Unit 13: Intracranial regulation

When communicating with a client who has aphasia, which of the following nursing interventions is inappropriate? 1. Present one thought at a time 2. Encourage the client NOT to write messages 3. Speak with normal volume 4. Make use of gestures

2. Encourage the client not to write messages; The nurse should encourage the client to write messages or use alternative forms of communication to avoid frustration. Presenting one thought at a time decreases stimuli that may distract the client, as does speaking in a normal volume and tone. The nurse should ask the client to show me and should encourage the use of gestures to assist in getting the message across with minimal frustration and exhaustion for the client

Question 2: Which of the following will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure (grand mal)? 1. Jerking in one extremity that spreads gradually to adjacent areas 2. Vacant staring and abruptly ceasing all activity 3. Facial grimaces, patting motions, and lip smacking 4. Loss of consciousness, body stiffening, and violent muscle contractions

4. Loss of consciousness, body stiffening, and violent muscle contractions.; A generalized tonic clonic seizure involves both a tonic phase and a clonic phase. The tonic phase consists of loss of consciousness, dilated pupils, and muscular stiffening or contraction which lasts about 20-30 seconds. The clonic phase involves repetitive movements. The seizure ends with confusion, drowsiness, and resumption of respirations.

Which clinical manifestation does the nurse expect in the client in the postictal phase of generalized tonic-clonic seizure? A. Drowsiness B. Inability to move C. Paresthesia D. Hypotension

A. Drowsiness; • Nurse should expect a client in the postictal phase to experience drowsiness to somnolence because exhaustion results from the abnormal spontaneous neuron firing and tonic-clonic motor response. • An inability to move a muscle part is not expected after tonic clonic seizure because a lack of motor function would be related to a complication, such as a lesion, tumor or stroke in the correlating brain tissue. • A change in sensation would not be expected because this would indicate a complication corresponding apart form the CNS system. • Hypotension is not typically a problem after a seizure.

• Situation: Ms. Margaret Baird is a 78 year old widow who has a brain tumor. Her history reveals headaches for the past several months. Her daughter reported she has also had personality changes. She was admitted to the hospital for further evaluation and surgical removal of the tumor. • After surgery to remove the brain tumor, the nurse established a nursing diagnosis of potential complication for increased intracranial pressure. An appropriate intervention is to position Ms. Baird _____. A. Recumbent, with extremities restrained. B. With the head of the bed elevated 30 degrees. C. On her left side, with her neck flexed. D. On her right side, with her neck extended.

B. With the head of the bed elevated 30 degrees.

Mrs. Edna Cowan has had a CVA affecting the right side of her body. Before initiating oral feeding for the first time for Mrs. Cowan, which nursing action is most important? A. Position Mrs. Cowan in an upright position. B. Assess Mrs. Cowan for the presence of the gag reflex. C. Assess Mrs. Cowan's ability to swallow ice chips or water before offering food D. Suction Mrs. Cowan's oral cavity to prevent aspiration of secretions

B.Assess Mrs. Cowan for the presence of the gag reflex.

•Situation: Mr. George Philips, a 25 year old accountant, was admitted to the hospital for diagnostic studies after he experienced a grand mal seizure at his office. •In which position in bed should the nurse place Mr. Philips after his seizure has ended? A. Low mid Fowlers position B. Side lying position C. Supine position D.Modified Trendelenburg position

B.Side lying position

During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's A. Pulse B. Respirations C. Blood pressure D. Temperature

C. Blood pressure; Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored, and blood pressure is maintained as identified by the physician specific to the clients ischemic tissue needs and risk of bleeding from treatment. The other vital signs are important, but the priority is to monitor blood pressure.

• Situation: Mrs. Dora Wilkins is a 25 year old high school teacher who was admitted to the hospital for evaluation after she suffered a generalized tonic-clonic seizure in her classroom. The nursing history reveals she has been a healthy young woman with no history of head trauma or birth injury, but she did have a grandmother who had a seizure disorder. The physician has ordered diagnostic testing. • Mrs. Wilkins has a tonic-clonic seizure while the nurse is in the room. Which nursing action is appropriate during the seizure? A. Restrain her arms and legs to prevent injury during the seizure. B. Insert an oral airway during the seizure to maintain a patent airway. C. Time the seizure, and observe and record the details of the seizure and the postictal phase. D. Avoid touching her to prevent further stimulation of the nervous system.

C. Time the seizure; observe and record the details of the seizure and the postictal phase.

The nurse assesses the client who has suffered a CVA. The client is able to speak, but the phrases have little meaning. The nurse determines the client has: A. Expressive aphasia (Broca's) B. Receptive aphasia (Wericke's) C. Dysarthria. D. Amnesic aphasia.

B. Receptive aphasia (Wernicke's)

Question 1: The nurse is teaching the family of a client with dysphagia from a CVA about decreasing the risk of aspiration while eating. Which of the following strategies is inappropriate? 1. Maintaining an upright position 2. Restricting the diet to liquids until swallowing improves 3. Introducing foods on the unaffected side of the mouth 4. Keeping distractions to a minimum

2. Restricting the diet to liquids until swallowing improves; A client with dysphagia commonly has the most difficulty ingesting thin liquids which are easily aspirated. Liquids should be thickened to avoid aspiration.

Look at come scale J.T arrived per EMS to the E.R. from a Motorcycle accident: he opens his eyes when you speak loudly to him and is verbal only with moans. His arms are drawn into his body with hands flexed tight, legs are extended and internally rotated.How will you document J.T.'s Glasgow Coma Scale # ? ______ Priority: Airway, Breathing, Circulation with a score this low

8

Transient ischemic attacks are A. Temporary episodes of neurologic dysfunction. B. Periods of alternating exacerbations and remissions of neurologic disease C. Attacks caused by multiple small emboli. D. Ischemic attacks which result in progressive neurologic deterioration

A. Temporary episodes of neurologic dysfunction.

The client's family asked the nurse what is the definition of a cerebrovascular accident. How should the nurse describe this? A. It is a sudden change in the blood pressure, resulting in damage to the brain. B. It is a disruption in the normal blood supply to the brain, producing focal neurologic deficits. C. It is fluctuations in blood flow, leading to dizziness and subsequent falls. D. It is increased blood flow, resulting in hemorrhage and subsequent tissue damage.

B. It is a disruption in the normal blood supply to the brain, producing focal neurologic deficits.

When preparing to teach a client about phenytoin sodium (Dilantin) therapy, the nurse should urge the client not to stop the drug suddenly because: A. Physical dependency on the drug develops over time B. Status epilepticus may develop C. A hypoglycemic reaction develops D. A heart block is likely to develop

B. Status epilepticus may develop; • Anticonvulsant drug therapy should never be stopped suddenly; doing so can lead to life-threatening status epilepticus. • Phenytoin sodium does not carry a risk of physical dependency or lead to hypoglycemia. • It has antiarrhythmic properties and discontinuation does not cause heart block

What is the priority nursing intervention in the postictal phase of a seizure? A. Reorient the client to time, person and place B. Determine the client's level of sleepiness C. Assess the client's breathing pattern D. Position the client comfortably

C. Assess the client's breathing pattern; • A priority for the client in the postictal phase (after a seizure) is to assess the client's breathing pattern for effective rate, rhythm and depth. • The nurse should apply oxygen and ventilation to the client as appropriate. • Other interventions to be completed after the airway has been established include reorientation of the client to time person, and place. • Determining the client's level of sleepiness is useful but it is not a priority. • Positioning the client comfortably promotes rest but is of less importance than ascertaining that the airway is patent.

A female client presents to the emergency department diagnosed with a stroke. Which of the client's current medication regimen is a risk factor for developing a stroke? A. Propranolol (lnderal) a beta blocker B. Furosemide (Lasix) a loop diuretic C. Estradiol/norgestimate (Ortho-Cyclen), a combination hormone of estrogen & progestaterone compounds D.Metformin (Glucophage), a biguanide

C. Estradiol/norgestimate (Ortho-Cyclen), a combination hormone of estrogen & progesterone compounds

An 87 year old client is admitted with a stroke. During the admission interview and assessment, his speech is slow, non-fluent, and labored. How should the nurse document this finding? A. Receptive aphasia B. Wernicke's aphasia C. Expressive aphasia D. Global aphasia

C. Expressive aphasia

Which of the following is the priority safety intervention when protecting the patient having a seizure? A. Placing a tongue blade between their teeth B. Ensure that the patient is restrained C. Position the patient to prevent aspiration of secretions D. Determine if the patient is incontinent

C. Position the patient to prevent aspiration of secretions

A nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which of the following measures would the nurse avoid in planning for the client's safety? (Check all that apply) A. Placing an airway, oxygen, and suction equipment at the bedside. B. Padding the side rails of the bed C. Putting a padded tongue blade at the head of the bed D. Having IV equipment ready for insertion of an IV accessE. Restraining the client's limbs

C. Putting a padded tongue blade at the head of the bed AND E. Restraining the client's limbs

When a client is admitted to the hospital in an unconscious state following subarachnoid hemorrhage resulting from a ruptured intracranial aneurysm, the nurse anticipates the manifestations preceding the loss of consciousness were: A. Generalized weakness and fatigue accompanied by anorexia B. Gradual loss of speech or vision C. Sudden severe headache accompanied by vomiting D.Weakness, fever, nausea, and vomiting

C. Sudden severe headache accompanied by vomiting

A client arrives in the emergency department with an ischemic stroke and receives recombinant tissue plasminogen activator alteplase (t-PA) administration. Which is the priority nursing assessment? Why is he given this drug? A. Current medications B. Complete physical and history C. Time of onset of current stroke D. Upcoming surgical procedures

C. Time of onset of current stroke; ;Studies show clients who receive recombinant t-Pa treatment within 3 hours after the onset of a stroke have better outcomes. The time from the onset of a stroke have better outcomes. The time from the onset of a stroke to t-PA treatment is critical.

______ Posturing: abnormal posture with the neck extended, , the jaw clenched, arms pronated, extended, and close to the sides. legs extended and feet plantar flexed, with adduction and rigid, extension of upper and lower extremities.

Decerebrate posturing

_____ posturing: abnormal posture with the arms close to the sides with the elbows, wrists, and fingers flexed, the legs extended, and internally rotated, and the feet plantar flexed, with upper extremity flexion.

Decorticate (turned towards the core)

Decorticate and Decerebrate posturing: -Poor prognosis: severe permanent neurological impairment if survives -Survival not expected

LOOK AT PICTURES

Mr. Allen is placed on Coumadin after a CVA, and needs teaching before transfer to the Rehab Unit on safety issues while taking this drug and foods to monitor. What will you tell him?

• Warfarin sodium suppresses the synthesis of vitamin K coagulation factors. Green, leafy vegetables contain vitamin K, (i.e. spinach) and will therefore interfere with the therapeutic effects of the drug as well as other foods high in Vitamin K. • Bruising is a common side effect and considered normal but keep an eye on them; note size and amount; avoid bumps, falls etc. for life threatening hemorrhaging • The drug should not be stopped unless prescribed by the physician. • Will need to be monitored with consistent lab tests. • Report any bleeding of gums, black tarry stools, excessive bruising

What is a priority nursing assessment in the first 24 hours after admission of the client with thrombotic stroke? 1. Cholesterol level 2. Pupil size and papillary response 3. Bowel sounds 4. Echocardiogram

2. Pupil size and papillary response - it is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves.

What is the expected outcome of thrombolytic drug therapy (fibrinolytic therapy) for stroke? 1. Increased vascular permeability 2. Vasoconstriction 3. Dissolved emboli 4. Prevention of hemorrhage

3. Dissolved emboli; Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, thus re-establishing cerebral perfusion.

A client is experiencing mood swings after a stroke (brain cell injury related) and often has episodes of tearfulness which are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? A. Sit quietly with the client until the episode is over B. Ignore the behavior C. Attempt to divert the client's attention D. Tell the client that this behavior is unacceptable

C. Attempt to divert the client's attention; ;A client who has brain damage may be emotionally labile and may cry or laugh for no explainable reason. Crying is best dealt with by attempting to divert the client's attention. Ignoring the behavior will not affect the mood swing or the crying and may increase the clients sense of isolation. Telling the client to stop in inappropriate.