AH3 #4

Pt with hemorrhagic stroke, family asking for info about condition

we might need consent for immediate surgical intervention

The nurse on the neurological care unit is assessing a client who has a Glasgow Coma Scale of 3. Which of the following findings is consistent with a GCS score of 3

Urinary and fecal incontinence

The nurse is caring for a client who has a ventriculostomy. Which of the following actions by the nurse would be appropriate?

Positioning the transducer at the level of the client's ear

Neuro unit, positioning pt 2 days post stroke with left sided hemiparesis. What's appropriate?

Trochanter roll on left side Securing left arm in a sling

1. The nurse is caring for a client who has expressive aphasia following a stroke. The nurse has taught the client's spouse about ways to facilitate communication. Which of the following comments by the client's spouse would require follow-up?

"I act like I understand when I do not, so that my spouse will not become frustrated."

Outpatient setting assessing pt risk for ischemic stroke. SATA

-diabetes -a fib -carotid stenosis

Starting Plavix, appropriate understanding of teaching

-ill tell dentist before apt

Staff education on subdural hematomas. Which physical condition is more prone?

Chronic Alcoholics

1. The nurse has assessed a client, who hit their head during a fall, using the Glasgow Coma Scale (GCS) and calculated a score of 6. Which of the following actions would be appropriate for the nurse to take in addition to notifying the health care provider of the GCS score?

Contact the anesthesiology department

Planning education conference about anticoagulation and the direct factor Xa inhibitor meds, which do you include SATA

Coumadin - anticoag -rivaroxaban - Xa inhibitor -apixaban - Xa inhibitor

The nurse is caring for a client immediately after receiving a craniotomy with an incision over the middle fossa and notes the client is in a supine position? Which of the following actions would be most appropriate for the nurse to take

Elevate the head of the bed 30 to 45 degrees and the complete an incident report

pt with expressive aphasia following stroke, fam taught them how to communicate, what needs follow up

I act like I understand when I don't to stop frustration

RN provides info to spouse of client who has stroke

I will have to care for long term Foley

Pt with hx TIA intracranial stent placed 30 min ago, standard post op care

Keep leg straight

Staff education on subdural hematomas. Which age group is more prone?

Older Adults

1. The nurse is caring for a client who has a subdural hematoma following a traumatic head injury. The nurse notes systolic hypertension with a widening pulse pressure and bradycardia. Which of the following actions would be appropriate for the nurse to take after notifying the health care provider?

Prepare the client for emergency surgery

How do you check for eye response, verbal, motor

Press firmly on a nail bed, response to pain, respond to speech, do they obey command

The nurse on the neurological care unit has received a client who has been diagnosed with subarachnoid hemorrhage. The nurse should prepare the client for which of the following potential treatments? Select all that apply

Ventriculostomy insertion IV antihypertensive administration Surgical clipping

The nurse on the neurological unit is caring for a client who sustained a basilar skull fracture 6 hours ago. The client is awake and oriented. Which of the following remarks by the client should be a priority for the nurse to follow up?

a. "I would like some tissues for my runny nose."

The nurse on the neurological care unit has received health care provider prescriptions for assigned clients. The nurse should contact the health care provider and question which of the following prescriptions?

a. 0.45% sodium chloride for a client with increased intracranial pressure following traumatic brain injury

The nurse is caring for a client with increased intracranial pressure (ICP). The nurse observes the client's urine output from the indwelling urethral catheter to be 1,500 ml for the last 2 hours. Which of the following should the nurse suspect the client is experiencing

a. Diabetes insipidus (DI)

The nurse on the neurological care unit is planning a staff education about condition that would require intracranial pressure monitoring with a ventriculostomy. Which of the following conditions should the nurse include in the conference? Select all that apply

a. Encephalitis b. Subdural hematoma c. Brain tumor

The nurse is caring for a client with increased intracranial pressure (ICP) who has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following prescribed interventions should the nurse implement

a. Fluid restriction

The nurse in the emergency department receives a client who was transported from a prison with high fever, severe headache, and a non-blanchable rash on the trunk and lower extremities. Which of the following actions would be appropriate for the nurse to take, while the staff works to confirm a diagnosis

a. Hang a respiratory isolation sign on the door of the client's room.

The nurse is providing discharge teaching about post-concussion syndrome for a client and the client's family. The nurse should include in the teaching that the client might experience which of the following? Select all that apply.

a. Headache b. Personality changes c. Decreased short-term memory

1. The nurse is caring for a client with a traumatic brain injury (TBI) following a fall. Which of the following medications should the nurse anticipate being prescribed for the client to reduce cerebral edema?

a. Mannitol

The nurse is caring for a client who suffered a skull fracture 6 hours ago and has a positive halo sign, or ring sign. The nurse should recognize that this finding is associated with an increased risk for which of the following?

a. Meningitis

The nurse is caring for a client that has a ventriculostomy for monitoring increased intracranial pressure (ICP). Which of the following would indicate to the nurse that the client is experiencing a complication of the ventriculostomy

a. Nuchal rigidity

The nurse is planning an education conference about an intravenous anesthetic sedative medication that has rapid onset, short-half life, and is used to manage anxiety and agitation in the ICU. Which of the following medications should the nurse include in the conference

a. Propofol

The nurse is assessing a client who fell in the hallway and notes the client is exhibiting an altered level of consciousness (LOC) and Battle's sign is present. Which of the following actions would be a priority for the nurse to take

a. Stabilize the client's neck

The nurse on the neurological unit is caring for a client who had a traumatic brain injury. The client's Glascow Coma Score has changed from 10 to 9, and the client is snoring. Which of the following actions would be appropriate for the nurse to take?

a. Suction the client's oral secretions

1. The nurse is caring for a client who has been diagnosed with acute subdural hematoma after falling at home. Which of the following findings should indicate to the nurse that the client is experiencing a complication?

a. Unilateral pupil dilation

Ischemic stroke pt having echo, fam asks why heart

an echo can tell is particles from heart might have gone to brain

Aphasia after stroke, communication technique

ask questions they can answer with one word

Stabilizing pt with stroke symptoms, intervene for NA doing

assist pt with sips of water

Stroke team rn pt exhibits s/s stroke for CT scan, what info is priority?

time symptoms and signs began

Recent diagnosis MS, what include in POC

daily muscle stretching

Pt with R hemisphere stroke evaluated by ST, pt has motor and visual deficits

encourage to swallow twice

ER pt has symptoms of stroke 90 min ago, CT confirms stroke, rules out hemorrhage, rn to do what

establish IV access

Pt with hemiparesis following R hemispheric stroke, when to intervene

instruct pt to reach out w L hand during WC transfer

Pt has multiple deficits after stroke, family is helping pt, intervene when

massage red area on sacrum

Pt with hx TIA scheduled carotid endarterectomy, what info to family

plaque removed from artery that supplies blood to brain

Caring for group of pt, who see first

recovering ischemic stroke, decreased lung sounds, prod cough, T 104.8