AH I Final- Neuro
Thrombolytic therapy should be initiated within what time frame of an ischemic stroke for best functional outcome?
3 hours
A patient is brought by ambulance to the emergency department 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?
A patient who is anticoagulated
A client has just been diagnosed with an aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client?
Avoid heavy lifting.
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 the Home Health Nurse because they are aware that the most common patient response to a change in body image is what?
Depression
A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take?
Face the client and establish eye contact.
A nurse is completing discharge teaching for the client who has left-sided hemiparesis following a stroke. When investigating the client's home environment, the nurse should focus on which nursing diagnosis?
Risk for injury
A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to your unit. You would be correct in assessing for what adverse effect of this therapy?
Gingivival hyperplasia
A nurse is providing education to a community group about ischemic strokes. One group member asks if there are ways to reduce the risk for stroke. Which of the following is a risk factor that can be modified?
Hypertension
A client you are caring for experiences a seizure. What would be a priority nursing action?
Protect the client from injury.
Which of the following terms refers to blindness in the right or left halves of the visual fields of both eyes?
Homonymous hemianopsia
A nurse is preparing a client for a computed tomography (CT) scan that requires infusion of radiopaque dye. Which question is the most important for the nurse to ask?
"Are you allergic to seafood or iodine?"
A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction?
"Avoid stimulants and alcohol for 24 to 48 hours before the test."
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?
"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."
A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family?
"The client is unaware of his left side. You should approach him on the right side."
A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?
Administer stool softeners.
Which of the following terms refers to the inability to recognize objects through a particular sensory system?
Agnosia
A client is diagnosed with a brain tumor. As the nurse assists the client from the bed to a chair, the client begins having a generalized seizure. Which action should the nurse take first?
Assist the client to the floor, in a side-lying position, and protect him with linens.
A preceptor is discussing stroke with the new nurse on the unit. What cardiac dysrhythmia would the preceptor tell the new nurse is associated with cardiogenic embolic strokes?
Atrial fibrillation
In reviewing a client's history and physical examination, a nurse finds that the client was found positive for ataxia during the physician's neurological testing. Which nursing diagnosis will be a priority for this client?
Risk for falls
A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?
Call the physician immediately.
The nurse is caring for a client who has been admitted with a head injury and continually assesses for signs of increasing intracranial pressure (ICP). The earliest sign of increasing ICP is
Change in level of consciousness
While completing a health history on a newly diagnosed patient with generalized seizure disorder the nurse would assess for what characteristic associated with the post-ictal state?
Confusion
A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test?
Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
When caring for a patient who has had a stroke a priority is reduction of intracranial pressure (ICP). What position is indicated to assist with this goal?
Elevation of the head of the bed
A female patient has undergone a lumbar puncture for a neurological assessment. The patient is put under the postprocedure care of a nurse. Which of the following important postprocedure nursing interventions should be performed to ensure maximum comfort to the patient?
Encourage a liberal fluid intake for the patient
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)?
Every 15 minutes
A patient admitted with a stroke is coming to your unit from the emergency department. The nurse assigned to care for the new patient knows that what assessment finding is indicative of a stroke?
Facial droop
A patient has been diagnosed as having global aphasia. The nurse recognizes that the patient will be unable to do which of the following actions?
Form words that are understandable or comprehend the spoken word
Which lobe of the brain is responsible for concentration and abstract thought?
Frontal
A patient with neurological disorder has difficulty swallowing. The nurse should take special care of the patient's diet because of a potential risk of imbalanced nutrition in the patient. Which of the following measures may be taken by the nurse to ensure that the patient's diet allows for easy swallowing?
Help the patient sit upright when eating and feed slowly
A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?
Heparin sodium
A nurse is caring for an older client who has had a hemorrhagic stroke. The client has exhibited impulsive behavior and, despite reminders from the nurse, doesn't recognize his limitations. Which priority measure should the nurse implement to prevent injury?
Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed.
You are taking care of a client who is taking an anticonvulsant. Why should you advise the client not to stop taking the drug abruptly?
It may trigger status epilepticus.
A 53-year-old man presents to the emergency department with a chief complaint of inability to form words, and numbness and weakness of the right arm and leg. Where would you locate the site of injury?
Left frontoparietal region
A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment?
Limited attention span and forgetfulness
A patient with a seizure disorder is presenting having a generalized seizure. An appropriate nursing intervention during the seizure would include what?
Loosen the patient's restrictive clothing
A nurse is caring for a patient diagnosed with a hemorrhagic stroke. What goal is a priority for this patient?
Maintain and improve cerebral tissue perfusion.
When caring for an unconscious patient what nursing intervention takes highest priority?
Maintaining a patent airway
A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority?
Maintenance of a patent airway
Which of the following would not be a recommended intervention for a patient with dysphagia?
Place food on the affected side of mouth
A female patient is diagnosed with a right 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 nurse is providing diet-related advice to a man who experienced a cerebrovascular accident (CVA). The client wants to minimize his volume of food and yet meet all nutritional requirements. Which of the following suggestions should the nurse give to the client about controlling the volume of food intake? Choose the correct option.
Provide thickened commercial beverages and fortified cooked cereals.
A patient scheduled for a Magnetic Resonance Imaging (MRI) has arrived at the radiology department. The nurse who prepares the patient for the MRI would be sure to include what?
Removing all metal-containing objects.
A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis?
Risk for aspiration
The nurse is performing a neurological assessment of a client who has sustained damage to the frontal cortex. Which of the following deficits will the nurse look for during assessment?
The inability to tell how a mouse and a cat are alike
A patient who suffered an ischemic stroke now has disturbed sensory perception. What should the nurse caring for this patient be aware of?
The patient should be approached on the side where visual perception is intact.
A patient has severe shoulder pain from subluxation of the shoulder is being cared for on the unit. To prevent further injury and pain, the nurse caring for this patient is aware of what?
The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder
The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members with the client with an aneurysm?
The stimulation can increase intracranial pressure (ICP) or trigger a seizure.
A client has sustained a head injury to the occipital area. He cannot identify a familiar object by looking at it. The nurse knows that this deficit is which of the following?
Visual agnosia
A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with:
body temperature control.
