AH chapter 39

A patient in a barbiturate coma for increased intracranial pressure (ICP) has audible gurgling through the endotracheal tube. What should the nurse do first before suctioning this patient? 1) Administer 100% oxygen 2) Elevate the head of the bed 3) Interrupt sedative administration 4) Place the head in a neutral position

1

A patient with a cerebral vasospasm is receiving triple H therapy. What parameter should the nurse use to determine adequacy of hemodilution? 1) Hemoglobin level = 30 g/dL 2) Blood pressure 154/80 mm Hg 3) Serum sodium level less than 160 mg/dL 4) Serum potassium level between 4.0 and 4.5 mEq/L

1

A patient with a traumatic brain injury is leaking clear fluid from the nose. What action should the nurse take? 1) Collect the fluid with gauze 2) Check the fluid for red blood cells 3) Send a specimen for a protein level 4) Insert a nasal plug in the nostril leaking the fluid

1

A patient with neurogenic shock is demonstrating vagal stimulation. What should the nurse expect to be prescribed for this patient? 1) Atropine2) Epinephrine3) Phenylephrine 4) Norepinephrine

1

The family of a patient with a traumatic brain injury asks why the bed side rails are padded. What should the nurse explain to the family? 1) "There is a risk for seizure activity after a head injury." 2) "The padding prevents injury when turning the patient." 3) "The padding prevents the patient from climbing out of bed." 4) "The padding ensures the side rails are kept elevated at all times."

1

The nurse is caring for a patient with hypotension caused by neurogenic shock. What action should the nurse take to reduce the risk of developing orthostatic hypotension? 1) Raise the head of the bed slowly 2) Elevate the foot of the bed 30 degrees 3) Place in the supine position with the head flat 4) Keep the head of the bed elevated at 60 degrees

1

The nurse contacts the health-care provider with data collected from a patient recovering from a stroke. Which information indicated the patient was experiencing central herniation? Select all that apply. 1) Coma 2) Bradycardia 3) Positive Babinski's 4) Unilateral dilated pupil 5) Increased systolic blood pressure

1,2,3,5

The nurse suspects a patient is experiencing an ischemic stroke of the basilar artery. What manifestations did the nurse most likely assess in this patient? Select all that apply. 1) Ataxia 2) Nausea N 3) Dysphasia 4) Inability to swallow 5) Difficulty with speech

1,2,4,5

A patient is demonstrating signs of increasing intracranial pressure (ICP). What physical actions should the nurse take to reduce this pressure? Select all that apply. 1) Placing the head in a neutral position 2) Turning into a left side-lying position 3) Raising the head of the bed 60 degrees 4) Elevating the foot of the bed 45 degrees 5) Placing supine with a pillow under the head

1,3

A patient with an ischemic stroke is being considered for recombinant tissue plasminogen activator (rt-PA). What would cause this procedure to be contraindicated in this patient? Select all that apply. 1) Age 83 years 2) Symptoms present for 45 minutes 3) CT scan demonstrates area of ischemia 4) 10-year history of type 2 diabetes mellitus 5) Takes warfarin sodium for atrial fibrillation

1,4,5

A patient is diagnosed with a subarachnoid hemorrhage caused by a cerebral aneurysm that has a wide neck and tortuous vascular anatomy. For which procedure should the nurse prepare teaching material for this patient? 1) Aneurysm coiling 2) Aneurysm clipping 3) Reinforcing aneurysm wall 4) Evacuation of the hematoma

2

A patient recovering from a hemorrhagic stroke has a blood pressure of 90/50 mm Hg. What action should the nurse take? 1) Increase the head of the bed 2) Notify the health-care provider 3) Place the head in a neutral position 4) Reassess the pressure in 15 minutes

2

A patient with increased intracranial pressure (ICP) has a body temperature of 100°F. What action should the nurse take to address this temperature elevation? 1) Place head in a neutral position 2) Administer antipyretic as prescribed 3) Auscultate lung sounds and increase fluids 4) Send a urine sample for culture and sensitivity

2

A patient with increased intracranial pressure (ICP) is sensitive to fluid-volume shifts. Which approach would be the safest to reduce this patient's cerebral edema? 1) Mannitol 2) 3% normal saline 3) Bacteriostatic saline 4) Preservative-free saline

2

A patient with neurogenic shock has a sustained heart rate of 38 beats per minute. Based on this observation, for what should the nurse prepare the patient? 1) Intravenous fluids 2) Pacemaker insertion 3) Cardiac catheterization 4) Arterial blood gas analysis

2

The nurse is preparing a patient for insertion of an intraventricular catheter intracranial pressure (ICP) monitoring device. What is an advantage of this device? 1) Must be inserted in the operating room 2) Catheter tip located in the lateral ventricle 3) Less mechanical drift of the measurement over time 4) Lower rate of infection because of no fluid reservoir

2

The nurse is preparing materials for the families of patients who have sustained a stroke. What information should the nurse include to reduce the risk for additional strokes? 1) Heart-healthy diet 2) Smoking cessation 3) Stress management 4) Weight-reduction strategies

2

A patient is being discharged after treatment for an ischemic stroke. Which medications should the nurse expect to be prescribed for this patient? Select all that apply. 1) Antibiotics 2) Anticoagulant 3) Antihypertensive 4) Antiplatelet therapy 5) Lipid-lowering agent

2,3,4,5

An adolescent seeks medical care after being in a street fight. Which observation indicates that this patient has sustained a basilar skull fracture? 1) Hyperthermia 2) Episodic tachycardia 3) Bruising around the ears 4) Rapid deterioration to comatose

3

The nurse is assessing a patient who sustained a traumatic brain injury several years ago. What finding should the nurse expect when completing the assessment? 1) Dysphagia2) Hemiparesis3) Memory loss4) Visual field deficits

3

The nurse is caring for a patient in a barbiturate coma for increased intracranial pressure (ICP). What should the nurse assess to determine this patient's cerebral function? 1) Gag reflex 2) Glasgow coma scale 3) Pupillary size and reaction 4) Blood pressure and heart rate

3

The nurse is caring for a patient with a diffuse axonal injury. What treatment plan should the nurse expect to be prescribed for this patient? 1) Craniotomy 2) Wound debridement 3) Monitor and observe 4) Evacuation of the hematoma

3

The nurse is caring for a patient with neurogenic shock. What finding should the nurse expect to assess in this patient? 1) Tachycardia 2) Hypertension 3) Warm dry skin 4) Rapid shallow respirations

3

The nurse is concerned that a patient is at high risk for having a stroke. What finding did the nurse use to make this clinical decision? 1) BMI 24.8 2) Heart rate 90 bpm 3) Blood pressure 182/90 mm Hg 4) Pulse oximetry 98% on room air

3

The nurse suspects that a patient is experiencing a hemorrhagic stroke from a ruptured cerebral aneurysm. What assessment finding caused the nurse to make this conclusion? 1) Slurred speech 2) Visual field deficits 3) Sudden severe headache

3

A patient recovering from a stroke has profound bradycardia. What should the nurse suspect as the cause of this manifestation? 1) Parasympathetic nervous system disruption 2) Irritation of the sympathetic nervous system 3) Shunting of fluid from the cerebral vasculature 4) Alteration in the vasomotor center in the brainstem

4

A patient recovering from an ischemic stroke is prescribed verapamil (Calan). In preparation for patient teaching, which medication category will the nurse review? 1) Diuretic 2) Beta blocker 3) Lipid-lowering agent 4) Calcium channel blocker

4