Exam #10

Guillian-Barre Syndrome (GBS)

Autoimmune attack on the myelin of peripheral and some cranial nerves.

Miotic eye solutions are often ordered in the treatment of glaucoma. Which is the best nursing rationale for the use of this medication? A) Constricts intraocular vessels B) Paralyzes ciliary muscles C) Constricts pupil D) Dilates the pupil

C) Constricts the pupil A miotic agent works by constricting the pupil and pulling the iris away from the drainage channels so that the aqueous fluid can escape. These medications increase outflow and decrease intraocular pressure. Cycloplegics paralyze the ciliary muscles of the eye. Mydriatics drugs are used to dilate the pupil and are contraindicated in glaucoma.

subdural hematoma

Collection of blood between the dura and the brain

A patient with low-tension glaucoma and an IOP of 22 mm Hg will be started on a medication regimen. The initial target score for a lowered IOP reading would be: A) 21. B) 19. C) 17. D) 15.

D) 15. The initial goal is to lower the IOP by 30%. Therefore, for a patient with an IOP of 22, the goal would be a mean daily reading of 15 (30% × 22 = 6.6 - 22 = 15.4). Levels do change throughout the day.

Bell's Palsy

Unilateral inflammation of the seventh cranial nerve, which results in weakness or paralysis of the facial muscles.

Decorticate

abnormal flexion of the upper extremities and extension of the lower extremities and indicates damage to the upper midbrain.

MG

acetylcholine

Encephalitis

acute inflammation of the brain tissue West Nile

epidrual hematoma

between the skull and dura

intracerebral hemorrhage

bleeding into parenchyma of the brain.

strabismus

crossed eyes

Decerebrate

extreme extension of the upper and lower extremities and indicates severe damage to the brain at the lower midbrain and upper pons

Hyperopia

farsightedness

MS

immune mediated

Meningitis

inflammation of protective membranes covering the brain and spinal cord. Nuchal rigidity

Conjunctivitis

inflammation of the conjunctiva

ALS

loss of upper and lower motor neurons

Amsler grid

macular degeneration

Myopia

nearsightedness

Parkinson's disease

A slowly progressive neurological disorder that eventually leads to disability. decreased levels of dopamine

A 34-year-old patient is diagnosed with relapsing-remitting MS. The nurse explains to the patient's family that they should expect: A) Acute attacks with full recovery or residual deficit upon recovery. B) Progressive disability from onset. C) Acute attacks followed by progression at a variable rate. D) Progression with clear relapses with or without recovery.

A) Acute attacks with full recovery or residual deficit upon recovery. With relapsing-remitting multiple sclerosis, recovery is usually complete with each relapse. Residual deficits may occur and accumulate over time, contributing to a functional decline.

The nurse is talking with a patient diagnosed with Ménière's disease about the patient's symptoms. What symptom does the patient inform the nurse is the most troublesome? A) Nausea B) Diarrhea C) Tinnitus D) Vertigo

D) Vertigo Vertigo is the misperception or illusion of motion of the person or the surroundings. Most people with vertigo describe a spinning sensation or say they feel as though objects are moving around them. Vertigo is usually the most troublesome complaint related to Ménière's disease.

Which of the following occurs when there is deviation from perfect ocular alignment? A) Strabismus B) Ptosis C) Chemosis D) Nystagmus

A) Stabismus Strabismus is a condition in which there is deviation from perfect ocular alignment. Ptosis is a drooping eyelids. Chemosis is edema of the conjunctiva. Nystagmus is an involuntary oscillation of the eyeball.

A nurse is preparing a plan of care for a client with otitis externa. Based on the typical assessment findings, which of the following would the nurse most likely identify as the priority nursing diagnosis? A) Acute pain related to inflammation B) Risk for infection related to drainage from the ear canal C) Disturbed sensory perception: auditory related to sensorineural hearing loss. D) Hyperthermia related to elevated temperature secondary to infection

A) Acute pain related to inflammation. The client with otitis externa typically reports pain as well as aural tenderness, making the nursing diagnosis of acute pain the priority. A major component of therapy is relief of the pain and discomfort with analgesics and antibiotics and corticosteroid agents to soothe the inflamed tissues. Inflammation is present, which could lead to infection, but this would not be the priority. Typically, clients with otitis externa experience a conductive hearing loss. Fever may or may not be present.

A patient has been diagnosed with hyphema. Which of the following medication classifications stabilizes clot formation at the site of hemorrhage? A) Antifibrinolytics B) Corticosteroids C) Antiplatelets D) Diuretics

A) Antifirinolytics An antifibrinolytic agent, aminocaproic acid (Amicar), stabilizes clot formation at the site of hemorrhage. Corticosteroids, antiplatelets, and diuretics do not have this action. Aspirin is contraindicated.

contusion

bruising of the brain

A gymnast sustained a head injury after falling off the balance beam at practice. The client was taken to surgery to repair an epidural hematoma. In postoperative assessments, the nurse measures the client's temperature every 15 minutes. This measurement is important to: A) decrease the potential for brain damage. B) assess for infection. C) follow hospital protocol. D) prevent embolism.

A) Decrease the potential for brain damage. It is important to monitor the client's body temperature closely; hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures.

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skill fracture. Which of the following correctly decribes Battle's sign? A) Ecchymosis over the mastoid B)Bruising under the eyes C) Drainage of cerebrospinal fluid from the nose D) Drainage of cerebrospinal fluid from the ears

A) Ecchymoisis over the mastoid With fractures of the base of the skull, an area of ecchymosis (bruising) may be seen over the mastoid and is called Battle's sign. Basilar skull fractures are suspected when cerebrospinal fluid escapes from the ears or the nose.

A client has noticed recently having clearer vision at a distance than up close. What is the term used to describe this client's visual condition? A) hyperopia B) emmetropia C) myopia D) astigmatism

A) Hyperopia Hyperopia is farsightedness. People who are hyperopic see objects that are far away better than objects that are close.

The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures? A) Insertion of a nasogastric tube B) A large volume enema C) Digital stimulation D) Bowel surgery

A) Insertion of a nasogastric tube Immediately after a SCI, a paralytic ileus usually develops. A nasogastric tube is often required to relieve distention and to prevent vomiting and aspiration. An enema and digital stimulation will not relieve a paralytic ileus. Bowel surgery is not necessary.

A nurse is conducting a health history with a client. During the history, the client tells the nurse, "Things that are far away often look blurred." The nurse inteprets this finding as: A) myopia B) hyperopia C) presbyopia D) cataract

A) Myopia Changes in vision can be associated with problems such as myopia (nearsightedness—distant objects appear blurred), hyperopia (farsightedness), presbyopia (diminished ability to focus on near objects with age due to the decline in amplitude of accommodation), and cataracts (opacity of the lens).

The nurse is assessing a client's hearing using the Rinne test. When providing instruction to elicit client feedback, which instruction is essential? A) Raise your hand when you hear the vibration. B) Raise your hand when you no longer hear sound. C) Raise your hand when the vibration exceeds the sound. D) Raise your hand when the sound exceeds the vibration.

B) Raise your hand when you no longer hear sound. It is essential to provide clear directions on when the client is to notify the nurse of client response. The information gleaned from the response is what the nurse uses to interpret the test. The correct time to induce feedback is when the vibration is held.

A 76-year-old client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? A) Stent placement B) Removal of the carotid artery C) Percutaneous transluminal coronary artery angioplasty D) Carotid endarterectomy

D) Carotid endarterectomy If narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a carotid endarterectomy (surgical removal of atherosclerotic plaque) is a treatment option. A balloon angioplasty, a procedure similar to a percutaneous transluminal coronary artery angioplasty, is performed to dilate the carotid artery and increase blood flow to the brain. Options A, B, and C are not surgical options to increase blood flow through the carotid artery to the brain.

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? A) Extreme thirst B) Intake and output C) Nutritional status D) Body temperature

D) body temperature It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Options A, B, and C are not the most important parameters to monitor.

If untreated, squamous cell carcinoma of the external ear can spread through the temporal bone, causing A) Facial nerve paralysis. B) nystagmus. C) motor impairment. D) diplopia.

A) Facial nerve paralysis If untreated, squamous cell carcinomas of the ear can spread through the temporal bone, causing facial nerve paralysis and hearing loss.

The nurse caring for a patient with bacterial meningitis is administering dexamethasone (Decadron) that has been ordered as an adjunct to antibiotic therapy. When does the nurse know is the appropriate time to administer this medication? A) 1 hour after the antibiotic has infused and daily for 7 days B) 15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days C) 2 hours prior to the administration of antibiotics for 7 days D) It can be administered every 6 hours for 10 days.

B) 15 to 20 minutes before the first does of antibiotic and every 6 hours for the next 4 days.

The nurse is reviewing the results of a client's audiometric testing. The nurse determines that the client has a mild hearing loss based on the result signifying which loss of decibels? A) 20 B) 30 C) 45 D) 80

B) 30 A mild hearing loss is identified by a loss of 25 to 40 decibels. A loss of up to 15 decibels would be classified as normal hearing. A loss of 15 to 25 decibels would be classified as slight hearing loss. A loss of 40 to 55 decibels would be classified as a moderate hearing loss. A loss of 70 to 90 decibels would be classified as severe hearing loss.

A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury? A) Lower back pain B) Burning sensation on urination C) Frequency of urination D) Fever and change in urine clarity

D) Fever and change in urine clarity Fever and change in urine clarity as early signs of UTI in a client with a spinal cord injury. Lower back pain is a late sign. A client with a spinal cord injury may not experience a burning sensation or urinary frequency.

Lucy VanPelt, a 63-year-old cartoonist, has noticed a decrease in the amount of sounds she can hear. She's visiting the ENT group where you practice nursing for evaluation. Her level of hearing loss will be determined by a hearing test administered by an audiologist. What is the description of her hearing loss based upon? A) The intensity of her first heard sound B) The location of her aural abnormality C) The depth of tone used in testing D) Physician estimation

A) The intensity of her first sound Hearing impairment is described as mild, moderate, severe, or profound, depending on the intensity of sound required for a person to hear it.

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? A) So that the patient will not have a respiratory arrest B) Because hypoxemia can create or worsen a neurologic deficit of the spinal cord C) To increase cerebral perfusion pressure D) To prevent secondary brain injury

B) because hypoxemia can create or worsen a neurological deficit of the spinal cord. Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2) because hypoxemia can create or worsen a neurologic deficit of the spinal cord.

A client is receiving phenylephrine eye drops in preparation for ophthalmoscopy. The client receives the final dose of drops at 10:30 a.m. The nurse informs the client that he will begin to notice the effects of the drug beginning to wear off around what time? A) 11:30 a.m. B) 12:30 p.m. C) 1:30 p.m. D) 2:30 p.m.

C) 1:30 Phenylephrine drops cause mydriasis and the client will begin to notice recovery from this effect in approximately 3 to 5 hours. Since the client received the drops at 10:30 a.m., he should begin to notice a change around 1:30 p.m.

A client who wears soft contact lenses opts for laser correction surgery. The nurse would instruct the client to discontinue using the contact lenses for which time period before surgery? A) 2 to 3 days B) About a week C) 2 to 3 weeks D) 1 month

C) 2 to 3 weeks The client is required to discontinue using soft contact lenses for 2 to 3 weeks before the laser correction surgery.

The nurse is caring for an 8-year-old and anticipates that the client has otitis externa from symptoms stated on the history. Which symptoms, from the history and physical examination, would confirm the diagnosis? A) Discomfort in the ear B) Difficulty hearing C) Pus noted in the ear canal D) Inflammation around the tympanic membrane

C) Pus noted in the ear canal The diagnosis of otitis externa (inflammation of the tissue of the outer ear) is confirmed by the presence of pus in the ear canal. The inflammation is usually caused by an overgrowth of pathogens. The other symptoms are also common in otitis media.

An elderly client with macular degeneration has received injections of angiogenesis inhibitors. Which assessment finding would indicate the condition is worsening? A) Blurred vision B) Burning sensation of the eyes C) of peripheral field vision D) Central vision impairment

D) Central vision impairment When the macula becomes irreparably damaged, central vision is lost and the client can only see images via peripheral field. Blurred vision is the initial symptom of the disease and does not signify worsening. Burning sensation is a common adverse reaction to the treatment injection.

Which medication classification increases aqueous fluid outflow in the client with glaucoma? A) Beta-blockers B) Alpha-adrenergic agonists C) Carbonic anhydrase inhibitors D) Cholinergics

D) Cholinergics Cholinergics increase aqueous fluid outflow by contracting the ciliary muscle, causing miosis and opening the trabecular meshwork. Beta-blockers decrease aqueous humor production. Alpha-adrenergic agonists decrease aqueous humor production. Carbonic anhydrase inhibitors decrease aqueous humor production.

Which of the following would not be included as a marker of medication effectiveness in glaucoma control? A) Opacity of the lens B) Lowering intraocular pressure (IOP) to target pressure C) Appearance of optic nerve head D) Visual field

A) Opacity of the lens Opacity of the lenses relates to cataract formation. The main markers of the efficacy of the medication in glaucoma control are lowering of the IOP to the target pressure, appearance of the optic nerve head, and the visual field.

A diabetic patient is scheduled for surgery for repair of a detached retina that was caused by proliferative retinopathy. The nurse prepared the patient for surgery, aware that the type of detachment is most likely classified as which of the following? A) Rhegmatogenous B) Traction C) Exudative D) Traction combined with rhegmatogenous

A) Rhegmatogenous Rhegmatogenous detachment is the most common form of retinal detachment. In this condition, a hole or tear develops in the sensory retina, allowing some of the liquid vitreous to seep through the sensory retina and detach it from the retinal pigment epithelium.

When preparing a teaching plan for a client diagnosed with otitis externa, the nurse instructs the client to avoid any water sport for which duration? A) 3 to 5 days B) 5 to 7 days C) 7 to 10 days D) 10 to 14 days

C) 7 to 10 days A client with otitis externa should refrain from any water sport for approximately 7 to 10 days to allow the canal to heal completely. Otherwise, recurrence is highly likely.

The nurse educator is reviewing the proper way to instill eye drops in a patient's eye. How long would the educator teach the nurses to wait between successive eye drops in the same eye, in order to achieve adequate eye drop drug retention and absorption? A) 30 seconds B) 1 minute C) 3 minutes D) 5 minutes

D) 5 minutes A 5-minute interval between successive eye drop administration allows for adequate drug retention and absorption. Any time frame less than 5 minutes will not allow adequate absorption.

A nurse is aware of the significant potential benefits of cochlear implants for certain individuals. Which one of the following individuals is the most appropriate candidate for a cochlear implant? A) An individual who has not yet experienced hearing loss but who possesses multiple risk factors B) An individual who has been diagnosed with presbycusis C) An individual who has longstanding and severe conductive hearing loss D) An individual who has profound, bilateral, sensorineural hearing loss

D) An individual who has profound, bilateral, sensorinueral hearing loss. A cochlear implant is an auditory prosthesis used for people with profound bilateral sensorineural hearing loss who do not benefit from conventional hearing aids. Cochlear implants are not used prophylactically. Presbycusis and conductive hearing loss are not indications for cochlear implants.

A nurse is caring for a client scheduled to have angiography of the right eye in 1 hour. What is the highest priority nursing intervention? A) Assess blood urea nitrogen (BUN) and creatinine levels. B) Instruct the client to hold their head still during the procedure. C) Educate the client about the feeling of warmth and metallic taste that may occur during the procedure. D) Assess for dark yellow to orange urine.

A) Assess blood urea nitrogen and creatinine levels. The nurse should assess the BUN and creatinine levels to ensure the client has adequate renal function to excrete the contrast used. Inability to excrete the contrast could lead to complications. Instructing the client to hold his or her head still and educating about the feeling of warmth and metallic taste that might occur are appropriate interventions; assessing renal function remains the highest priority. Assessing for dark yellow to orange urine is appropriate in the postprocedural time frame, so it would not be the highest priority.

A nurse is obtaining a history from a new client with glaucoma. The client indicates having read about the diagnosis and understanding that this type of glaucoma is due to the degeneration and obstruction of the trabecular meshwork, whose original function is to absorb the aqueous humor. The loss of absorption will lead to an increased resistance, and thus a chronic, painless buildup of pressure in the eye. Which type of glaucoma has the client described? A) open angle B) angle closure C) congenital D) secondary

A) Open angle The client described open-angle glaucoma. This type of glaucoma develops painlessly, and visual changes occur slowly. As the IOP rises, it causes edema of the cornea, atrophy of nerve fibers in the peripheral areas of the retina, and degeneration of the optic nerve.

Which of the following is the overall aim of glaucoma treatment? A) Prevent optic nerve damage B) Optimize the patient's remaining vision C) Reverse optic nerve damage D) Reattach the retina

A) Prevent optic nerve damage The aim of all glaucoma treatment is prevention of optic nerve damage. Although treatment cannot reverse optic nerve damage, further damage can be controlled. Reattachment of the retina is not part of glaucoma treatment.

The initial symptoms of variant Creutzfeldt-Jakob disease (vCJD) include A) sensory disturbance, limb pain, and behavioral changes. B) memory and cognitive impairment. C) diplopia and bradykinesia. D) akathisia and dysphagia.

A) Sensory disturbance, limb pain, and behavioral changes. Sensory disturbance, limb pain, and behavioral changes are the initial symptoms of vCJD. Memory and cognitive impairment occur late in the course of vCJD. The other symptoms listed may happen in the later stages of vCJD.

Which of the following occurs when there is deviation from perfect ocular alignment? A) Strabismus B) Ptosis C) Chemosis D) Nystagmus

A) Strabismus Strabismus is a condition in which there is deviation from perfect ocular alignment. Ptosis is a drooping eyelids. Chemosis is edema of the conjunctiva. Nystagmus is an involuntary oscillation of the eyeball.

The nursing instructor is discussing the difference between sensorineural and conductive hearing loss with his class. The discussion turns to evaluation for determining what kind of hearing loss a patient has. What Weber test result would indicate the presence of a sensorineural loss? A) The sound is heard better in the ear in which he has better hearing. B) The sound is heard equally in both ears. C) The sound is heard better in the ear in which he has poorer hearing. D) The sound is heard longer in the ear in which he has better hearing.

A) The sound is heard better in the ear in which he has better hearing. A patient with sensorineural hearing loss hears the sound better in the ear in which he has better hearing. The Weber test assesses bone conduction of sound and is used for assessing unilateral hearing loss. A tuning fork is used. A patient with normal hearing hears the sound equally in both ears or describes the sound as centered in the middle of the head. A patient whose hearing loss is conductive hears the sound better in the affected ear.

A nurse is caring for a client with a history of severe migraines. The client has a medical history that includes asthma, gastroesophageal reflux disease, and three pregnancies. Which medication does the nurse anticipate the physician will order for the client's migraines? A) Verapamil (Calan) B) Metoprolol (Lopressor) C) Amiodarone (Cordarone) D) Captopril (Coreg)

A) Verapamil Calcium channel blockers, such as verapamil, and beta-adrenergic blockers, such as metoprolol, are commonly used to treat migraines because they help control cerebral blood vessel dilation. Calcium channels blockers, however, are ordered for clients who may not be able to tolerate beta-adrenergic blockers, such as those with asthma. Amiodarone and captopril aren't used to treat migraines

The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke? A) Weakness on one side of the body and difficulty with speech B) Severe headache and early change in level of consciousness C) Footdrop and external hip rotation D) Vomiting and seizures

A) Weakness on one side of the body and difficulty with speech. The main presenting symptoms for an ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Footdrop and external hip rotation are things that can occur if a stroke victim is not turned or positioned correctly.

A nurse has developed a strong therapeutic rapport with a male patient during the patient's recovery in hospital from a stroke. The patient has had a largely successful recovery but has admitted to the nurse that he has concerns about how his sexual relationship will be affected upon discharge. The nurse should respond to the patient's statement by: A) Encouraging him to focus on his achievements rather than his perceived deficits B) Encouraging him to consider alternative forms of sexual expression with his partner C) Encouraging him to prioritize the emotional aspects of his relationship rather than the physical aspects D) Encouraging him with the fact that this aspect of his life is not likely to have been affected by his stroke

B) Encourage him to consider alternative forms of sexual expression with his partner. Encouraging the patient to explore alternative methods of sexual expression acknowledges the patient's concerns and provides a realistic and empathic response. It is inappropriate to divert the patient's concerns or to provide unrealistic expectations.

The nurse is preparing a presentation for a local community group comparing photorefractive keratectomy and LASIK refractive surgeries. Which of the following would the nurse include? A) PRK is used primarily for people without an astigmatism. B) LASIK involves working with the cornea on a deeper level. C) LASIK is appropriate for people with very thin corneas. D) PRK requires that a thin flap be made to allow access to the cornea.

B) LASIK involves working with the cornea on a deeper level. LASIK involves the creation of a corenal flap to allow access to the corneal stroma at a deeper level. PRK is used to treat myopia and hyperopia with or without an astigmatism and is now reserved for clients unsuitable for LASIK, such as those with very thin corneas.

An aging client is brought to the eye clinic by the son. The son states he has seen his parent holding reading materials at an increasing distance to focus properly. What age-related changes does this indicate? A) Cataract B) Presbyopia C) Myopia D) Macular degeneration

B) Presbyopia Refractive changes, such as presbyopia, occur in older adults where the lens cannot readily accommodate aging. In such cases, the client is observed holding reading materials at an increasing distance to focus properly. In case of a cataract, the client should report increased glare, decreased vision, and changes in color perception. Macular degeneration affects the central vision. Myopia is the inability to see things at a distance clearly.

A client has been referred to an ophthalmologist for suspected macular degeneration. The nurse knows to prepare what test for the physician to give the client? A) Ishihara polychromatic plates B) Visual field C) Amsler grid D) Slit lamp

C) Amsler grid Clients with macular problems are tested with an Amsler grid. It is made up of a geometric grid of identical squares with a central fixation point. The examiner instructs the client to stare at the central fixation spot on the grid and report if they see any distortion of the squares. Clients with macular problems may say some of the squares are faded or wavy. An Ishihara polychromatic plate, visual field, or slit lamp test will not diagnose macular degeneration.

Which is be an accurate clinical manifestation of a retinal detachment? A) Colored halos around lights B) Chemosis and redness of the sclera C) Bright flashing lights D) Sudden onset of intense pain

C) Bright flashing lights Clients can complain of bright flashing lights as a clinical manifestation of retinal detachment. Clients with retinal detachment do not complain of pain. Colored halos around lights is specific to glaucoma. Chemosis does not usually occur with retinal detachment.

While making your initial rounds after coming on shift, you find a client thrashing about in bed complaining of a severe headache. The client tells you the pain is behind his right eye which is red and tearing. What type of headache would you suspect this client of having? A) Migraine B) Tension C) Cluster D) Sinus

C) Cluster A person with a cluster headache has pain on one side of the head, usually behind the eye, accompanied by nasal congestion, rhinorrhea (watery discharge from the nose), and tearing and redness of the eye. The pain is so severe that the person is not likely to lie still; rather he or she paces or thrashes about. The symptoms in the scenario do not describe a sinus headache.

A patient has had an ischemic stroke and has been admitted to the unit. The nurse knows the importance of the principles of body alignment and correct positioning to stroke victims. How should the nurse position the patient to prevent joint deformities? A) Place the patient flat in the prone position for 30 minutes per day. B) Assist the patient in acutely flexing the thigh to promote movement. C) Place a pillow in the axilla when there is limited external rotation. D) Place patient's hand in pronation.

C) Place a pillow in the axilla when there is limited external rotation. A pillow in the axilla prevents adduction of the affected shoulder and keeps the arm away from the chest. The prone position with a pillow under the pelvis, not flat, promotes hyperextension of the hip joints, essential for normal gait. To promote venous return and prevent edema, the upper thigh should not be flexed acutely. The hand is placed in slight supination, not pronation, which is its most functional position.

The nurse is aware that in an ischemic stroke there is an area of low CBF around the infracted area (penumbra region). This area cannot be saved if tissue plasminogen activator (tPA) is administered at a CBF level of: A) 48 mL/100 g/min. B) 38 mL/100 g/min. C) 28 mL/100 g/min. D) 8 mL/100 g/min.

D) 8 mL/100 g/min There is tissue viability up to 10 mL/100 g/min. When CBF is less than 10 mL/100 g/min, cellular death occurs. Refer to Figure 47-4 in the text.

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? A) Encouraging oral fluid intake B) Suctioning the client once each shift C) Elevating the head of the bed 90 degrees D) Administering a stool softener as ordered

D) Administering a stool softener To prevent the client from straining at stool, which may cause a Valsalva maneuver that increases ICP, the nurse should institute a regular bowel program that includes use of a stool softener. For a client at risk for increased ICP, the nurse should prevent, not encourage, oral fluid intake and should elevate the head of the bed only 30 degrees. Suctioning, indicated for a client with lung congestion, isn't necessary for this client.