Adult Health II Test Review Chapters 61 - 64

A rehabilitation nurse caring for a patient who has had a stroke is approached by the patient's family and asked why the patient has to do so much for herself when she is obviously struggling. What would be the nurse's best answer?

"The focus on care in a rehabilitation facility is to help the patient to resume as much self-care as possible."

An adult client has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months. Which of the following questions addresses potential etiologic factors?

1. "Are you exposed to any toxins or chemicals at work?" 2. "How would you describe your ability to cope with stress?" 3. "What medications are you currently taking?" 4. "Does anyone else in your family struggle with headaches?"

The nurse is caring for a client who is rapidly progressing toward brain death. The nurse should be aware of what cardinal sign(s) of brain death?

1. Coma 2. Apena 3. Absence of brain stem reflexes

The nurse caring for a client in a persistent vegetative state is regularly assessing for potential complications. The nurse should assess for which complications?

1. Contractures 2. Pressure ulcers 3. Venous thromboembolism 4. Pneumonia

The nurse is caring for a client with a brain tumor and is aware that the normal compensation measures to keep ICP (intracranial pressure) within normal limits may no longer be effective. What are the normal compensation measures for the brain?

1. Displacing or shifting cerebral spinal fluid (CSF) 2. Increasing the absorption of CSF 3. Decreasing cerebral blood volume

During a patient's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help patients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply.

1. National Institutes of Health Stroke Scale (NIHSS) score 2. LOC at time of admission 3. Age

The nurse is admitting a client to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this client's admission orders?

1. Transcranial Doppler flow study 2. Cerebral angiography 3. MRI

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?

Absence seizure

A nurse has received an unconscious client with a traumatic brain injury (TBI). The nurse is concerned about the client's skin integrity and implements interventions to prevent pressure injuries. Which action should the nurse implement during the shift?

Assessing all body surfaces and documenting skin integrity every 8 hours

The nurse has implemented interventions aimed at facilitating family coping in the care of a client with a traumatic brain injury. How can the nurse best facilitate family coping?

Assist the family in setting appropriate short-term goals.

The nurse caring for a patient in ICU diagnosed with Guillain-Barr syndrome should prioritize monitoring for what potential complication?

Autonomic dysfunction

A client with a history of epilepsy is admitted preoperatively for a surgical procedure and dies overnight. The health care provider suspects sudden unexpected death in epilepsy (SUDEP). Which condition is most likely related to SUDEP?

Cardiac abnormalities

A client with a C5 spinal cord injury has tetraplegia. After being moved out of the ICU, the client reports a severe throbbing headache. What should the nurse do first?

Check the client's indwelling urinary catheter for kinks to ensure patency.

The nurse planning the care of a client with head injuries is addressing the client's nursing diagnosis of "sleep deprivation." What action should the nurse implement?

Cluster overnight nursing activities to minimize disturbances

The nurse is discharging home a patient who suffered a stroke. He has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common patient response to a change in body image?

Depression

A middle-aged woman has sought care from her primary care provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the woman to seek care?

Difficulty in coordination

What should you teach a patient NOT do to if they have Intracranial Pressure?

Do not do Valsalva Maneuver (constipation/straining) Do not lay flat or prone or supine Do not lay Trendelenburg

The emergency room (ER) nurse is caring for a client who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding(s) are suggestive of a basilar skull fracture?

Epistaxis Bruising over the mastoid

A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what?

Evidence of hemorrhagic stroke

The nurse is developing a plan of care for a patient newly diagnosed with Bells palsy. The nurses plan ofcare should address what characteristic manifestation of this disease?

Facial paralysis

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?

Generalized seizure

A client is experiencing dysphagia following a stroke. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing?

Help the client sit upright when eating and feed slowly.

The nurse caring for a client with a spinal cord injury notes that the client is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action?

Increase the frequency of ROM exercises.

A client is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this client, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this client?

Ineffective breathing patterns related to weakness of the intercostal muscles

During the examination of an unconscious client, the nurse observes that the client's pupils are fixed and dilated. What is the most plausible clinical significance of the nurse's finding?

It indicates an injury at the midbrain level

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?

Keeping the client in one position to decrease bleeding

A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?

Loosen the client's restrictive clothing

A 73-year-old man comes to the clinic complaining of weakness and loss of sensation in his feet and legs. Assessment of the patient shows decreased reflexes bilaterally. Why would it be a challenge to diagnose a peripheral neuropathy in this patient?

Many symptoms can be the result of normal aging process.

The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this patient?

Monitoring neurologic status closely

Following a spinal cord injury, a client is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action?

Notify the neurosurgeon of the occurrence

A client with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this client?

Orthostatic hypotension Autonomic dysreflexia DVT

A client is recovering from intracranial surgery that was performed using the transsphenoidal approach. The nurse should be aware that the client may have required surgery on what neurologic structure?

Pituitary gland

A female patient is diagnosed with a right-sided stroke. The patient is now experiencing hemianopsia. How might the nurse help the patient manage her potential sensory and perceptional difficulties?

Place the patient's extremities where she can see them.

The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action?

Prepare for interventions to increase the client's BP.

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?

Right-sided paralysis.

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:

Severe headache and early change in level of consciousness

Which is indicative of a right hemisphere stroke?

Spatial-perceptual deficits

The nurse is preparing health education for a patient who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education?

Take antihypertensive medication as ordered.

A 48-year-old patient has been diagnosed with trigeminal neuralgia following recent episodes of unilateral face pain. The nurse should recognize the implication of this diagnosis?

The patient needs to be assessed for MS.

A male client who is being treated in the hospital for a spinal cord injury (SCI) is advocating for the removal of the urinary catheter, stating that they want to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention?

Urinary catheter use often leads to urinary tract infections (UTIs).

A client has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication?

Vigilant monitoring of fluid balance

A patient diagnosed with Bells palsy is having decreased sensitivity to touch of the involved nerve.What should the nurse recommend to prevent atrophy of the muscles?

Whistling

The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI?

Young age Male gender Alcohol or drug use