143 FINAL - Mod 6: Neuro (PRACTICE QUESTIONS)

The nurse is caring for a client who is known to be at risk for cardiogenic embolic strokes. What arrhythmia does this client most likely have? A. Ventricular tachycardia B. Atrial fibrillation C. Supraventricular tachycardia D. Bundle branch block

ANS: B Rationale: Cardiogenic embolic strokes are associated with cardiac arrhythmias, which is usually atrial fibrillation. Absence of a regular contraction of the fibrillating atria leads to an increase of atrial pressure and dilation, which together with hemoconcentration, endothelial dysfunction, and a prothrombotic state are prerequisites for thrombus formation. In other words, the irregularity of the heartbeat caused by atrial fibrillation makes the heart more likely to form clots. Studies have shown that strokes that are caused by atrial fibrillation have an increased poor outcome in terms of severity and resulting disability. The other listed arrhythmias are less commonly associated with this type of stroke.

A client reports light-headedness, speech disturbance, and left-sided weakness lasting for several hours. The neurologist diagnosed a transient ischemic attack, which caused the client great concern. What would the nurse include during client education? A. Symptoms of a TIA may linger for up to a week. B. Two thirds of people that experience a TIA will go on to develop a stroke. C. A TIA is an insidious, often chronic episode of neurologic impairment. D. When symptoms cease, the client will return to presymptomatic state.

D. Impaired blood circulation can be caused by arteriosclerosis, cardiac disease, or diabetes. A TIA is a sudden, brief episode of neurologic impairment. Symptoms may disappear within 1 hour; some continue for as long as 1 day. One third of people who experience a TIA subsequently develop a stroke.

Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere? A. Expressive aphasia B. Inability to move the right arm C. Neglect of the right side D. Neglect of the left side

D. This client would have deficits on the left side. Expressive aphasia typically occurs with left-hemisphere stroke.

Which of the following are causes or triggers of seizures? Select all that apply. A) Alcohol withdrawal B) Brain tumor C) Hypocalcemia D) Infection E) Fever

A, B, C, D, E. Seizures are caused by anything that can cause brain swelling or hypoxia. The most common causes of seizures are infection, trauma, brain mass, increased intracranial pressure (ICP), fever, and alcohol and drug withdrawal. Infections due to Streptococcus agalactiae (a group B Streptococcus) and Escherichia coli are the most common causes of neonatal meningitis and cause seizures. Brain masses or tumors that metastasize, trauma, and fever add additional pressure on the brain, increasing the intracranial pressure, which results in swelling and seizures.

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action? A. Form words that are understandable or comprehend spoken words B. Comprehend spoken words C. Form words that are understandable D. Speak at all

A. Global aphasia is a combination of expressive and receptive aphasia and presents a tremendous challenge to the nurse to effectively communicate with the client. In receptive and expressive aphasia, the client is unable to form words that are understandable. The client who is unable to speak at all is referred to as mute.

A client is having a grand mal seizure. Which of these interventions by the nurse will ensure safety during the seizure? A) Protect the client from injury B) Place a padded tongue blade between the teeth C) Lay the client in a supine position D) Give oxygen via facemask

A. Grand mal seizures are violent and can potentially cause injury to the client. The most important thing to remember with seizures is to maintain safety and protect the client from injury. Placing clients in the recovery position and monitoring their airway are two of the most important interventions. These interventions can help prevent aspiration and prevent injury. Other interventions include padding the side rails of the bed and placing the bed in the lowest position. It is important not to restrain a seizing client. Place suction materials at the bedside. Remember to observe the length of the seizure and afterwards to document the time it started and the time it ended and what happened during the seizure.

The nurse is assessing a client who has been on phenytoin for 10 years. Which characteristic finding is observed in clients with a long-term history of taking phenytoin sodium? A) Excess growth of gum tissue B) Enlarged tonsils C) Dry, scaly skin D) Mania

A. Phenytoin is an anti-epileptic or anticonvulsant medication used to prevent and treat certain types of seizures. It works by decreasing the impulse activity in the brain that can cause seizures. Long-term use of phenytoin can cause gingival hyperplasia (excessive growth of gum tissue). The client should be instructed to have good oral hygiene and to follow-up at least every 6 months with the dentist to have this potential complication of phenytoin monitored. Self-monitoring should be taught to the client and any change of the gums reported to the health care professional.

A client is being discharged with a new prescription of phenytoin. Which instruction by the nurse is most important to include? A) If stopped abruptly, status epilepticus may occur B) Sulfonamides will decrease phenytoin levels in the blood C) Take the medication with antacids to reduce gastric upset D) This will not affect contraceptive effectiveness

A. Phenytoin is an anti-epileptic or anticonvulsant medication used to prevent and treat certain types of seizures. It works by decreasing the impulse activity in the brain that can cause seizures. The nurse should teach a client newly prescribed phenytoin to never abruptly stop taking the medication. Abrupt withdrawal of this medication is dangerous and can cause life threatening seizure activity. The client should always plan ahead to have prescriptions filled, have extra medications available, and be systematic and consistent with taking phenytoin. Phenytoin is one of a few medications with therapeutic blood levels needed to be effective and prevent toxicity side effects. Blood levels should be monitored and maintained at 10-20 mcg/mL to prevent toxicity symptoms including CNS effects such as nystagmus, slurring speech, lethargy, coma, or death.

A client with a diagnosis of epileptic seizures is on anticonvulsant therapy, phenytoin and is at the clinic for follow-up. The client reveals signs of central nervous system (CNS) depression with complaints of increased lethargy and confusion. The nurse provides further instruction on CNS depression after the client discloses use of which of the following? A) Alcohol B) Furosemide C) Metformin D) Calcium

A. Phenytoin is an anticonvulsant medication used to control seizures. The medication works by slowing down the impulses in the brain which cause seizures. It is a CNS depressant. Phenytoin, when mixed with other CNS depressants, such as alcohol, causes additional CNS depression. Alcohol, in particular, will increase phenytoin serum levels, which may induce toxicity and CNS depression. Phenytoin toxicity signs and symptoms include CNS depression, lethargy, confusion, lack of coordination, slurred speech, double vision, and nystagmus. These symptoms should be reported immediately.

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: A. Severe headache and early change in level of consciousness B. Confusion or change in mental status C. Weakness on one side of the body and difficulty with speech D. Foot drop and external hip rotation

A. The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Foot drop and external hip rotation can occur if a stroke victim is not turned or positioned correctly.

The nurse is educating a group of nursing students about COVID-19 and risk for cerebrovascular disorders. The nurse educator notes that COVID-19 has shown to increase which condition? A. Ischemic stroke B. Decrease inflammation C. Hemorrhagic stroke D. Hypertension

ANS: A Rationale: Blood clotting abnormalities have been found to occur in COVID-19 afflicted clients. With the clotting abnormalities, there is an increased risk for ischemic stroke. There is no evidence that COVID-19 causes any of the other conditions.

A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client? A. The client should be approached on the side where visual perception is intact. B. Attention to the affected side should be minimized in order to decrease anxiety. C. The client should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. D. The client should be approached on the opposite side of where the visual perception is intact to promote recovery.

ANS: A Rationale: Clients with decreased field of vision should first be approached on the side where visual perception is intact. All visual stimuli should be placed on this side. The client can and should be taught to turn the head in the direction of the defective visual field to compensate for this loss. The nurse should constantly remind the client of the other side of the body and should later stand at a position that encourages the client to move or turn to visualize who and what is in the room.

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? A. Provide a board of commonly used needs and phrases. B. Have the client speak to loved ones on the phone daily. C. Help the client complete his or her sentences as needed. D. Speak in a loud and deliberate voice to the client.

ANS: A Rationale: The inability to talk on the telephone or answer a question or exclusion from conversation causes anger, frustration, fear of the future, and hopelessness. A common pitfall is for the nurse or other health care team member to complete the thoughts or sentences of the client. This should be avoided because it may cause the client to feel more frustrated at not being allowed to speak and may deter efforts to practice putting thoughts together and completing a sentence. The client may also benefit from a communication board, which has pictures of commonly requested needs and phrases. The board may be translated into several languages.

A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what? A. Evidence of hemorrhagic stroke B. Blood pressure of 180/110 mm Hg C. Evidence of stroke evolution D. Previous thrombolytic therapy within the past 12 months

ANS: A Rationale: Thrombolytic therapy would exacerbate a hemorrhagic stroke with potentially fatal consequences. Stroke evolution, high BP, or previous thrombolytic therapy does not contraindicate its safe and effective use.

A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety? A. Place the client in a side-lying position. B. Pad the client's bed rails. C. Administer anti anxiety medications as prescribed. D. Reassure the client and family members.

ANS: A Rationale: To prevent complications, the client is placed in the side-lying position to facilitate drainage of oral secretions. Suctioning is performed, if needed, to maintain a patent airway and prevent aspiration. None of the other listed actions promotes safety during the immediate recovery period.

A client with a recent stroke history is admitted to a rehabilitation unit and placed on high fall risk precautions. The client is impulsive, easily distracted, frequently forgets his/her cane when walking, and the location of his/her room. What stroke conditions do these signs best indicate? A. Ischemic stroke B. Right hemispheric stroke C. Hemorrhagic stroke D. Left hemispheric stroke

ANS: B Rationale. In right hemispheric stroke, signs include a client that is easily distracted and has impulsive behavior and poor judgment. The client can be unaware of deficits like motor weakness, as demonstrated by the client forgetting the cane. Clients can also have spatial or perceptual deficits. This means they can get lost in familiar and unfamiliar places. This client was unable to find his/her room. The client who has a right hemisphere stroke demonstrates weakness on the left side of the body. The client with left hemispheric stroke has signs such as paralysis or weakness in the right side of the body, right-sided visual deficits, and slow cautious behaviors. Ischemic and hemorrhagic strokes describe what caused the stroke rather than what side of the brain was affected. Signs and symptoms differ for each type of stroke. Ischemic strokes can include numbness to one side of the face. Headache, decreased level of consciousness, and seizures typically are signs of a hemorrhagic stroke.

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? A. Generalized pain B. Alteration in level of consciousness (LOC) C. Tonic-clonic seizures D. Shortness of breath

ANS: B Rationale: Alteration in LOC is the earliest sign of deterioration in a client after a hemorrhagic stroke, such as mild drowsiness, slight slurring of speech, and sluggish papillary reaction. Sudden headache may occur, but generalized pain is less common. Seizures and shortness of breath are not identified as early signs of hemorrhagic stroke.

A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized? A. Prevent complications of immobility. B. Maintain and improve cerebral tissue perfusion. C. Relieve anxiety and pain. D. Relieve sensory deprivation.

ANS: B Rationale: Each of the listed goals is appropriate in the care of a client recovering from a stroke. However, promoting cerebral perfusion is a priority physiologic need, on which the client's survival depends.

The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipate administering to halt the seizure immediately? A. Intravenous phenobarbital B. Intravenous lorazepam C. Oral lorazepam D. Oral phenytoin

ANS: B Rationale: Medical management of status epilepticus includes IV diazepam and IV lorazepam given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state. Oral medications are not given during status epilepticus.

A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and staring into space, according to the playground supervisor. How would the nurse document the girl's activity in her chart at school? A. Generalized seizure B. Absence seizure C. Focal seizure D. Unclassified seizure

ANS: B Rationale: Staring episodes characterize an absence seizure, whereas focal seizures, generalized seizures, and unclassified seizures involve uncontrolled motor activity.

A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication? A. Acute pain B. Septicemia C. Bleeding D. Seizures

ANS: C Rationale: Bleeding is the most common side effect of t-PA administration, and the client is closely monitored for any bleeding. Septicemia, pain, and seizures are much less likely to result from thrombolytic therapy.

A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? A. Unclassified seizure B. Absence seizure C. Generalized seizure D. Focal seizure

ANS: C Rationale: Generalized seizures often involve both hemispheres of the brain, causing both sides of the body to react. Intense rigidity of the entire body may occur, followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction). This pattern of rigidity does not occur in clients who experience unclassified, absence, or focal seizures.

A client who has been on long-term phenytoin therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the client's plan of care? A. Monitoring of pulse oximetry B. Administration of a low-protein diet C. Administration of thorough oral hygiene D. Fluid restriction as prescribed

ANS: C Rationale: Gingival hyperplasia (swollen and tender gums) can be associated with long-term phenytoin use. Thorough oral hygiene should be provided consistently and encouraged after discharge. Fluid and protein restriction are contraindicated and there is no particular need for constant oxygen saturation monitoring.

A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for which purpose? A. To decrease cerebral edema B. To prevent seizure activity that is common following a TIA C. To remove atherosclerotic plaques blocking cerebral flow D. To determine the cause of the TIA

ANS: C Rationale: The main surgical procedure for select clients with TIAs is carotid endarterectomy, the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in clients with occlusive disease of the extracranial arteries. An endarterectomy does not decrease cerebral edema, prevent seizure activity, or determine the cause of a TIA.

A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? A. Sit with the client for a few minutes. B. Administer an analgesic. C. Inform the nurse manager. D. Call the health care provider immediately.

ANS: D Rationale: A headache may be an indication that the aneurysm is leaking. The nurse should notify the health care provider immediately. The health care provider will decide whether administration of an analgesic is indicated. Informing the nurse manager is not necessary. Sitting with the client is appropriate, once the health care provider has been notified of the change in the client's condition.

A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? A. Restrain the client to prevent injury. B. Open the client's jaws to insert an oral airway. C. Place client in high Fowler position. D. Loosen the client's restrictive clothing.

ANS: D Rationale: An appropriate nursing intervention would include loosening any restrictive clothing on the client. No attempt should be made to restrain the client during the seizure because muscular contractions are strong and restraint can produce injury. Do not attempt to pry open jaws that are clenched in a spasm to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. If possible, place the client on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus.

The nurse is providing care for a client who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the client has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following? A. The ability of the client to follow instructions during the seizure. B. The success or failure of the care team to physically restrain the client. C. The client's ability to explain his seizure during the postictal period. D. The client's activities immediately prior to the seizure.

ANS: D Rationale: Before and during a seizure, the nurse observes the circumstances before the seizure, including visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; and hyperventilation. Communication with the client is not possible during a seizure and physical restraint is not attempted. The client's ability to explain the seizure may not be accurate since the client is often still confused during the postictal period.

When planning nursing care for a patient with a stroke, the nurse should consider which primary goal of medical management? 1. Restoration of cerebral blood flow and limiting the size of the infarcted area of the brain 2. Keeping the blood pressure under control pharmacologically 3. Transferring the patient for rehabilitation as soon as medically stable 4. Reestablishing blood flow to the infarcted area surgically

Answer: 1 Explanation: 1. The goal is to recover as much function as possible. The most vulnerable area of the brain is the penumbra, and the sooner the circulation can be restored to that area the better the cells in that area will recover. 2. The patient's blood pressure should be controlled, but this goal is not global enough to be the primary goal. 3. Transferring the patient to a long-term care facility as soon as medically stable is a goal for patients to recover enough function to return to their former settings. This is not the primary goal for medical management. 4. Surgical options are not available for most stroke patients.

The nurse is assessing a newly admitted older patient for modifiable risk factors for stroke development. The nurse would include teaching about which findings? Select all that apply. 1. Blood pressure is consistently above 95 diastolic. 2. The patient has had two recent hospital admissions to treat dehydration. 3. The patient reports drinking a glass of wine with dinner every evening. 4. The patient uses smokeless tobacco. 5. Testing has previously indicated the patient has hypercholesterolemia.

Answer: 1, 2, 5 Explanation: 1. Diastolic hypertension (consistent readings above 95) is a modifiable risk factor for stroke development. 2. Dehydration may cause dangerous lowering of blood pressure and decrease cerebral perfusion, especially in older patients. This decrease in cerebral perfusion may precipitate stroke. 3. Moderate alcohol use, such as one glass of wine per day, is not associated with stroke development. 4. While smoking does increase risk for stroke, the use of smokeless tobacco has not been shown to have the same effect. 5. Hypercholesterolemia is a risk factor for atherosclerosis in the cerebral vascular beds and increases risk for stroke.

The nurse is triaging a patient who just presented to the emergency department. Which cluster of assessment findings would the nurse evaluate as indicating the greatest possibility that this patient is having a stroke? 1. Radicular pain, decreased deep tendon reflexes, loss of bladder control 2. Difficulty with balance, hemianopsia, hemiparesis 3. Dystonia, dysphagia, dysarthria 4. Paresthesia, priapism, loss of reflexes

Answer: 2 Explanation: 1. Radicular pain, decreased deep tendon reflexes, and loss of bladder control are more likely associated with other neurologic conditions rather than stroke. 2. The most common cluster of symptoms seen in a stroke is difficulty with balance, hemianopsia, and hemiparesis. 3. Dysphagia is common in stroke, but dystonia and dysarthria are not common findings associated with stroke. 4. The patient having stroke may have some paresthesia, but priapism and loss of reflexes are not common initial findings.

A patient in the intensive care unit begins exhibiting seizure activity. What nursing interventions are indicated? Select all that apply. 1. Hold the patient as still as possible to prevent tissue damage. 2. Roll the patient to the side if possible. 3. Place a padded tongue blade in the patient's mouth. 4. Time the seizure from beginning to end. 5. Call the rapid response team.

Answer: 2, 4 Explanation: 1. The nurse should remove hard objects if possible and pad objects that cannot or should not be removed. This action will help prevent injury. The nurse should not attempt to hold the patient still. 2. Rolling the patient to the side will allow secretions to clear the mouth and will help prevent aspiration. 3. No attempt to place anything in the patient's mouth should be made. 4. Length of seizure is important assessment information that can be collected by the nurse. 5. The nurse working in the intensive care unit should be adequately prepared to manage a patient having a seizure. There is no need to call for a rapid response team for a simple seizure.

A patient is receiving tissue plasminogen activator (tPA) for the treatment of an ischemic stroke. Which nursing interventions are indicated? 1. Insert a nasogastric tube for nutritional support. 2. Monitor for renal stone formation. 3. Monitor for deterioration of neurological status. 4. Reposition every 15 minutes.

Answer: 3 Explanation: 1. Insertion of a nasogastric tube can cause injury and should be avoided in this patient. 2. Renal stone formation is not a complication of this medication. 3. Deterioration of neurological status can occur as a result of bleeding or if tPA is not effective in lysing the clot. The nurse should monitor for this evolving situation. 4. Frequent moving can increase the risk of bleeding; therefore, the patient should not be repositioned every 15 minutes.

A patient had a stroke that resulted in Broca's aphasia. What instructions should the nurse provide when teaching the family how to communicate with this patient? Select all that apply. 1. Speak slowly and loudly to the patient. 2. Use paper and pencil for all communication. 3. Ask the patient yes-no questions. 4. Anticipate the patient's answers and finish questions and sentences. 5. Give the patient time to search for words.

Answer: 3, 5 Explanation: 1. Patients who are aphasic often complain that people shout at them as if they cannot hear. A hearing deficit is not a part of Broca's aphasia and speaking loudly is not indicated. 2. Writing ability may also be impaired with Broca's aphasia. 3. The patient with Broca's aphasia can comprehend speech, but has difficulty responding verbally. Asking yes-no questions allows the patient to respond nonverbally. 4. The patient with Broca's aphasia may retain some speech. It is not helpful, however, for others to complete the patient's questions or sentences. 5. Allowing the patient time to search for words may result in adequate expression of needs. It may also help the patient improve word finding, which would improve speech.

A patient who has been admitted with symptoms of stroke is to have a CT scan. What rationale for this testing would the nurse provide to the patient and family? 1. CT scans are used to determine the effectiveness of the cerebral circulation to perfuse all areas of the brain. 2. The CT scan will evaluate how much brain swelling is associated with this stroke. 3. The CT scan will pinpoint the exact area of the brain affected by the stroke. 4. The CT scan can guide treatment by differentiating hemorrhagic from ischemic causes of the stroke.

Answer: 4 Explanation: 1. A CT scan alone will not determine the effectiveness of cerebral circulation. 2. CT scans cannot determine the extent of brain swelling. 3. CT scans cannot pinpoint the exact area of the brain affected by stroke, but can help to establish the anatomical region in which the stroke occurred. 4. A CT scan will be used to rule out a hemorrhagic stroke from an ischemic stroke, especially if thrombolytic therapy is being considered, and to determine any areas of localized hematoma formation as a result of a hemorrhage.

A client is following up after a visit to the emergency department where testing indicated that the client had suffered a transient ischemic attack. What lifestyle changes would the nurse include in teaching to prevent further recurrence? Select all that apply. A. Physical activity limitations B. Smoking cessation C. Weight loss D. Blood pressure control E. High-dose aspirin

B, C, D. Primary prevention of ischemic stroke remains the best approach. A healthy lifestyle including not smoking, engaging in physical activity (at least 40 minutes a day, 3 to 4 days a week), maintaining a healthy weight, and following a healthy diet (including modest alcohol consumption) can reduce the risk of having a stroke. Specific diets that have decreased risk of stroke include the Dietary Approaches to Stop Hypertension (DASH) diet (high in fruits and vegetables, moderate in low-fat dairy products, and low in animal protein), the Mediterranean diet (supplemented with nuts), and overall diets that are rich in fruits and vegetables. Research findings suggest that low-dose aspirin may lower the risk of a first stroke for those who are at risk.

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? A. Sleeping quietly after the seizure B. Seizure was 1 minute in duration including tonic-clonic activity. C. The client cried out before the seizure began. D. Seizure began at 1300 hours.

B. Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and their skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity.

How are seizures diagnosed? A) An EKG B) An EEG C) A CBC D) An X-ray of the brain

B. Seizures are diagnosed by an electroencephalogram or EEG. Electrodes are placed on the client's scalp with a substance like paste to record the client's brain's electrical activity. Clients may have blood drawn between 10-20 minutes past the seizure and the client's prolactin increases in the blood if the client had a generalized tonic-clonic or complex partial seizure. If an EEG does not provide enough information for the healthcare provider, a magnetic resonance imaging (MRI) may be ordered. The MRI can reveal tumors and infections. It can reveal localized areas of the client's brain where seizures begin and provide information regarding other problems neurologically. An ECG is an electrocardiogram and records information about the client's heart. A CT or x-ray of the brain is not normally used to diagnose seizures.

The patient is having a continuous seizure that has lasted over 5 minutes. What is the priority action of the nurse? A) Take the patient to MRI so that his brain can be imaged B) Complete vital signs and a full neuro assessment C) Administer prescribed lorazepam D) Ensure that the stat lab work gets completed

C. A seizure lasting longer than 5 minutes is termed status epilepticus and is an emergency. Status epilepticus affects airway and oxygenation. Seizures that last 30 minutes or longer can cause brain injury. The priority nursing interventions for a patient having a seizure is safety and stopping (aborting) the seizure. Medications such as lorazepam and diazepam may be used for seizure abortion. They work by increasing GABA and cause the brain to calm and rest.

Which of the following is the initial diagnostic in suspected stroke? A. CT with contrast B. Magnetic resonance imaging (MRI) C. Noncontrast computed tomography (CT) D. Cerebral angiography

C. An initial head CT scan will determine whether or not the patient is experiencing a hemorrhagic stroke. An ischemic infarction will not be readily visible on initial CT scan if it is performed within the first few hours after symptoms onset; however, evidence of bleeding will almost always be visible.

A client with a history of tonic-clonic seizures is started on new medication. One month later the client complains of bleeding gums, increased facial hair, and double vision. Which of the following anticonvulsant medications is responsible for these symptoms? A) Diazepam B) Phenobarbital C) Phenytoin D) Valproic acid

C. Clients with a history of tonic-clonic seizures are prescribed phenytoin. Phenytoin is the first-line treatment for acute tonic-clonic seizures. Phenytoin blocks sodium channels in the brain, reducing the symptoms and frequency of seizure episodes. The adverse effects of phenytoin are bleeding enlarged gums, increased facial hair (hirsutism), and double vision (diplopia). Clients may also experience symptoms of yellow-brown skin. Phenytoin causes teratogenicity; therefore, clients must be educated to use contraception to reduce the risk of fetal abnormalities.

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer? A. Clinical manifestations of a stroke depend on how quickly the clot can be dissolved. B. Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client. C. Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation. D. Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing.

C. Clinical manifestations following a stroke are highly variable and depend on the area of the cerebral cortex and the affected hemisphere, the degree of blockage (total, partial), and the presence or absence of adequate collateral circulation. (Collateral circulation is circulation formed by smaller blood vessels branching off from or near larger occluded vessels.) Clinical manifestations of a stroke do not depend on the cardiovascular health of the client or how quickly the clot can be dissolved. Clinical manifestations of a stroke are not general but individual.

An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy? A. Taking digoxin B. Surgery 6 weeks ago C. International normalized ratio greater than 2 D. Two hour time period of the stroke

C. The client is at risk for further bleeding if the international normalized ratio is greater than 2. Thrombolytic therapy must be initiated within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetalol do not prohibit thrombolytic therapy.

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode? A. Recent weight gain and loss B. The type of anticonvulsant prescribed to manage the epileptic condition C. Compliance with the prescribed medication regimen D. Recent stress level

C. The most common cause of status epilepticus is sudden withdrawal of anticonvulsant therapy. The type of medication prescribed, the client's stress level, and weight change don't contribute to this condition.

A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time? A. 2:00 p.m. B. 3:00 p.m. C. 4:00 p.m. D. 7:00 p.m.

C. Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset. Therefore, since symptom onset was 1:00 pm, the window of opportunity ends at 4:00 pm.

The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see: A. Spatial-perceptual deficits. B. Impulsive behavior. C. Left visual field deficit. D. Right-sided paralysis.

D. A left hemispheric stroke will cause right-sided weakness or paralysis. Because upper motor neurons decussate, a disturbance on one side of the body can cause damage on the opposite side of the brain. Refer to Box 47-2 in the text.

The school nurse notes a 6-year-old running across the playground with friends. The child stops in mid-stride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child? A. A partial seizure B. A complex seizure C. A tonic-clonic seizure D. An absence seizure

D. Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness, during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. A generalized seizure involves the whole brain.

The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following? A. Cerebral aneurysm B. Arteriovenous malformation C. Intracerebral hemorrhage D. Cardiogenic emboli

D. Aneurysms, hemorrhages, and malformations are all examples of a hemorrhagic stroke. An embolism can block blood flow, leading to ischemia.

A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? A. Nausea, vomiting, and profuse sweating B. Difficulty breathing or swallowing C. Tachycardia, tachypnea, and hypotension D. Hemiplegia, seizures, and decreased level of consciousness

D. Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased level of consciousness, aphasia, hemiparesis, and increased focal symptoms. Nausea, vomiting, and profuse sweating suggest a delayed reaction to the contrast medium used in cerebral angiography. Difficulty breathing or swallowing may signal a hematoma in the neck. Tachycardia, tachypnea, and hypotension suggest internal hemorrhage.

The nurse assesses a client in the postictal phase (recovery phase). Which of these actions will the nurse prioritize during the postictal phase of a seizure? A) Assess level of lethargy B) Place a pillow under the head C) Reorient the client to surroundings D) Perform a respiratory assessment

D. The length of the postictal phase (recovery phase) of a seizure is dependent on the type of seizure. It can last anywhere from minutes to days. During this phase, the client may feel sore, confused, sleepy, weak, and even experience feelings of sadness. During the postictal state, it is important to keep the client safe from injury until this phase resolves. Often before this state, the client may have respiratory depression or may have aspirated. Respiratory assessment will be necessary following a seizure.

The nursing student describes the seizure observed as stiffening then jerking all over. The nurse correctly identifies this as which type of seizure? A) Clonic B) Absence C) Atonic D) Tonic-Clonic

D. There are different seizure types. Some seizures impair consciousness such as generalized seizures or complex partial seizures while others do not as in simple partial seizures. Some seizures are brief and can appear to be daydreaming, such as in absence seizures. If the tone is affected the word tonic is used. Atonic is the loss of tone, whereas, tonic is the increase of tone, meaning rigid. Clonic is jerking and may be part of the body or all of the body.