Chapter 41 - Neurological Emergencies
A client in the emergency department is having a stroke. The client weighs 225 pounds. After the initial bolus of t-Pa, at what rate should the nurse set the IV pump? (Record your answer using a decimal rounded to the nearest tenth.) ____ mL/hr
ANS: 1.4 mL/hr The client weighs 102 kg. The dose of t-PA is 0.9 mg/kg with a maximum of 90 mg, so the clients dose is 90 mg. 10% of the dose is given as a bolus IV over the first minute (9 mg). That leaves 81 mg to run in over 59 minutes. , which rounds to 1.4 mL/hr.
A client in the emergency department is having a stroke and the provider has prescribed the tissue plasminogen activator (t-PA) alteplase (Activase). The client weighs 146 pounds. How much medication will this client receive? (Record your answer using a whole number.) _____ mg
ANS: 60 mg The dose of t-PA is 0.9 mg/kg with a maximum dose of 90 mg. The client weighs 66.4 kg. 0.9 mg 66.4 = 59.76 mg, which rounds to 60 mg.
A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first? a. Client with a Glasgow Coma Scale score that was 10 and is now is 8 b. Client with a Glasgow Coma Scale score that was 9 and is now is 12 c. Client with a moderate brain injury who is amnesic for the event d. Client who is requesting pain medication for a headache
ANS: A A 2-point decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement in the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the declining Glasgow Coma Scale score.
A client had an embolic stroke and is having an echocardiogram. When the client asks why the provider ordered a test on my heart, how should the nurse respond? a. Most of these types of blood clots come from the heart. b. Some of the blood clots may have gone to your heart too. c. We need to see if your heart is strong enough for therapy. d. Your heart may have been damaged in the stroke too.
ANS: A An embolic stroke is caused when blood clots travel from one area of the body to the brain. The most common source of the clots is the heart. The other statements are inaccurate.
A male client was admitted with a left-sided stroke this morning. The assistive personnel asks about meeting the client's nutritional needs. Which response by the nurse is appropriate? a. "He is NPO until the speech-language pathologist performs a swallowing evaluation." b. "You may give him a full-liquid diet, but please avoid solid foods until he gets stronger." c. "Just be sure to add some thickener in his liquids to prevent choking and aspiration." d. "Be sure to sit him up when you are feeding him to make him feel more natural."
ANS: A Any client who has or is suspected of having a stroke should have nothing by mouth until he or she is evaluated for any swallowing problem by the speech-language pathologist (SLP). If dysphagia is present, the SLP makes specific recommendations for the client's plan of care which all staff members must follow to prevent choking and aspiration/aspiration pneumonia.
After a stroke, a client has ataxia. What intervention is most appropriate to include on the clients plan of care? a. Ambulate only with a gait belt. b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform post-void residuals.
ANS: A Ataxia is a gait disturbance. For the clients safety, he or she should have assistance and use a gait belt when ambulating. Ataxia is not related to swallowing, aspiration, or voiding
A client has a brain tumor and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying that the client does not have a seizure disorder. What response by the nurse is correct? a. "Increased pressure from the tumor can cause seizures." b. "Preventing febrile seizures with a tumor is important." c. "Seizures always occur in clients with brain tumors." d. "This drug is used to sedate with a brain tumor."
ANS: A Brain tumors can lead to seizures as a complication. The nurse would explain this to the spouse. Preventing febrile seizures is not related to a tumor. Seizures are possible but do not always occur in clients with brain tumors. This drug is not used for sedation.
A client with a stroke has damage to Brocas area. What intervention to promote communication is best for this client? a. Assess whether or not the client can write. b. Communicate using yes-or-no questions. c. Reinforce speech therapy exercises. d. Remind the client not to use neologisms.
ANS: A Damage to Brocas area often leads to expressive aphasia, wherein the client can understand what is said but cannot express thoughts verbally. In some instances the client can write. The nurse should assess to see if that ability is intact. Yes-or-no questions are not good for this type of client because he or she will often answer automatically but incorrectly. Reinforcing speech therapy exercises is good for all clients with communication difficulties. Neologisms are made-up words often used by clients with sensory aphasia.
A client who had therapeutic hypothermia after a traumatic brain injury is slowly rewarmed to a normal core temperature. For which assessment finding would the nurse monitor during the rewarming process? a. Cardiac dysrhythmias b. Loss of consciousness c. Nausea and vomiting d. Fever
ANS: A Due to fluid and electrolyte changes that typically occur during the rewarming process, the nurse monitors for cardiac dysrhythmias. The other findings are not common during this process.
A nurse is providing community screening for risk factors associated with stroke. Which person would the nurse identify as being at the highest risk for a stroke? a. A 27-year-old heavy-cocaine user. b. A 30-year-old who drinks a beer a day. c. A 40-year-old who uses seasonal antihistamines. d. A 65-year-old who is active and on no medications.
ANS: A Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this person uses them seasonally and there is no information that they are abused or used heavily. The 65 year old has only age as a risk factor.
A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The patient's spouse is very frustrated, stating that the patient's personality has changed and the situation is very difficult. What response by the nurse is most appropriate? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse that this is expected and he or she will have to learn to cope
ANS: A Personality and behavior often change permanently after head injury. The nurse will explain this to the spouse. Asking the client about his or her behavior isn't useful because the patient probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to learn to cope belittles his or her concerns and feelings.
A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI). The nurse notes the presence of an aneurysm clip in the clients record. What action by the nurse is best? a. Ask the client how long ago the clip was placed. b. Have the client sign an informed consent form. c. Inform the provider about the aneurysm clip. d. Reschedule the client for computed tomography.
ANS: A Some older clips are metal, which would preclude the use of MRI. The nurse should determine how old the clip is and relay that information to the MRI staff. They can determine if the client is a suitable candidate for this examination. The client does not need to sign informed consent. The provider will most likely not know if the client can have an MRI with this clip. The nurse does not independently change the type of diagnostic testing the client receives.
A client is admitted with a sudden decline in level of consciousness. What is the nursing action at this time? a. Assess the client for hypoglycemia and hypoxia. b. Place the client on his or her side. c. Prepare for administration of a fibrinolytic agent. d. Start a continuous IV heparin sodium infusion.
ANS: A The cause of a sudden decline in level of consciousness may or may not be related to a neurologic health problem. Therefore, the client must be evaluated for other common causes, especially hypoglycemia and hypoxia. Placing the client on his or her side may be helpful to prevent aspiration in case the client experiences vomiting, but the clinical situation does not indicate that the client has nausea or vomiting. Administering either an anticoagulant like heparin or a fibrinolytic agent assumes that the client has an acute ischemic stroke, which has not been confirmed through imaging tests.
A client is admitted with a diagnosis of cerebellar stroke. What intervention is most appropriate to include on the client's plan of care? a. Ambulate only with a gait belt. b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform postvoid residuals.
ANS: A The client who has a cerebellar stroke would be expected to have ataxia, an abnormal gait. For the client's safety, he or she should have assistance and use a gait belt when ambulating. Ataxia is not related to swallowing, aspiration, or voiding.
A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting. The clients mental status is deteriorating. What action by the nurse is most appropriate? a. Attempt to find the family to sign a consent. b. Inform the provider that the procedure cannot occur. c. Nothing; no consent is needed in an emergency. d. Sign the consent form for the client.
ANS: A The nurse should attempt to find the family to give consent. If no family is present or can be found, under the principle of emergency consent, a life-saving procedure can be performed without formal consent. The nurse should not just sign the consent form.
. A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority? a. Call the provider or Rapid Response Team. b. Increase the rate of the IV fluid administration. c. Notify respiratory therapy for a breathing treatment. d. Prepare to give IV pain medication.
ANS: A These manifestations indicate Cushings syndrome, a potentially life-threatening increase in intracranial pressure (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not need a breathing treatment or pain medication.
A client who had a severe traumatic brain injury is being discharged home, where the spouse will be a fulltime caregiver. What statement by the spouse would lead the nurse to provide further education on home care? a. I know I can take care of all these needs by myself. b. I need to seek counseling because I am very angry. c. Hopefully things will improve gradually over time. d. With respite care and support, I think I can do this.
ANS: A This caregiver has unrealistic expectations about being able to do everything without help. Acknowledging anger and seeking counseling show a realistic outlook and plans for accomplishing goals. Hoping for improvement over time is also realistic, especially with the inclusion of the word hopefully. Realizing the importance of respite care and support also is a realistic outlook.
A nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and determines the clients score to be 36. How should the nurse plan care for this client? a. The client will need near-total care. b. The client will need cuing only. c. The client will need safety precautions. d. The client will be discharged home.
ANS: A This client has severe neurologic deficits and will need near-total care. Safety precautions are important but do not give a full picture of the clients dependence. The client will need more than cuing to complete tasks. A home discharge may be possible, but this does not help the nurse plan care for a very dependent client.
. A client has a subarachnoid bolt. What action by the nurse is most important? a. Balancing and recalibrating the device b. Documenting intracranial pressure readings c. Handling the fiberoptic cable with care to avoid breakage d. Monitoring the clients phlebostatic axis
ANS: A This device needs frequent balancing and recalibration in order to read correctly. Documenting readings is important, but it is more important to ensure the devices accuracy. The fiberoptic transducer-tipped catheter has a cable that must be handled carefully to avoid breaking it, but ensuring the devices accuracy is most important. The phlebostatic axis is not related to neurologic monitoring.
The nurse assesses a client who has a mild traumatic brain injury (TBI) for signs and symptoms consistent with this injury. What signs and symptoms does the nurse expect? (Select all that apply.) a. Sensitivity to light and sound b. Reports "feeling foggy" c. Unconscious for an hour after injury d. Elevated temperature e. Widened pulse pressure
ANS: A, B A mild TBI would possibly lead to sensitivity to light and sound and a feeling of mental fogginess. The patient would have been unconscious for less than 30 minutes. An elevated temperature is not related. A widened pulse pressure is indicative of increased intracranial pressure, not a mild TBI.
A nurse is seeing many clients in the neurosurgical clinic. With which clients should the nurse plan to do more teaching? (Select all that apply.) a. Client with an aneurysm coil placed 2 months ago who is taking ibuprofen (Motrin) for sinus headaches b. Client with an aneurysm clip who states that his family is happy there is no chance of recurrence c. Client who had a coil procedure who says that there will be no problem following up for 1 year d. Client who underwent a flow diversion procedure 3 months ago who is taking docusate sodium (Colace) for constipation e. Client who underwent surgical aneurysm ligation 3 months ago who is planning to take a Caribbean cruise
ANS: A, B After a coil procedure, up to 20% of clients experience re-bleeding in the first year. The client with this coil should not be taking drugs that interfere with clotting. An aneurysm clip can move up to 5 years after placement, so this client and family need to be watchful for changing neurologic status. The other statements show good understanding.
The nurse would recognize which signs and symptoms as consistent with brainstem tumors? (Select all that apply.) a. Hearing loss b. Facial pain c. Nystagmus d. Vomiting e. Hemiparesis
ANS: A, B, C Hearing loss (CN VIII), facial pain (CN V), and nystagmus (CN III, IV, and VI) all are indicative of a brainstem tumor because these cranial nerves originate in the brainstem. Vomiting and hemiparesis are more indicative of cerebral tumors.
A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury. What actions should the nurse include in the clients care? (Select all that apply.) a. Assess tube placement per agency policy. b. Keep the head of the bed elevated at least 30 degrees. c. Listen to lung sounds at least every 4 hours. d. Run continuous feedings on a feeding pump. e. Use blue dye to determine proper placement
ANS: A, B, C, D All of these options are important for client safety when continuous enteral feedings are in use. Blue dye is not used because it can cause lung injury if aspirated.
A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying a cool washcloth to the head b. Assisting the client to a position of comfort c. Keeping voices soft and soothing d. Maintaining low lighting in the room e. Providing antipyretics for fever
ANS: A, B, C, D The client with meningitis often has high fever, pain, and some degree of confusion. Cool washcloths to the forehead are comforting and help with pain. Allowing the client to assume a position of comfort also helps manage pain. Keeping voices low and lights dimmed also helps convey caring in a nonthreatening manner. The nurse provides antipyretics for fever.
A nurse is caring for a group of stroke patients. Which clients would the nurse consider referring to a mental health provider? (Select all that apply.) a. Female client who exhibits extreme emotional lability b. Male client with an initial National Institutes of Health (NIH) Stroke Scale score of 38 c. Female client with mild forgetfulness and a history of depression d. Male client who has a past hospitalization for a suicide attempt e. Male client who is unable to walk or eat 3 weeks poststroke
ANS: A, B, C, D, E Patients most at risk for poststroke depression are those with a previous history of depression, severe stroke (NIH Stroke Scale score of 38 is severe), and poststroke physical or cognitive impairment.
The nurse is assessing a client who has symptoms of stroke. What are the leading causes of a stroke for which the nurse would assess for this client? (Select all that apply.) a. Heavy alcohol intake b. Diabetes mellitus c. Elevated cholesterol d. Obesity e. Smoking f. Hypertension
ANS: A, B, C, D, E, F The leading causes of stroke include all of these factors.
Based on the known risk factors for stroke, which health promotion practices would the nurse teach a client to promote heart health and prevent strokes? (Select all that apply.) a. Blood pressure control b. Aspirin use c. Smoking cessation d. Low carbohydrate diet e. Cholesterol management f. Increased red wine consumption
ANS: A, B, C, E The evidence-based health promotion practices include blood pressure control, aspirin use, smoking cessation, and cholesterol management. There is no consensus on which diet is best to promote heart health and red wine does not protect the heart or prevent strokes.
The nurse is caring for a client with increasing intracranial pressure (ICP) following a stroke. Which evidence-based nursing actions are indicated for this client? (Select all that apply.) a. Hyperoxygenate the client before and after suctioning. b. Avoid sudden or extreme hip or neck flexion. c. Provide oxygen to maintain an SaO2 of 95% or greater. d. Maintain the client in a supine position at all times. e. Avoid clustering care nursing activities and procedures. f. Provide environmental stimulation to improve cognition.
ANS: A, B, C, E These precautions help prevent further increases in ICP. Clustering nursing activities and procedures and providing stimulation can increase ICP and should be avoided.
The nurse is preparing for discharge of a client who had a carotid artery angioplasty with stenting to prevent a stroke. For which signs and symptoms with the nurse teach the family to report to the primary health care provider immediately? (Select all that apply.) a. Muscle weakness b. Hoarseness c. Acute confusion d. Mild neck discomfort e. Severe headache f. Dysphagia
ANS: A, B, C, E, F Muscle weakness, acute confusion, severe headache, and dysphagia are all signs and symptoms that could indicate that a stroke occurred. Hoarseness and severe neck pain and swelling may occur as a result of the interventional radiologic procedure.
A nursing student studying the neurologic system learns which information? (Select all that apply.) a. An aneurysm is a ballooning in a weakened part of an arterial wall. b. An arteriovenous malformation is the usual cause of strokes. c. Intracerebral hemorrhage is bleeding directly into the brain. d. Reduced perfusion from vasospasm often makes stroke worse. e. Subarachnoid hemorrhage is caused by high blood pressure.
ANS: A, C, D An aneurysm is a ballooning of the weakened part of an arterial wall. Intracerebral hemorrhage is bleeding directly into the brain. Vasospasm often makes the damage from the initial stroke worse because it causes decreased perfusion. An arteriovenous malformation (AVM) is unusual. Subarachnoid hemorrhage is usually caused by a ruptured aneurysm or AVM.
A nurse cares for older clients who have traumatic brain injury. What does the nurse understand about this population? (Select all that apply.) a. Admission can overwhelm the coping mechanisms for older clients. b. Alcohol is typically involved in most traumatic brain injuries for this age-group. c. These clients are more susceptible to systemic and wound infections. d. Other medical conditions can complicate treatment for these clients. e. Very few traumatic brain injuries occur in this age-group.
ANS: A, C, D Older adults often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and noisy. Because of decreased protective mechanisms, they are more susceptible to both local and systemic infections. Other medical conditions can complicate their treatment and recovery. Alcohol is typically not related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes.
The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.) a. Alcohol intake b. Diabetes c. High-fat diet d. Obesity e. Smoking
ANS: A, C, D, E Alcohol intake, a high-fat diet, obesity, and smoking are all modifiable risk factors for stroke. Diabetes is not modifiable but is a risk factor that can be controlled with medical intervention.
A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include? (Select all that apply.) a. Discharging the client on a statin medication b. Providing the client with comprehensive therapies c. Meeting goals for nutrition within 1 week d. Providing and charting stroke education e. Preventing venous thromboembolism
ANS: A, D, E Core Measures established by The Joint Commission include discharging stroke clients on statins, providing and recording stroke education, and taking measures to prevent venous thromboembolism. The client must be assessed for therapies but may go elsewhere for them. Nutrition goals are not part of the Core Measures.
A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.) a. A client with a moderate trauma may need hospitalization. b. A Glasgow Coma Scale score of 10 indicates a mild brain injury. c. Only open head injuries can cause a severe TBI. d. A client with a Glasgow Coma Scale score of 3 has severe TBI. e. The terms mild TBI and concussion have similar meanings.
ANS: A, D, E Mild TBI is a term used synonymously with the term concussion. A moderate TBI has a Glasgow Coma Scale (GCS) score of 9 to 12, and these clients may need to be hospitalized. Both open and closed head injuries can cause a severe TBI, which is characterized by a GCS score of 3 to 8.
A client is receiving IV alteplase and reports a sudden severe headache. What is the nurse's first action? a. Perform a comprehensive pain assessment. b. Discontinue the infusion of the drug. c. Conduct a neurologic assessment. d. Administer an antihypertensive drug.
ANS: B A severe headache may indicate that the client's blood pressure has markedly increased and, therefore, the drug should be stopped immediately as the first action. The nurse would then perform the appropriate assessments and possibly administer an antihypertensive medication.
. A client has an intraventricular catheter. What action by the nurse takes priority? a. Document intracranial pressure readings. b. Perform hand hygiene before client care. c. Measure intracranial pressure per hospital policy. d. Teach the client and family about the device.
ANS: B All of the actions are appropriate for this client. However, performing hand hygiene takes priority because it prevents infection, which is a possibly devastating complication.
A client with a traumatic brain injury is agitated and fighting the ventilator. What drug should the nurse prepare to administer? a. Carbamazepine (Tegretol) b. Dexmedetomidine (Precedex) c. Diazepam (Valium) d. Mannitol (Osmitrol)
ANS: B Dexmedetomidine is often used to manage agitation in the client with traumatic brain injury. Carbamazepine is an antiseizure drug. Diazepam is a benzodiazepine. Mannitol is an osmotic diuretic.
A client is being prepared for a mechanical embolectomy. What action by the nurse takes priority? a. Assess for contraindications to fibrinolytics. b. Ensure that informed consent is on the chart. c. Perform a full neurologic assessment. d. Review the clients medication lists.
ANS: B For this invasive procedure, the client needs to give informed consent. The nurse ensures that this is on the chart prior to the procedure beginning. Fibrinolytics are not used. A neurologic assessment and medication review are important, but the consent is the priority.
A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death? a. Client with a core temperature of 95 F (35 C) for 2 days b. Client in a coma for 2 weeks from a motor vehicle crash c. Client who is found unresponsive in a remote area of a field by a hunter d. Client with a systolic blood pressure of 92 mm Hg since admission
ANS: B In order to determine brain death, clients must meet four criteria: 1) coma from a known cause, 2) normal or near-normal core temperature, 3) normal systolic blood pressure, and 4) at least one neurologic examination. The client who was in the car crash meets two of these criteria. The clients with the lower temperature and lower blood pressure have only one of these criteria. There is no data to support assessment of brain death in the client found by the hunter.
. A clients mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the clients cerebral perfusion pressure, what should the nurse anticipate for this client? a. Impending brain herniation b. Poor prognosis and cognitive function c. Probable complete recovery d. Unable to tell from this information
ANS: B The cerebral perfusion pressure (CPP) is the intracranial pressure subtracted from the mean arterial pressure: in this case, 60 20 = 40. For optimal outcomes, CPP should be at least 70 mm Hg. This client has very low CPP, which will probably lead to a poorer prognosis with significant cognitive dysfunction should the client survive. This data does not indicate impending brain herniation or complete recovery
The nurse is teaching assistive personnel (AP) about care for a male client diagnosed with acute ischemic stroke and left-sided weakness. Which statement by the AP indicates understanding of the nurse's teaching? a. "I will use "yes" and "no" questions when communicating with the client." b. "I will remind the client frequently to not get out of bed without help." c. "I will offer a urinal every hour to the client due to incontinence." d. "I will feed the client slowly using soft or pureed foods."
ANS: B The client who has left-sided weakness has likely had a right-sided stroke in the brain. Clients who have strokes on the right side of the brain tend to be very impulsive and exhibit poor judgment. Therefore, to keep the client safe, the staff will need to remind the client to stay in bed unless he has assistance to prevent falling. There is no evidence in the clinical situation that the client has aphasia (which is less common in those with right-sided strokes), difficulty swallowing, or urinary incontinence.
After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes, acute confusion, and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse would the nurse take first? a. Assess the client's urinary output. b. Assess the client's serum sodium level. c. Increase the rate of the IV infusion. d. Provide oral care every hour.
ANS: B This client has signs and symptoms of hypernatremia, which is a possible complication after craniotomy. The nurse would assess the client's serum sodium level first and then possibly increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessing laboratory results.
A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt numbness in his left leg. Currently the client's neurologic examination is normal. About what drug would the nurse plan to teach the patient? a. Alteplase b. Clopidogrel c. Heparin sodium d. Mannitol
ANS: B This client's signs and symptoms are consistent with a transient ischemic attack, and the client would likely be prescribed aspirin or clopidogrel to prevent platelet aggregation on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition.
A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best? a. Have the student ask the client if it is desired or not. b. Inform the student that the docusate should be given. c. Tell the student to document the rationale. d. Tell the student to give it unless the client refuses.
ANS: B Stool softeners should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Valsalva maneuver when constipated. The supervising nurse should instruct the student to administer the docusate. The other options are not appropriate. The medication could be held for diarrhea.
A client is admitted with a confirmed left middle cerebral artery occlusion. Which assessment findings will the nurse expect? (Select all that apply.) a. Ataxia b. Dysphagia c. Aphasia d. Apraxia e. Hemiparesis/hemiplegia f. Ptosis
ANS: B, C, D, E, F All of these assessment findings are common in clients who have a stroke caused by an occlusion of the left middle cerebral artery with the exception of ataxia (most often present in clients who have cerebellar strokes). This artery supplies the majority of the left side of the brain where motor, sensory, speech, and language centers are located.
A client had an embolectomy for an arteriovenous malformation (AVM). The client is now reporting a severe headache and has vomited. What action by the nurse takes priority? a. Administer pain medication. b. Assess the clients vital signs. c. Notify the Rapid Response Team. d. Raise the head of the bed.
ANS: C This client may be experiencing a rebleed from the AVM. The most important action is to call the Rapid Response Team as this is an emergency. The nurse can assess vital signs while someone else notifies the Team, but getting immediate medical attention is the priority. Administering pain medication may not be warranted if the client must return to surgery. The optimal position for the client with an AVM has not been determined, but calling the Rapid Response Team takes priority over positioning
A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometer b. Is allergic to acetaminophen (Tylenol) c. Laughing, says Strenuous? Whats that? d. Lives alone and is new in town with no friends e. Plans to have a beer and go to bed once home
ANS: B, D, E Clients should take acetaminophen for headache. An allergy to this drug may mean the client takes aspirin or ibuprofen (Motrin), which should be avoided. The client needs neurologic checks every 1 to 2 hours, and this client does not seem to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A thermometer is not needed. The client laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this.
A nurse is discharging a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometer. b. Is allergic to acetaminophen. c. Laughing, says "Strenuous? What's that?" d. Lives alone and is new in town with no friends. e. Plans to have a beer and go to bed once home.
ANS: B, D, E Clients who have mild traumatic brain injuries should take acetaminophen for headache. An allergy to this drug may mean that the patient takes aspirin or ibuprofen, which should be avoided. The patient needs neurologic checks every 1 to 2 hours, and this client does not seem to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A thermometer is not needed. The patient laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this.
A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess neurologic status with the Glasgow Coma Scale. b. Check and document oxygen saturation every 1 to 2 hours. c. Cluster client care to allow periods of uninterrupted rest. d. Elevate the head of the bed to 45 degrees to prevent aspiration. e. Position the client supine with the head in a neutral midline position.
ANS: B, E The UAP can take and document vital signs, including oxygen saturation, and keep the clients head in a neutral, midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees.
A client is admitted with a traumatic brain injury. What is the nurse's priority assessment? a. Complete neurologic assessment b. Comprehensive pain assessment c. Airway and breathing assessment d. Functional assessment
ANS: C Although the client has a brain injury, the most important assessment is to assess the client's ABCs, which includes airway, breathing, and circulation. The other assessments are performed later after the client is stabilized.
A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that the expected outcome for this problem has been met? a. Chooses preferred items from the menu. b. Eats 75 to 100% of all meals and snacks. c. Has clear lung sounds on auscultation. d. Gains 2 lb (1 kg) after 1 week.
ANS: C Impaired swallowing can lead to aspiration and then aspiration pneumonia, so the expected outcome for this problem is to experience no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate that the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration.
A client who is experiencing a traumatic brain injury has increasing intracranial pressure (ICP). What drug will the nurse anticipate to be prescribed for this client? a. Phenytoin b. Lorazepam c. Mannitol d. Morphine
ANS: C Increased intracranial pressure is often the result of cerebral edema as a result of traumatic brain injury. Therefore, as osmotic diuretic such as mannitol or a loop diuretic like furosemide is administered. The other drugs are not appropriate to manage increasing ICP
A nurse is caring for four clients in the neurologic/neurosurgical intensive care unit. Which client should the nurse assess first? a. Client who has been diagnosed with meningitis with a fever of 101 F (38.3 C) b. Client who had a transient ischemic attack and is waiting for teaching on clopidogrel (Plavix) c. Client receiving tissue plasminogen activator (t-PA) who has a change in respiratory pattern and rate d. Client who is waiting for subarachnoid bolt insertion with the consent form already signed
ANS: C The client receiving t-PA has a change in neurologic status while receiving this fibrinolytic therapy. The nurse assesses this client first as he or she may have an intracerebral bleed. The client with meningitis has expected manifestations. The client waiting for discharge teaching is a lower priority. The client waiting for surgery can be assessed quickly after the nurse sees the client who is receiving t-PA, or the nurse could delegate checking on this client to another nurse.
The nurse is preparing a client for discharge from the emergency department after experiencing a transient ischemic attack (TIA). Before discharge, which factor would the nurse identify as placing the client at high risk for a stroke? a. Age greater than or equal to 75 b. Blood pressure greater than or equal to 160/95 c. Unilateral weakness during a TIA d. TIA symptoms lasting less than a minute
ANS: C The client who has a TIA is at risk for a stroke is he or she has one-sided (unilateral) weakness during a TIA. Risk factors also include an age greater than or equal to 60, blood pressure greater than or equal to 140/90 (either or both systolic and diastolic), and/or a long duration of TIA symptoms. One minute is not a very long time for symptoms to occur.
A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time? a. Inability to communicate b. Nutritional deficit c. Risk for acquiring an infection d. Risk for skin breakdown
ANS: C The positive halo sign indicates a leak of cerebrospinal fluid. This places the client at high risk of acquiring an infection. Communication and nutrition are not priorities compared with preventing a brain infection. The client has a definite risk for a skin breakdown, but it is not the immediate danger a brain infection would be.
The nurse assesses a clients Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client? a. Can ambulate independently b. May have trouble swallowing c. Needs frequent re-orientation d. Will need near-total care
ANS: C This client will most likely be confused and need frequent re-orientation. The client may not be able to ambulate at all but should do so independently, not because of mental status. Swallowing is not assessed with the GCS. The client will not need near-total care.
The nurse is caring for four clients with traumatic brain injuries. Which client would the nurse assess first? a. Client with amnesia for the incident b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg and on a ventilator d. Client who has a temperature of 102° F (38.9° C)
ANS: D A fever is a poor prognostic indicator in patients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and amnesia for the incident are all either expected or positive findings.
The nurse is preparing to administer IV alteplase for a client diagnosed with an acute ischemic stroke. Which statement is correct about the administration of this drug? a. The recommended time for drug administration is within 90 minutes after admission to the emergency department. b. The drug is given in a bolus over the first 3 minutes followed by a continuous infusion. c. The maximum dosage of the drug, including the bolus, is 120 mg intravenously. d. The drug is not given to clients who are already on anticoagulant or antiplatelet therapy
ANS: D Alteplase is a thrombolytic which dissolves clots and can cause bleeding as an adverse effect. Clients who are already taking an anticoagulant or antiplatelet agent are at risk for bleeding and therefore they are not candidates for alteplase therapy.
A nurse receives a hand-off report on a female client who had a left-sided stroke with homonymous hemianopsia. What action by the nurse is most appropriate for this client? a. Assess for bladder and bowel retention and/or incontinence. b. Listen to the client's lungs after eating or drinking for diminished breath sounds. c. Support the client's left side when sitting in a chair or in bed. d. Remind the client to move her head from side to side to increase her visual field.
ANS: D Homonymous hemianopsia is blindness on the same side of both eyes. The client must turn his or her head to see the entire visual field. This condition is not related to bladder function, difficulty swallowing, or lack of trunk control.
A client with a severe traumatic brain injury has an organ donor card in his wallet. Which nursing action is appropriate? a. Request a directive form the client's primary health care provider. b. Ask the family if they agree to organ donation for the client. c. Wait until brain death is determined before acting on organ donation. d. Contact the local organ procurement organization as soon as possible.
ANS: D The appropriate nursing action is to respect the client's desire to be an organ donor and contact the local organ procurement organization even if family members do not agree. In most agencies, the primary health care provider does not have to write an order or directive to approve the organ donation. Family consent is not required.
The nurse is caring for a client who had a hemorrhagic stroke. Which assessment finding is the earliest sign of increasing intracranial pressure (ICP) for this client? a. Projectile vomiting b. Dilated and nonreactive pupils c. Severe hypertension d. Decreased level of consciousness
ANS: D The earliest sign of increasing ICP is decreased level of consciousness. The other signs occur later.
The nurse is taking a history from a daughter about her father's onset of stroke signs and symptoms. Which statement by the daughter indicates that the client likely had an embolic stroke? a. Client's symptoms occurred slowly over several hours. b. Client because increasingly lethargic and drowsy. c. Client reported severe headache before other symptoms. d. Client has a long history of atrial fibrillation.
ANS: D The major cause of embolic strokes is a history of heart disease, especially atrial fibrillation. Most clients who have an embolic stroke have acute sudden neurologic symptoms but stay alert rather than lethargic. Decreasing level of consciousness and severe headache are more common in clients who have hemorrhagic strokes.
A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset
ANS: D The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this client. The other information is not as critical.
A client in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best? a. Ensure that informed consent is on the chart. b. Document these findings in the clients record. c. Give the prescribed preprocedure sedation. d. Notify the provider of the findings immediately.
ANS: D This client is exhibiting signs of increased intracranial pressure. The nurse should notify the provider immediately because performing the LP now could lead to herniation. Informed consent is needed for an LP, but this is not the priority. Documentation should be thorough, but again this is not the priority. The preprocedure sedation (or other preprocedure medications) should not be given as the LP will most likely be canceled.
