consciousness.

The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? 1. Administer a nonnarcotic analgesic. 2. Prepare for STAT magnetic resonance imaging (MRI). 3. Start an intravenous infusion with D5W at 100 mL/hr. 4. Complete a neurological assessment.

The charge nurse on a medical-surgical unit is reviewing client diagnostic reports. Which report warrants immediate intervention? 1. Client A - Male 64 2. Client B - Female 34 3. Client C - Male 45 4. Client D - Female 56

The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? 1. Obtain a rubber mat to place under the dinner plate. 2. Purchase a long-handled bath sponge for showering. 3. Purchase clothes with Velcro closure devices. 4. Obtain a raised toilet seat for the client's bathroom.

The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? 1. Assess neurological status. 2. Monitor pulse, respiration, and blood pressure. 3. Initiate an intravenous access. 4. Maintain an adequate airway.

The concept of intracranial regulation is identified for a client diagnosed with a brain tumor. Which intervention should the nurse include in the client's plan of care? 1. Tell the client to remain on bedrest. 2. Maintain the intravenous rate at 150 mL/hour. 3. Provide a soft, bland diet with three (3) snacks per day. 4. Place the client on seizure precautions.

The intensive care unit nurse is admitting a client with a traumatic brain injury. Which health-care provider medication order would the nurse question? 1. Dexamethasone. 2. 0.9% NS. 3. Nicotine patch. 4. Morphine sulfate.

The cerebral perfusion pressure (CPP) is the pressure needed to ensure blood flow to the brain. Normal CPP is 60 to 100 mm Hg. Calculate the CPP of a patient whose blood pressure (BP) is 106/52 mm Hg and ICP is 14 mm Hg. ________________________________________________ mm Hg

An unconscious patient with a traumatic head injury has a blood pressure of 130/76 mm Hg and an intracranial pressure (ICP) of 20 mm Hg. The nurse will calculate the cerebral perfusion pressure (CPP) as ____ mm Hg.

Calculate the CPP for the patient with an ICP of 34 mm Hg and a systemic BP of 108/64 mm Hg. ________________________________________________ mm Hg

A patient is suspected of having a brain tumor. The signs and symptoms include memory deficits, visual disturbances, weakness of right upper and lower extremities, and personality changes. The nurse recognizes that the tumor is most likely located in the a. frontal lobe. b. parietal lobe. c. occipital lobe. d. temporal lobe.

A 68-yr-old male patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first? a) Check oxygen saturation. b) Assess pupil reaction to light. c) Palpate the head for injuries d) Verify Glasgow Coma Scale (GCS) score.

A CT scan of a 68-yr-old male patient's head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? A. Maintenance of the patient's airway B. Positioning to promote cerebral perfusion C. Control of fluid and electrolyte imbalances D. Administration of tissue plasminogen activator (tPA)

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether the patient is developing postconcussion syndrome? a) Short-term memory b) Muscle coordination c) Glasgow Coma Scale d) Pupil reaction to light

A female patient who had a stroke 24 hours ago has expressive aphasia. An appropriate nursing intervention to help the patient communicate is to a) ask questions that the patient can answer with "yes" or "no." b) develop a list of words that the patient can read and practice reciting. c) have the patient practice her facial and tongue exercises with a mirror. d) prevent embarrassing the patient by answering for her if she does not respond.

A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now complaining of a headache. Which prescribed interventions should the nurse implement first? a) Administer IV 5% hypertonic saline. b) Draw blood for arterial blood gases (ABGs). c) Send patient for computed tomography (CT). d) Administer acetaminophen (Tylenol) 650 mg orally.

A newly admitted patient diagnosed with a right-sided brain stroke has a nursing diagnosis of disturbed visual sensory perception related to homonymous hemianopsia. Early in the care of the patient, what should the nurse do? a. Place objects on the right side within the patient's field of vision. b. Approach the patient from the left side to encourage the patient to turn the head. c. Place objects on the patient's left side to assess the patient's ability to compensate. d. Patch the affected eye to encourage the patient to turn the head to scan the environment.

A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema. What is an appropriate nursing intervention for the patient? a. Avoid positioning the patient with neck and hip flexion. b. Maintain hyperventilation to a PaCO2 of 15 to 20 mm Hg. c. Cluster nursing activities to provide periods of uninterrupted rest. d. Routinely suction to prevent accumulation of respiratory secretions.

A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care? a) Apply intermittent pneumatic compression stockings. b) Assist to dangle on edge of bed and assess for dizziness. c) Encourage patient to cough and deep breathe every 4 hours. d) Insert an oropharyngeal airway to prevent airway obstruction.

A patient has a tumor in the cerebellum. The nurse will plan interventions to a) prevent falls. b) stabilize mood. c) avoid aspiration. d) improve memory.

A patient is admitted with a headache, fever, and general malaise. The HCP has asked that the patient be prepared for a lumbar puncture. What is a priority nursing action to avoid complications? a. Ensure that CT scan is performed prior to lumbar puncture. b. Assess laboratory results for changes in the white cell count. c. Provide acetaminophen for the headache and fever before the procedure. d. Administer antibiotics before the procedure to treat the potential meningitis.

A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? a) "The obstructing plaque is surgically removed from inside an artery in the neck." b) "The diseased portion of the artery in the brain is replaced with a synthetic graft." c) "A wire is threaded through an artery in the leg to the clots in the carotid artery, and the clots are removed." d) "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque."

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question? a) Restrict oral fluids to 1000 mL/day. b) Elevate the head of the bed 20 degrees. c) Administer ceftriaxone (Rocephin) 1 g IV every 12 hours. d) Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache.

A patient's eyes jerk while the patient looks to the left. The nurse will record this finding as a. nystagmus. b. CN VI palsy. c. ophthalmic dyskinesia. d. oculocephalic response.

Admission vital signs for a brain-injured patient are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse? Blood pressure of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12 breaths/min Blood pressure of 134/72 mm Hg, pulse of 90 beats/min, respirations of 32 breaths/min Blood pressure of 148/78 mm Hg, pulse of 112 beats/min, respirations of 28 breaths/min Blood pressure of 110/70 mm Hg, pulse of 120 beats/min, respirations of 30 breaths/min

After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a) A 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed b) A 50-yr-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c) A 30-yr-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled d) A 40-yr-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due

During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for a. patency of airway. b. presence of a neck injury. c. neurologic status with the Glasgow Coma Scale. d. cerebrospinal fluid leakage from the ears or nose.

During change-of-shift report, the nurse learns that a patient with a head injury has decorticate posturing to noxious stimulation. Which positioning shown in the accompanying figure will the nurse expect to observe? a) 1 b) 2 c) 3 d) 4

During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status at least every 4 hours. What is a cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow? a. Hypertension b. Fluid overload c. Cardiac dysrhythmias d. S3 and S4 heart sounds

Following a lumbar puncture, for what should the nurse assess the patient? a. Headache b. Lower limb paralysis c. Allergic reactions to the dye d. Hemorrhage from the puncture site

For the patient undergoing a craniotomy, when should the nurse provide information about the use of wigs and hairpieces or other methods to disguise hair loss? a. During preoperative teaching b. If the patient asks about their use c. In the immediate postoperative period d. When the patient expresses negative feelings about his or her appearance

Four days following a stroke, a patient is to start oral fluids and feedings. Before feeding the patient, what should the nurse do first? a. Check the patient's gag reflex. b. Order a soft diet for the patient. c. Raise the head of the bed to a sitting position. d. Evaluate the patient's ability to swallow small amounts of crushed ice or ice water.

In which patient would it be the most important for the nurse to assess the glossopharyngeal and vagus nerves? a) A 50-yr-old woman with lethargy from a drug overdose b) A 40-yr-old man with a complete lumbar spinal cord injury c) A 60-yr-old man with severe pain from trigeminal neuralgia d) A 30-yr-old woman with a high fever and bacterial meningitis

Patient-Centered Care: A 54-yr-old man is recovering from a skull fracture with a subacute subdural hematoma that caused unconsciousness. He has return of motor control and orientation but appears apathetic and has reduced awareness of his environment. When planning discharge of the patient, what should the nurse explain to the patient and family? a. The patient is likely to have long-term emotional and mental changes that may require professional help. b. Continuous improvement in the patient's condition should occur until he has returned to pretrauma status. c. The patient's complete recovery may take years, and the family should plan for his long-term dependent care. d. Role changes in family members will be necessary because the patient will be dependent on his family for care and support.

Priority Decision: A patient has ICP monitoring with an intraventricular catheter. What is a priority nursing intervention for the patient? a. Aseptic technique to prevent infection b. Constant monitoring of ICP waveforms c. Removal of CSF to maintain normal ICP d. Sampling CSF to determine abnormalities

The nurse is caring for a patient after a lumbar puncture. Which is a priority action by the nurse? a) Assess for drainage or bleeding from the puncture site. b) Monitor for bladder dysfunction and bowel incontinence. c) Maintain bed rest until lower extremities move normally. d) Check for loss of muscle strength in the upper extremities.

The nurse is caring for a patient who has a head injury. Which finding, when reported to the health care provider, should the nurse expect will result in new prescribed interventions? a) Pale yellow urine output of 1200 mL over the past 2 hours. b) Ventriculostomy drained 40 mL of fluid in the past 2 hours. c) Intracranial pressure spikes to 16 mm Hg when patient is turned. d) LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.

The nurse is caring for a patient with a neurologic disease that affects the pyramidal tract. What clinical manifestation does the nurse assess in this patient? a) Impaired muscle movement b) Decreased deep tendon reflexes c) Decreased level of consciousness d) Impaired sensation of touch, pain, and temperature

During the secondary assessment of the patient with a stroke, what should be included (select all that apply)? a. Gaze b. Sensation c. Facial palsy d. Proprioception e. Current medications f. Distal motor function

A, B, C, D, F

The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions (select all that apply.)? A. Ticlopidine B. Clopidogrel C. Enoxaparin D. Dipyridamole E. Enteric-coated aspirin F. Tissue plasminogen activator (tPA)

A, B, D, E

The nurse is monitoring a patient for increased ICP following a head injury. What are manifestations of increased ICP (select all that apply)? a. Fever b. Oriented to name only c. Narrowing pulse pressure d. Right pupil dilated greater than left pupil e. Decorticate posturing to painful stimulus

A, B, D, E

Priority Decision: What factors should be considered as priorities when taking the history of a patient with a neurologic problem (select all that apply)? a. Avoid suggesting symptoms. b. Include the CN assessment as the first assessment. c. Mental status must be accurately assessed to ensure that the reported history is factual. d. Do a focused assessment of the neurologic system, as other body systems will not be affected. e. The mode of onset and course of illness are especially important aspects of the nursing history

A, C, E

Which components are able to change to adapt to small increases in intracranial pressure (ICP) (select all that apply)? a. Blood b. Skull bone c. Brain tissue d. Scalp tissue e. Cerebrospinal fluid (CSF)

A, C, E

Which factors decrease cerebral blood flow (select all that apply)? a. Increased ICP b. PaO2 of 45 mm Hg c. PaCO2 of 30 mm Hg d. Arterial blood pH of 7.3 e. Decreased mean arterial pressure (MAP)

A, C, E

Common psychosocial reactions of the stroke patient to the stroke include (select all that apply) a. depression. b. disassociation. c. intellectualization. d. sleep disturbances. e. denial of severity of stroke.

A, D, E

Priority Decision: A patient is admitted to the ED following a head injury. Number the nurse's actions in order of priority in management of the patient. Use 1 for the first action and 6 for the last action. ________ a. Confirm patent airway. ________ b. Anticipate cerebral surgery. ________ c. Maintain cervical spine precautions. ________ d. Monitor for changes in neurologic status. ________ e. Determine the presence of increased ICP. _______ f. Establish IV access with a large-bore catheter.

A. 1, B. 6, C. 2, D. 5, E. 4, F. 3

. Indicate whether the following manifestations of a stroke are more likely to occur with right brain damage (R) or left brain damage (L). A B C D E F G

A. L B. R C. R D. L E. R F. R G. L

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about a) tPA. b) aspirin. c) warfarin (Coumadin). d) nimodipine

A patient with a head injury has bloody drainage from the ear. What should the nurse do to determine if CSF is present in the drainage? a. Examine the tympanic membrane for a tear. b. Test the fluid for a halo sign on a white dressing. c. Test the fluid with a glucose-identifying strip or stick. d. Collect 5 mL of fluid in a test tube and send it to the laboratory for analysis.

A patient is seen in the emergency department after diving into the pool and hitting the bottom with a blow to the face that hyperextended the neck and scraped the skin off the nose. The patient also described "having double vision" when looking down. During the neurologic exam, the nurse finds the patient is unable to abduct either eye. The nurse recognizes this finding is related to a. a basal skull fracture. b. a stretch injury to bilateral CN VI. c. a stiff neck from the hyperextension injury. d. facial swelling from the scrape on the bottom of the pool.

A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse expect to take? a) Administer IV furosemide (Lasix). b) Prepare the patient for craniotomy. c) Initiate high-dose barbiturate therapy. d) Type and crossmatch for blood transfusion.

A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. What should the nurse record as the patient's GCS score? a. 6 b. 7 c. 9 d. 11

14. When the patient has a rapidly growing brain tumor, what part of the brain slows expansion of cerebral brain tissue into the adjacent hemisphere? a. Ventricles b. Falx cerebri c. Arachnoid layer d. Tentorium cerebella

5. A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as a. 9. b. 11. c. 13. d. 15.

A 19-yr-old woman is hospitalized for a frontal skull fracture from a blunt force head injury. Thin bloody fluid is draining from the patient's nose. What action by the nurse is most appropriate? A. Test the drainage for the presence of glucose. B. Apply a loose gauze pad under the patient's nose. C. Place the patient in a modified Trendelenburg position. D. Ask the patient to gently blow the nose to clear the drainage.

A 20-yr-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? a) Have the patient gently blow the nose. b) Check the drainage for glucose content. c) Teach the patient that rhinorrhea is expected after a head injury. d) Obtain a specimen of the fluid to send for culture and sensitivity.

A 28-yr-old female patient has been diagnosed with occipital lobe damage after a car accident. With what should the nurse expect the patient to need help? a. Being able to feel heat c. Identifying smells appropriately b. Processing visual images d. Being able to say what she means

A 39-yr-old patient with a suspected herniated intervertebral disc is scheduled for a myelogram. Which information communicated by the nurse to the health care provider before the procedure would change the procedural plans? a) The patient is anxious about the test results. b) The patient reports a previous allergy to shellfish. c) The patient has back pain when lying flat for more than 4 hours. d) The patient drank apple juice 4 hours before the scheduled procedure.

A 70-yr-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a) Take the patient's blood pressure. b) Check the respiratory rate and effort. c) Assess the Glasgow Coma Scale score. d) Send the patient for a computed tomography (CT) scan.

A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates which treatment option that would be considered for the patient? a. Hyperventilation therapy b. Surgical clipping of the aneurysm c. Administration of hyperosmotic agents d. Administration of thrombolytic therapy

A female patient has left-sided hemiplegia after an ischemic stroke 4 days earlier. How should the nurse promote skin integrity? A. Position the patient on her weak side the majority of the time. B. Alternate the patient's positioning between supine and side-lying. C. Avoid the use of pillows in order to promote independence in positioning. D. Establish a schedule for the massage of areas where skin breakdown emerges.

A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to a. keep the head of the bed flat. b. elevate the head of the bed to 30 degrees. c. maintain patient on the left side with the head supported on a pillow. d. use a continuous-rotation bed to continuously change patient position.

A nursing measure that is indicated to reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is a. administering codeine for relief of head and neck pain. b. controlling fever with prescribed drugs and cooling techniques. c. keeping the room dark and quiet to minimize environmental stimulation. d. maintaining the patient on strict bed rest with the head of the bed slightly elevated.

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a) Document the BP and ICP in the patient's record. b) Report the BP and ICP to the health care provider. c) Elevate the head of the patient's bed to 60 degrees. d) Continue to monitor the patient's vital signs and ICP.

A patient has a lesion involving the fasciculus gracilis and fasciculus cuneatus of the spinal cord. The nurse should expect the patient to experience the loss of what? a. Pain and temperature sensations b. Touch, deep pressure, vibration, and position sense c. Subconscious information about body position and muscle tension d. Voluntary muscle control from the cerebral cortex to the peripheral nerves

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best for this situation? "This type of monitoring system is complex and it is managed by skilled staff." "The monitoring system helps show whether blood flow to the brain is adequate." "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure." "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage."

For a patient who had a right hemisphere stroke, the nurse anticipates planning interventions to manage a) impaired physical mobility related to right-sided hemiplegia. b) risk for injury related to denial of deficits and impulsiveness. c) impaired verbal communication related to speech-language deficits. d) ineffective coping related to depression and distress about disability.

For a patient who is suspected of having a stroke, one of the most important pieces of information that the nurse can obtain is a. time of the patient's last meal. b. time at which stroke symptoms first appeared. c. patient's hypertension history and management. d. family history of stroke and other cardiovascular diseases.

Priority Decision: While the nurse performs range of motion (ROM) on an unconscious patient with increased ICP, the patient experiences severe decerebrate posturing reflexes. What should the nurse do first? a. Use restraints to protect the patient from injury while posturing. b. Perform the exercises less frequently because posturing indicates increased ICP. c. Administer central nervous system (CNS) depressants to lightly sedate the patient. d. Continue the exercises because they are necessary to maintain musculoskeletal function.

Propranolol (Inderal), a b-adrenergic blocker that inhibits sympathetic nervous system activity, is prescribed for a patient who has extreme anxiety about public speaking. The nurse monitors the patient for a) dry mouth. b) bradycardia. c) constipation. d) urinary retention.

Several patients have been hospitalized for diagnosis of neurologic problems. Which patient will the nurse assess first? a) A patient with a transient ischemic attack (TIA) returning from carotid duplex studies b) A patient with a brain tumor who has just arrived on the unit after a cerebral angiogram c) A patient with a seizure disorder who has just completed an electroencephalogram (EEG) d) A patient prepared for a lumbar puncture whose health care provider is waiting for assistance

Several weeks after a stroke, a 50-yr-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training program? a) Limit fluid intake to 1200 mL daily to reduce urine volume. b) Assist the patient onto the bedside commode every 2 hours. c) Perform intermittent catheterization after each voiding to check for residual urine. d) Use an external "condom" catheter to protect the skin and prevent embarrassment.

The client has undergone a craniotomy for a brain tumor. Which data indicate a complication of this surgery? a. The client complains of a headache at "3" to "4" on a 1-to-10 scale. b. The client has an intake of 1,000 mL and an output of 3,500 mL. c. The client complains of a raspy, sore throat. d. The client experiences dizziness when trying to get up too quickly.

The client is being admitted to rule out a brain tumor. Which classic triad of symptoms supports a diagnosis of brain tumor? a) Nervousness, metastasis to the lungs, and seizures. b) Headache, vomiting, and papilledema. c) Hypotension, tachycardia, and tachypnea. d) Abrupt loss of motor function, diarrhea, and changes in taste.

The client is diagnosed with a metastatic brain tumor, and radiation therapy is scheduled. The client asks the nurse, "Why not try chemotherapy first? It has helped my other tumors." The nurse's response is based on which scientific rationale? a. Chemotherapy is only used as a last resort in caring for clients with brain tumors. b. The blood-brain barrier prevents medications from reaching the brain. c. Radiation therapy will have fewer side effects than chemotherapy. d. Metastatic tumors become resistant to chemotherapy and it becomes useless.

The male client diagnosed with a brain tumor is scheduled for a magnetic resonance imaging (MRI) scan in the morning. The client tells the nurse that he is scared. Which response by the nurse indicates an appropriate therapeutic response? a) "MRIs are loud but there will not be any invasive procedure done." b) "You're scared. Tell me about what is scaring you." c) "This is the least thing to be scared about—there will be worse." d) "I can call the MRI tech to come and talk to you about the scan."

The nurse admitting a patient who has a right frontal lobe tumor would expect the patient may have a) expressive aphasia. b) impaired judgment. c) right-sided weakness. d) difficulty swallowing.

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question? a) Keep the head of bed elevated. b) Insert nasogastric tube to low suction. c) Turn patient side to side every 2 hours. d) Apply cold packs intermittently to face.

The nurse is assessing the muscle strength of an older adult patient. The nurse knows the findings cannot be compared with those of a younger adult because a. nutritional status is better in young adults. b. muscle bulk and strength decrease in older adults. c. muscle strength should be the same for all adults. d. most young adults exercise more than older adults.

The nurse is caring for a patient admitted with a subdural hematoma after a motor vehicle accident. What change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)? A. Tachypnea B. Bradycardia C. Hypotension D. Narrowing pulse pressure

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a) The pulse rate is 102 beats/min. b) The patient has difficulty speaking. c) The blood pressure is 144/86 mm Hg. d) There are fine crackles at the lung bases.

Which assessments will the nurse make to monitor a patient's cerebellar function (select all that apply)? a) Test for graphesthesia. b) Observe arm swing with gait. c) Perform the finger-to-nose test. d) Assess heat and cold sensation. e) Measure strength against resistance.

B, C

Which descriptions are characteristic of encephalitis (select all that apply)? a. Increased CSF production b. Is an inflammation of the brain c. Almost always has a viral cause d. Most frequently caused by bacteria e. May be transmitted by insect vectors f. Involves inflammation of tissues surrounding the brain and spinal cord

B, C, E

The nurse is caring for a patient admitted to the hospital with a head injury who requires frequent neurologic assessment. Which components are assessed using the Glasgow Coma Scale (GCS) (select all that apply.)? A. Judgment B. Eye opening C. Abstract reasoning D. Best verbal response E. Best motor response F. Cranial nerve function

B, D, E

Which CNs are involved with oblique eye movements (select all that apply)? a. Optic (CN II) b. Trochlear (CN IV) c. Trigeminal (CN V) d. Abducens (CN VI) e. Oculomotor (CN III)

B, D, E

What are causes of vasogenic cerebral edema (select all that apply)? a. Hydrocephalus b. Ingested toxins c. Destructive lesions or trauma d. Local disruption of cell membranes e. Fluid flowing from intravascular to extravascular space

B, E

The nurse is caring for an older adult patient. Which normal nervous system changes of aging put this patient at higher risk of falls (select all that apply.)? a) Memory deficit b) Sensory deficit c) Motor function deficit d) Cranial and spinal nerves e) Reticular activation system f) Central nervous system changes

B, F

A patient's sudden onset of hemiplegia has necessitated a CT scan of her head. Which action should be the nurse's priority before this diagnostic study? a) Assess the patient's immunization history. b) Screen the patient for any metal parts or a pacemaker. c) Assess the patient for allergies to shellfish, iodine, or dyes. d) Assess the patient's need for tranquilizers or antiseizure medications.

A 68-yr-old man with suspected bacterial meningitis just had a lumbar puncture in which cerebrospinal fluid was obtained for culture. Which medication should the nurse administer first? A. Codeine B. Phenytoin (Dilantin) C. Ceftriaxone (Rocephin) D. Acetaminophen (Tylenol)

A carotid endarterectomy is being considered as treatment for a patient who has had several TIAs. What should the nurse explain to the patient about this surgery? a. It involves intracranial surgery to join a superficial extracranial artery to an intracranial artery. b. It is used to restore blood circulation to the brain following an obstruction of a cerebral artery. c. It involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke. d. It is used to open a stenosis in a carotid artery with a balloon and stent to restore cerebral circulation.

A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care? a) Provide a wide variety of food choices. b) Provide oral care before and after meals. c) Assist the patient to eat with the right hand. d) Teach the patient the "chin-tuck" technique.

A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient's wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient? a) Interrupted family processes related to effects of illness of a family member b) Situational low self-esteem related to increasing dependence on spouse for care c) Disabled family coping related to inadequate understanding by patient's spouse d) Impaired nutrition: less than body requirements related to hemiplegia and aphasia

A patient admitted with possible stroke has been aphasic for 3 hours, and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question? a) Keep head of bed elevated at least 30 degrees. b) Infuse normal saline intravenously at 75 mL/hr. c) Start a labetalol drip to keep BP less than 140/90 mm Hg. d) Administer tissue plasminogen activator (tPA) intravenously per protocol.

A patient experiencing TIAs is scheduled for a carotid endarterectomy. The nurse 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 plaques blocking cerebral blood flow. d. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation.

A patient has a systemic blood pressure of 120/60 mm Hg and an ICP of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? A. High blood flow to the brain B. Normal intracranial pressure C. Impaired blood flow to the brain D. Adequate autoregulation of blood flow

A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, what will the nurse anticipate that the HCP will request? a. Lumbar puncture b. Cerebral angiography c. Magnetic resonance imaging (MRI) d. Computed tomography (CT) scan with contrast

A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? a) The patient has dysphasia. b) The patient has atrial fibrillation. c) The patient reports that symptoms began with a severe headache. d) The patient has a history of brief episodes of right-sided hemiplegia.

A patient is exhibiting word finding difficulty and weakness in his right arm. What area of the brain is most likely involved? a. brainstem. b. vertebral artery. c. left middle cerebral artery. d. right middle cerebral artery.

A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a) Document that the aspirin was refused by the patient. b) Tell the patient that the aspirin is used to prevent a fever. c) Explain that the aspirin is ordered to decrease stroke risk. d) Call the health care provider to clarify the medication order.

A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a) Encourage coughing and deep breathing. b) Position the patient with knees and hips flexed. c) Keep the head of the bed elevated to 30 degrees. d) Cluster nursing interventions to provide rest periods.

A patient will attempt oral feedings for the first time after having a stroke. The nurse should assess the gag reflex and then a) order a varied pureed diet. b) assess the patient's appetite. c) assist the patient into a chair. d) offer the patient a sip of juice.

A patient with a stroke has a right-sided hemiplegia. What does the nurse teach the family to prepare them to cope with the behavior changes seen with this type of stroke? a. Ignore undesirable behaviors manifested by the patient. b. Provide directions to the patient verbally in small steps. c. Distract the patient from inappropriate emotional responses. d. Supervise all activities before allowing the patient to pursue them independently.

A patient with increased intracranial pressure after a head injury has a ventriculostomy in place. Which action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work in the intensive care unit? a) Document intracranial pressure every hour. b) Turn and reposition the patient every 2 hours. c) Check capillary blood glucose level every 6 hours. d) Monitor cerebrospinal fluid color and volume hourly.

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? a) Complete blood count (CBC) b) Chest radiograph (chest x-ray) c) Computed tomography (CT) scan d) 12-Lead electrocardiogram (ECG)

An unconscious patient is admitted to the emergency department (ED) with a head injury. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment being given. What action is best for the nurse to take? a) Call the family's pastor or spiritual advisor to take them to the chapel. b) Ask the family to stay in the waiting room until the assessment is completed. c) Allow the family to stay with the patient and briefly explain all procedures to them. d) Refer the family members to the hospital counseling service to deal with their anxiety.

An unconscious patient with increased ICP is on ventilatory support. Which arterial blood gas (ABG) measurement should prompt the nurse to notify the HCP? a. pH of 7.43 b. SaO2 of 94% c. PaO2 of 70 mm Hg d. PaCO2 of 35 mm Hg

Bladder training in a male patient who has urinary incontinence after a stroke includes a. limiting fluid intake. b. keeping a urinal in place at all times. c. assisting the patient to stand to void. d. catheterizing the patient every 4 hours.

During an assessment of the motor system, the nurse finds that the patient has a staggering gait and an abnormal arm swing. What should the nurse use this information to do? a. Assist the patient to cope with the disability. b. Plan a rehabilitation program for the patient. c. Protect the patient from injury caused by falls. d. Help to establish a diagnosis of cerebellar dysfunction

During neurologic assessment of the older adult, what should the nurse know is an effect of aging on the neurologic system? a. Absent deep tendon reflexes b. Below-average intelligence score c. Decreased sensation of touch and temperature d. Decreased frequency of spontaneous awakening

During neurologic testing, the patient is able to perceive pain elicited by pinprick. Based on this finding, the nurse may omit testing for a. position sense. b. patellar reflexes. c. temperature perception. d. heel-to-shin movements.

During the change of shift report, a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have a) dysphasia. b) confusion. c) visual deficits. d) poor judgment.

During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurse's directions to move his hands and feet. The nurse will suspect a) cerebellar injury. b) a brainstem lesion. c) frontal lobe damage. d) a temporal lobe lesion.

How is cranial nerve (CN) III, originating in the midbrain, assessed by the nurse for an early indication of pressure on the brainstem? a. Assess for nystagmus b. Test the corneal reflex c. Test pupillary reaction to light d. Test for oculocephalic (doll's eyes) reflex

How should the nurse most accurately assess the position sense of a patient with a recent traumatic brain injury? a) Ask the patient to close his or her eyes and slowly bring the tips of the index fingers together. b) Ask the patient to close his or her eyes and identify the presence of a common object on the forearm. c) Ask the patient to stand with the feet together and eyes closed and observe for balance maintenance. d) Place the two points of a calibrated compass on the tips of the fingers and toes and ask the patient to discriminate the points.

In noting the results of an analysis of CSF, what should the nurse identify as an abnormal finding? a. pH of 7.35 b. Clear, colorless appearance c. Glucose level of 30 mg/dL (1.7 mmol/L) d. WBC count of 5 cells/μL (5 × 106 cells/L)

In planning long-term care for a patient after craniotomy, what must the nurse include in family and caregiver education? A. Seizure disorders may occur in weeks or months. B. The family will be unable to cope with role reversals. C. There are often residual changes in personality and cognition. D. Referrals will be made to eliminate residual deficits from the damage.

In promoting health maintenance for prevention of strokes, the nurse understands that the highest risk for the most common type of stroke is present in which people? a. African Americans b. Women who smoke c. Individuals with hypertension and diabetes d. Those who are obese with high dietary fat intake

Increased ICP in the left cerebral cortex caused by intracranial bleeding causes displacement of brain tissue to the right hemisphere beneath the falx cerebri. The nurse knows that this is referred to as what? a. Uncal herniation b. Tentorial herniation c. Cingulate herniation d. Temporal lobe herniation

On physical examination of a patient with headache and fever, the nurse should suspect a brain abscess when the patient has a. seizures. b. nuchal rigidity. c. focal symptoms. d. signs of increased ICP.

Patient-Centered Care: A patient with a right hemisphere stroke has a nursing diagnosis of unilateral neglect related to sensory-perceptual deficits. During the patient's rehabilitation, what nursing intervention is important for the nurse to do? a. Avoid positioning the patient on the affected side. b. Place all objects for care on the patient's unaffected side. c. Teach the patient to care consciously for the affected side. d. Protect the affected side from injury with pillows and supports.

Teamwork and Collaboration: Which intervention should the nurse delegate to the licensed practical nurse (LPN) when caring for a patient following an acute stroke? a. Assess the patient's neurologic status. b. Assess the patient's gag reflex before beginning feeding. c. Administer ordered antihypertensives and platelet inhibitors. d. Teach the patient's caregivers strategies to minimize unilateral neglect.

The charge nurse is observing a new staff nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action indicates a need for further teaching of the new nurse about neurologic assessment? a) The new nurse tests for light touch before testing for pain. b) The new nurse has the patient close the eyes during testing. c) The new nurse asks the patient if the instrument feels sharp. d) The new nurse uses an irregular pattern to test for intact touch.

A 63-yr-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? (Put a comma and a space between each answer choice [A, B, C, D].)a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%.d. Use National Institute of Health Stroke Scale to assess patient.

C, D, A, B

The rehabilitation nurse assesses the patient, caregiver, and family before planning the rehabilitation program for this patient. What must be included in this assessment (select all that apply)? a. Cognitive status of the family b. Patient resources and support c. Physical status of all body systems d. Rehabilitation potential of the patient e. Body strength remaining after the stroke f. Patient and caregiver expectations of the rehabilitation

C, D, F

Nursing management of a patient with a brain tumor includes (select all that apply) a. discussing with the patient methods to control inappropriate behavior. b. using diversion techniques to keep the patient stimulated and motivated. c. assisting and supporting the family in understanding any changes in behavior. d. limiting self-care activities until the patient has regained maximum physical functioning. e. planning for seizure precautions and teaching the patient and the caregiver about antiseizure drugs.

C, E

What methods are used to assess the facial (CN VII) nerve (select all that apply)? Functional Health Pattern a. Gag reflex b. Visual fields c. Corneal (blink) reflex test d. Light touch to the face e. Smile, frown, and close eyes f. Salt and sugar discrimination

C, E, F

A patient with intracranial pressure monitoring has a pressure of 12 mm Hg. The nurse understands that this pressure reflects a. a severe decrease in cerebral perfusion pressure. b. an alteration in the production of cerebrospinal fluid. c. the loss of autoregulatory control of intracranial pressure. d. a normal balance between brain tissue, blood, and cerebrospinal fluid.

A patient with suspected meningitis is scheduled for a lumbar puncture. Before the procedure, the nurse will plan to a) enforce NPO status for 4 hours. b) transfer the patient to radiology. c) administer a sedative medication. d) help the patient to a lateral position.

How do spinal nerves of the peripheral nervous system (PNS) differ from cranial nerves (CNs)? a. Only spinal nerves occur in pairs. b. CNs affect only the sensory and motor functions of the head and neck. c. Cell bodies of all CNs are located in the brain, whereas cell bodies of spinal nerves are located in the spinal cord. d. All spinal nerves contain both afferent sensory and efferent motor fibers, whereas CNs contain one or the other or both.

In a patient with a disease that affects the myelin sheath of nerves, such as multiple sclerosis, the glial cells affected are the a. microglia. b. astrocytes. c. ependymal cells. d. oligodendrocytes.

In the neurologic nursing assessment, the patient is unable to hear a ticking watch. What neurologic problem could be the cause of this finding? a. The patient is distracted. b. The patient is hard of hearing. c. The vagus (CN X) nerve is malfunctioning. d. The cochlear branch of the acoustic (CN VIII) nerve is damaged.

Information provided by the patient that would help differentiate a hemorrhagic stroke from a thrombotic stroke includes a. sensory disturbance. b. a history of hypertension. c. presence of motor weakness. d. sudden onset of severe headache.

A patient's wife asks the nurse why her husband did not receive the clot busting medication (tissue plasminogen activator [tPA]) she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What is the best response by the nurse to the patient's wife? a. "He didn't arrive within the timeframe for that therapy." b. "Not everyone is eligible for this drug. Has he had surgery lately?" c. "You should discuss the treatment of your husband with his doctor." d. "The medication you are talking about dissolves clots and could cause more bleeding in your husband's brain."

After having a craniectomy and left anterior fossae incision, a 64-yr-old patient has impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to a) cluster nursing activities to allow longer rest periods. b) turn and reposition the patient side to side every 2 hours. c) position the bed flat and log roll to reposition the patient. d) perform range-of-motion (ROM) exercises every 4 hours.

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a) A 20-yr-old patient whose cranial x-ray shows a linear skull fracture b) A 50-yr-old patient who has an initial Glasgow Coma Scale score of 13 c) A 30-yr-old patient who lost consciousness for a few seconds after a fall d) A 40-yr-old patient whose right pupil is 10 mm and unresponsive to light

Drugs or diseases that impair the function of the extrapyramidal system may cause loss of a. sensations of pain and temperature. b. regulation of the autonomic nervous system. c. integration of somatic and special sensory inputs. d. automatic movements associated with skeletal muscle activity.

How are the metabolic and nutritional needs of the patient with increased ICP best met? a. Enteral feedings that are low in sodium b. Simple glucose available in D5W IV solutions c. Fluid restriction that promotes a moderate dehydration d. Balanced, essential nutrition in a form that the patient can tolerate

A patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should a) use a calm voice to ask the patient to stop the crying behavior. b) explain to the family that depression is normal following a stroke. c) have the family members leave the patient alone for a few minutes. d) teach the family that emotional outbursts are common after strokes.

A patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a) Impulsive behavior b) Right-sided neglect c) Hyperactive left-sided tendon reflexes Difficulty comprehending instructions

A 32-yr-old female patient is diagnosed with diabetes insipidus after transsphenoidal resection of a pituitary adenoma. What should the nurse consider as a sign of improvement? A. Serum sodium of 120 mEq/L B. Urine specific gravity of 1.001 C. Fasting blood glucose of 80 mg/dL D. Serum osmolality of 290 mOsm/kg

A 74-yr-old man who has right-sided extremity paralysis related to a thrombotic stroke develops constipation. Which action should the nurse take first? A. Assist the patient to the bathroom every 2 hours. B. Provide incontinence briefs to wear during the day. C. Administer a bisacodyl (Dulcolax) rectal suppository every day. D. Arrange for several servings per day of cooked fruits and vegetables.

A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for a) surgical endarterectomy. b) transluminal angioplasty. c) intravenous heparin drip administration. d) tissue plasminogen activator (tPA) infusion.

A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order should the nurse implement first? a) Administer ceftizoxime (Cefizox) 1 g IV. b) Give acetaminophen (Tylenol) 650 mg PO. c) Use a cooling blanket to lower temperature. d) Swab the nasopharyngeal mucosa for cultures.

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? a) The patient receives a regular diet tray. b) The bedrails on both sides of the bed are elevated. c) Staff have turned off the lights in the patient's room. d) Staff have entered the patient's room without a mask.

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a) The patient's speech is difficult to understand. b) The patient's blood pressure (BP) is 144/90 mm Hg. c) The patient takes a diuretic because of a history of hypertension. d) The patient has atrial fibrillation and takes warfarin (Coumadin).

A patient is admitted to the hospital with possible bacterial meningitis. During the initial assessment, the nurse questions the patient about a recent history of what? a. Mosquito or tick bites b. Chickenpox or measles c. Cold sores or fever blisters d. An upper respiratory infection

A patient is having a transsphenoidal hypophysectomy. The nurse should provide preoperative patient teaching about what potential deficit as a result of the surgery? a) Increased heart rate b) Loss of coordination c) Impaired swallowing d) Altered sense of smell

A patient sustained a diffuse axonal injury from a traumatic brain injury (TBI). Why are IV fluids being decreased and enteral feedings started? A. Free water should be avoided. B. Sodium restrictions can be managed. C. Dehydration can be better avoided with feedings. D. Malnutrition promotes continued cerebral edema.

A patient with heart failure and type 1 diabetes mellitus is scheduled for a positron emission tomogram (PET) of the brain. Which medication prescribed by the health care provider should the nurse expect to administer before the diagnostic study? a) Furosemide 20 mg (IV) b) Alprazolam 0.5 mg (PO) c) Ciprofloxacin 500 mg (PO) d) Regular insulin 6 units (SQ)

Patient-Centered Care: A patient comes to the emergency department (ED) immediately after experiencing numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient requests discharge. Why should the nurse emphasize that it is important for the patient to be treated before leaving? a. The patient has probably experienced an asymptomatic lacunar stroke. b. The symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours. c. Neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off. d. The patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebrovascular disease.

Priority Decision: What is the priority intervention in the ED for the patient with a stroke? a. IV fluid replacement b. Administration of osmotic diuretics to reduce cerebral edema c. Initiation of hypothermia to decrease the oxygen needs of the brain d. Maintenance of respiratory function with a patent airway and oxygen administration

Priority Decision: When assessing the body functions of a patient with increased ICP, what should the nurse assess first? a. Corneal reflex testing b. Pupillary reaction to light c. Extremity strength testing d. Circulatory and respiratory status

Skull x-rays and a CT scan provide evidence of a depressed parietal fracture with a subdural hematoma in a patient admitted to the ED following an automobile accident. In planning care for the patient, what should the nurse anticipate? a. The patient will receive life support measures until the condition stabilizes. b. Immediate burr holes will be made to rapidly decompress the intracranial cavity. c. The patient will be treated conservatively with close monitoring for changes in neurologic status. d. The patient will be taken to surgery for a craniotomy for evacuation of blood and decompression of the cranium.

The client diagnosed with a brain tumor has a diminished gag response and weakness on the left side of the body. Which intervention should the nurse implement? a. Make the client NPO until seen by the health-care provider. b. Position the client in low Fowler's position for all meals. c. Place the client on a mechanically ground diet. d. Teach the client to direct food and fluid toward the right side.

The client diagnosed with a brain tumor was admitted to the intensive care unit with decorticate posturing. Which indicates that the client's condition is becoming worse? a. The client has purposeful movement with painful stimuli. b. The client has assumed adduction of the upper extremities. c. The client is aimlessly thrashing in the bed. d. The client has become flaccid and does not respond to stimuli.

The client has been diagnosed with a brain tumor. Which presenting signs and symptoms help to localize the tumor position? a) Widening pulse pressure and bounding pulse. b) Diplopia and decreased visual acuity. c) Bradykinesia and scanning speech. d) Hemiparesis and personality changes.

The female patient has been brought to the emergency department complaining of the most severe headache of her life. Which type of stroke should the nurse anticipate? A. TIA B. Embolic stroke C. Thrombotic stroke D. Subarachnoid hemorrhage

The incidence of ischemic stroke in patients with TIAs and other risk factors is reduced with the administration of which medication? a. Nimodipine b. Furosemide (Lasix) c. Warfarin (Coumadin) d. Daily low-dose aspirin

The nurse assesses a patient for signs of meningeal irritation. Which finding indicates nuchal rigidity is present? A. Tonic spasms of the legs B. Curling in a fetal position C. Arching of the neck and back D. Resistance to flexion of the neck

The nurse can best assist the patient and family in coping with the long-term effects of a stroke by doing what? a. Informing family members that the patient will need assistance with almost all ADLs b. Explaining that the patient's prestroke behavior will return as improvement progresses c. Encouraging the patient and family members to seek assistance from family therapy or stroke support groups d. Helping the patient and family to understand the significance of residual stroke damage to promote problem solving and planning

The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? A. A 92-yr-old female patient who takes warfarin (Coumadin) for atrial fibrillation B. A 28-yr-old male patient who uses marijuana after chemotherapy to control nausea C. A 42-yr-old female patient who takes oral contraceptives and has migraine headaches D. A 72-yr-old male patient who has hypertension and diabetes mellitus and smokes tobacco

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding indicates a possible complication that should be reported to the health care provider? a) Complaint of severe headache b) Large contusion behind left ear c) Bilateral periorbital ecchymosis d) Temperature of 101.4° F (38.6° C)

The nurse is caring for a patient with peripheral neuropathy who is scheduled for EMG studies tomorrow morning. The nurse should a. ensure the patient has an empty bladder. b. instruct the patient about the risk of electric shock. c. ensure the patient has no metallic jewelry or metal fragments. d. instruct the patient that pain may be experienced during the study.

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