CH. 45 Evolve NCLEX
The nurse is teaching the spouse and client who has had a brain attack about rehabilitation. Which statement by the spouse demonstrates understanding of the nurse's instruction? "Frequent stimulation will help with the rehabilitation process." "My spouse will no longer need to take blood pressure medication." "Rehabilitation and physical therapy are the same thing." "The rehabilitation therapist will help identify changes needed at home."
"The rehabilitation therapist will help identify changes needed at home." Understanding instructions about brain attack is demonstrated by the statement that the rehabilitation therapist will help identify any needed home changes. The rehabilitation therapist and home health professionals assist the client and family in adapting the home environment to the client's needs and assess the client's need for therapy.An appropriate amount of stimulation based on the client's needs will be determined by the therapist and incorporated into a comprehensive plan. Any medication regimen established for the client after the brain attack must be maintained. Rehabilitation is much more comprehensive than physical therapy.
The nurse is assessing a client with a traumatic brain injury after a skateboarding accident. Which sign/symptom is the nurse most concerned about? Amnesia Asymmetric pupils Headache Head laceration
Asymmetric pupils The nurse is most concerned about asymmetric pupils in the client with traumatic brain injury. Asymmetric (uneven) pupils are treated as herniation of the brain from increased intracranial pressure (ICP) until proven otherwise. The nurse must report and document any changes in pupil size, shape, and reactivity to the primary health care provider immediately.Amnesia, a headache and a head laceration, can be signs of mild traumatic brain injuries and need to be investigated more thoroughly.
The nurse is monitoring a client after supratentorial surgery. Which sign/symptom does the nurse report immediately to the provider? Periorbital edema Bilateral ecchymoses of both eyes Moderate amount of serosanguineous drainage on the head dressing Decorticate positioning
"I can go home the day of my craniotomy." The nurse knows that further instruction is needed when a client considering treatment for malignant brain tumor says, "I can go home the day of my craniotomy." Craniotomies are inclient procedures. The client will be admitted to critical care for monitoring after the procedure and may be mechanically ventilated for 24-48 hours postprocedure.Chemotherapy, radiation, and surgery are often used in conjunction with each other to treat malignancies. For a craniotomy, several burr holes are drilled into the skull, and a saw is used to remove a piece of bone (bone flap) to expose the tumor area. The goals of treatment of brain tumor are to decrease tumor size, improve quality of life, and improve survival time.
The nurse is teaching a client and family about home care after a stroke. Which statement made by the client's spouse indicates a need for further teaching? "I should spend all my time with my husband in case I'm needed." "My husband may get depressed." "My husband must take his medicine every day to prevent another stroke." "The physical therapist will show us how to use the equipment so my husband can climb the stairs and get into and out of bed."
"I should spend all my time with my husband in case I'm needed." Further home care teaching is needed when the stroke client's wife says that "I need to spend all my time with my husband in case I'm needed." Although well intentioned, family members can start to feel socially isolated when caring for a loved one. The family may need to plan for regular respite care in a structured day-care respite program or through relief provided by a friend or neighbor.The life changes associated with stroke often cause a change in the client's self-esteem. The client who has had a stroke needs to maintain a regular medication regimen to help prevent another stroke. If it is determined necessary after a home assessment, the physical and occupational therapist will show the client and family how to use equipment so they are able to mobilize and function in the home setting.
A client is eating a soft diet while recovering from a stroke. The client reports food accumulating in the cheek of the affected side. What is the nurse's best response? "Next time you eat, try lifting your chin when you swallow." "Let's advance your diet to solid food." "Let's see if the dietitian can help." "Let's see if the speech-language pathologist can help."
"Let's see if the speech-language pathologist can help." The nurse's best response about food gathering in the cheek of a stroke client is to see what the speech pathologist says may help. The speech-language pathologist identifies strategies to prevent food from accumulating in the cheek of the affected side of a client recovering from a stroke. The speech pathologist will assist the client with tongue exercises that will help move the food bolus to the unaffected side.Lifting the chin is not an appropriate technique. A solid diet would not necessarily be the best choice. The dietitian will be consulted to evaluate the nutritional status of the client as well as make recommendations regarding the correct diet.
The daughter of a client who has had a stroke asks the nurse for additional resources. What is the nurse's best response? "Call hospice." "Check the Internet." "The National Stroke Association has resources available." "The charge nurse at the desk has all of the information."
"The National Stroke Association has resources available." The nurse's best response about additional resources for stroke is the National Stroke Association. The National Stroke Association is a specific and reliable resource that can be recommended. Additional resources are frequently provided as part of the discharge teaching the nurse will provide.Hospice care is appropriate for clients who are terminally ill, not a client who has had a stroke necessarily. Sources on the Internet may be very broad and unreliable or lack evidence to support their recommendations. The role of the client's nurse is to advocate for the client and not to refer all questions to the charge nurse.
A client is being discharged home after surgery for brain cancer. Which statement by the client's spouse indicates a correct understanding of the nurse's discharge teaching? "I will have to quit my job to care for my spouse." "Life will be back to normal soon." "The case manager will provide home care." "We can find a support group through the local American Cancer Society."
"We can find a support group through the local American Cancer Society." The statement by the spouse of a brain cancer client that shows correct understanding of discharge teaching is when the spouse says, "We can find a support group through the local American Cancer Society." The American Cancer Society is a good community resource for clients with malignant tumors and their families.It is not a requirement that the client's spouse quit his or her job but may need some assistance in home. A diagnosis of brain cancer is life changing and the client and spouse will find a "new normal"; however this will not happen immediately. The case manager helps coordinate care and will be able to locate home care but does not provide that care.
The nurse is evaluating the collaborative care of a client with traumatic brain injury (TBI). What is the most important goal for this client? Achieving the highest level of functioning Increasing cerebral perfusion Preventing further injury Preventing skin breakdown
Achieving the highest level of functioning The most important nurse's goal for the client with TBI is to help him or her achieve the highest level of functioning possible.The nurse assesses cerebral perfusion, such as oxygenation status, but cannot increase cerebral perfusion. Prevention of injury from falls, infection, or further impairment of cerebral perfusion is part of a larger goal for this client. Prevention of skin breakdown is a goal for the care of any client.
A client hospitalized for hypertension presses the call light and reports "feeling funny." When the nurse gets to the room, the client is slurring words and has right-sided weakness. What does the nurse do first? Assesses airway, breathing, and circulation Calls the provider Performs a neurologic check Assists the client to a sitting position
Assesses airway, breathing, and circulation When a client reports "feeling funny" and then starts slurring words and has right-sided weakness, the nurse must first assess for airway, breathing, and circulation. The priority is assessment of the "ABCs"—airway, breathing, and circulation.Calling the Rapid Response Team, not the provider, after assessing ABCs would be appropriate. The first 10 minutes after onset of symptoms is crucial. A neurologic check will be performed rapidly but is not the top priority. The client would be placed in bed, easily accessible for healthcare providers to assess and begin treatment. This does not need to be a seated position.
A client with a traumatic brain injury from a motor vehicle crash is monitored for signs/symptoms of increased intracranial pressure (ICP). Which sign/symptoms does the nurse monitor for? Changes in breathing pattern Dizziness Increasing level of consciousness Reactive pupils
Changes in breathing pattern The nurse monitors for changes in breathing pattern. This may be indicative of increased intracranial pressure secondary to compression of areas of the brain responsible for respiratory control.Dizziness is a symptom of brain injury, not increased intracranial pressure. Increasing level of consciousness and reactive pupils are desired outcomes for this client.
A client recovering from a stroke reports double vision that is preventing the client from effectively completing activities of daily living. How does the nurse help the client compensate? Approaches the client on the affected side Covers the affected eye Encourages turning the head from side to side Places objects in the client's field of vision
Covers the affected eye The nurse helps the stroke client compensate with double vision by covering the affected eye. Covering the client's affected eye with a patch prevents diplopia.The client who is recovering from a stroke would always be approached on the unaffected side. The nurse may encourage side-to-side head turning for clients with hemianopsia (blindness in half of the visual field). Objects would be placed in the field of vision for the client with a decreased visual field.
A client is considering treatments for a malignant brain tumor. Which statement by the client indicates a need for further instruction by the nurse? "A combination of treatments might be necessary." "In a craniotomy, holes are cut in the skull to access the tumor." "I can go home the day of my craniotomy." "The goal is to decrease tumor size and improve survival time."
Decorticate positioning In a postoperative supratentorial client, the nurse must immediately report decorticate positioning to the provider. The major complications of supratentorial surgery are increased intracranial pressure from cerebral edema or hydrocephalus and hemorrhage. Decorticate positioning indicates damage to the pathway between the brain and the spinal cord.Periorbital edema and a small-to-moderate amount of serosanguineous drainage are expected after a craniotomy. Ecchymoses in the facial region, especially around the eyes, are expected after a craniotomy.
A client is being discharged home after treatment for a brain attack. What is the mnemonic that the nurse can teach the family and client to help recognize and act on another stroke? A-V-P-U F-A-S-T K-I-N-D O-P-Q-R-S-T
F-A-S-T The mnemonic F-A-S-T is utilized to teach the client, family, and community how to recognize and respond to a stroke. The purpose is to observe the Face, Arms, Speech, and then Time of onset and knowing it's Time to call 9-1-1.A-V-P-U is the mnemonic for level of awareness (alert, verbal, painful, and unresponsive). K-I-N-D is a mnemonic for treatment of hyperkalemia (kayexalate, insulin, NaHCO3, diuretics). O-P-Q-R-S-T is a mnemonic for assessing pain (onset, provokes, quality, radiates, severity, time).
Which are risk factors for stroke? Select all that apply. High blood pressure Previous stroke or transient ischemic attack (TIA) Smoking Use of oral contraceptives Female gender
High blood pressure Previous stroke or transient ischemic attack (TIA) Smoking Use of oral contraceptives Common modifiable risk factors for developing a stroke include smoking and the use of oral contraceptives. Other risk factors include high blood pressure and history of a previous TIA.Gender is not a known risk factor for stroke; however, the female client is at risk for delayed recognition of early stroke symptoms.
A client has been admitted with a diagnosis of stroke (brain attack). The nurse suspects that the client has had a right hemisphere stroke because the client exhibits which symptoms? Aphasia and cautiousness Impulsiveness and smiling Inability to discriminate words Quick to anger and frustration
Impulsiveness and smiling Impulsiveness and smiling are signs and symptoms indicative of a right hemisphere stroke.Aphasia, cautiousness, the inability to discriminate words, quick to anger, and frustration are signs and symptoms indicative of a left hemisphere stroke.
A client has had a traumatic brain injury and is mechanically ventilated. Which technique does the nurse use to prevent increasing intracranial pressure (ICP)? Assessing for Grey Turner's sign Maintaining neutral head position Placing the client in the Trendelenburg position Suctioning the client frequently
Maintaining neutral head position To prevent ICP in a client with traumatic brain injury who is being mechanically ventilated, the nurse needs to maintain the patent's head in a neutral position. Maintaining the head in neutral alignments prevents obstruction of blood flow and is an important component of ICP.Grey Turner's sign is a bluish gray discoloration in the flank region caused by retroperitoneal hemorrhage. The head of the bed needs to be at 30 degrees. The Trendelenburg position will cause the client's ICP to increase. Although some suctioning is necessary, frequent suctioning would be avoided because it increases ICP.
The nurse is monitoring a postoperative craniotomy client with increased intracranial pressure (ICP). Which pharmacologic agent does the nurse expect to be requested to maintain the ICP within a specified range? Dexamethasone (Decadron) Hydrochlorothiazide (HydroDIURIL) Mannitol (Osmitrol) Phenytoin (Dilantin)
Mannitol (Osmitrol) In a postoperative craniotomy client with ICP, the nurse expects Mannitol to be requested to keep the ICP within a certain range. Mannitol is an osmotic diuretic used specifically to treat cerebral edema.Glucocorticoids have no demonstrated benefit in reducing ICP. Hydrochlorothiazide is only a mild diuretic and is not beneficial in maintaining ICP. Dilantin is used to treat seizure activity caused by increased ICP.
A client is admitted with a stroke (brain attack). Which tool does the nurse use to facilitate a focused neurologic assessment of the client? Glasgow Coma Score (GCS) Intracranial pressure monitor Mini-Mental State Examination (MMSE; mini-mental status examination) National Institutes of Health Stroke Scale (NIHSS)
National Institutes of Health Stroke Scale (NIHSS) The nurse uses the NIHSS tool to perform a focused neurologic assessment. Health care providers and nurses at designated stroke centers use a specialized stroke scale such as the NIHSS to assess clients.The Glasgow Coma Score (GCS) provides a non-specific indication of level of consciousness. An intracranial pressure monitor would be requested by the health care specialist if signs and symptoms indicated increased intracranial pressure. The MMSE is used primarily to differentiate among dementia, psychosis, and affective disorders.
A client presents to the Emergency Department from an assisted living facility after a ground level fall with a head strike. The client has a Glasgow Coma Score (GCS) of 12, which is decreased for this client, and has projectile vomiting. What is the priority intervention for this client? Calling the Stroke Team Establishing an IV Positioning the client to prevent aspiration Preparing for thrombolytic administration
Positioning the client to prevent aspiration Positioning the client while maintaining cervical spine immobilization to prevent aspiration is the nurse's priority intervention. Maintaining a patent airway is essential especially since this client is vomiting.Calling the Stroke Team would not be necessary. Establishing an IV is important for this client but it is not the first priority. If this client was having a stroke, thrombolytics would be contraindicated because of the fall with head strike.
A client in the emergency department (ED) has slurred speech, confusion, and visual problems and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The client also has a history of hypertension and atherosclerosis. What does the nurse suspect that the client is probably experiencing? Embolic stroke Hemorrhagic stroke Thrombotic stroke Transient ischemic attack
Thrombotic stroke The client's signs and symptoms fit the description of a thrombotic stroke due to its gradual onset.Signs and symptoms of embolic stroke have a sudden onset, unlike this client's symptoms. Hemorrhagic strokes more frequently present with sudden, severe headache. Intermittent episodes of slurred speech, confusion, and visual problems are transient ischemic attacks, which often are warning signs of an impending ischemic stroke.
