Neuro Prep-U
The nurse is caring for a client admitted with a diagnosis of septic meningitis. The nurse is aware that this infection is caused by which of the following? a) Leukemia b) Lymphoma c) Bacteria d) Virus
Bacteria Explanation: Septic meningitis is caused by bacteria. In aseptic meningitis, the cause is viral or secondary to lymphoma, leukemia, or human immunodeficiency virus.
A nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely? a) Hyper-alertness b) Negative Kernig's sign c) Increased intake d) Positive Brudzinski's sign
Positive Brudzinski's sign Correct Explanation: A positive Brudzinski's sign is a common finding in the client with meningitis. When the client's neck is flexed, flexion of the knees and hips is produced. A positive Kernig's sign is usual with meningitis. The client will develop lethargy as the illness progresses, not increased intake or hyper-alertness.
Thrombolytic therapy should be initiated within what time frame of an ischemic stroke for best functional outcome? a) 12 hours b) 9 hours c) 6 hours d) 3 hours
3 hours Correct Explanation: Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in patients with ischemic stroke lead to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months.
A nurse is assisting with a community screening for people at high risk for stroke. To which of the following clients would the nurse pay most attention? a) A 28-year-old pregnant African-American woman b) A 60-year-old African-American man c) A 40-year-old Caucasian woman d) A 62-year-old Caucasian woman
A 60-year-old African-American man Correct Explanation: The 60-year-old African-American man has three risk factors: gender, age, and race. African Americans have almost twice the incidence of first stroke compared with Caucasians.
In myasthenia gravis (MG), there is a decrease in the number of receptor sites of which neurotransmitter? a) Norepinephrine b) Dopamine c) Acetylcholine d) Epinephrine
Acetylcholine Correct Explanation: In MG, there is a reduction in the number of acetylcholine receptor sites because antibodies directed at the acetylcholine receptor sites impair transmission of impulses across the neuromuscular junction. There are no decreased receptor sites of epinephrine, norepinephrine, or dopamine implicated in MG.
A nurse is providing education to a client with newly diagnosed multiple sclerosis (MS). Which of the following will the nurse include? a) Take moderate amounts of alcohol. b) Avoid hot temperatures. c) Avoid physical activity. d) Avoid analgesic medication.
Avoid hot temperatures. Correct Explanation: Fatigue affects most people with MS. Avoidance of hot temperatures may help control fatigue. A balance of rest and activity is a good strategy, but avoidance of any physical activity is not recommended. Avoidance of all alcohol is a good strategy. Analgesics may be required for pain management.
A nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)? a) Maintain a well-lit room. b) Turn the client and change his position every 2 hours. c) Suction the airway every hour and as needed. d) Elevate the head of the bed 15 to 30 degrees.
Elevate the head of the bed 15 to 30 degrees. Correct Explanation: To facilitate venous drainage and avoid jugular compression, the nurse should elevate the head of the bed 15 to 30 degrees. Clients with increased ICP poorly tolerate suctioning and shouldn't be suctioned on a regular basis. Turning the client from side to side increases the risk of jugular compression and rises in ICP, so turning and changing positions should be avoided. The room should be kept quiet and dimly lit.
The trochlear nerve serves which of the following functions? a) Eye muscle movement b) Hearing and equilibrium c) Visual acuity d) Movement of the tongue
Eye muscle movement Correct Explanation: The trochlear nerve coordinates the muscles that move the eye. The acoustic nerve functions in hearing and equilibrium. The optic nerve functions in visual acuity and visual fields. The hypoglossal nerve functions in the movement of the tongue.
Which of the following is the most common clinical manifestation of multiple sclerosis? a) Ataxia b) Spasticity c) Fatigue d) Pain
Fatigue Correct Explanation: Fatigue affects 87% of people with MS and 40% of that group indicate that fatigue is the most disabling symptom. Pain, spasticity, and ataxia are clinical manifestations of MS.
A client tells the nurse that they have transient ischemic attacks. The client reports having undergone a carotid artery surgery. In such a case, what important assessments should be performed by the nurse? a) Blood pressure and weight b) Frequent neurologic checks c) Motor and sensory responses d) Sexual history
Frequent neurologic checks Explanation: If the client undergoes carotid artery surgery, the nurse performs frequent neurologic checks to detect paralysis, confusion, facial asymmetry, or aphasia. Body weight is measured because obesity, hyperlipidemia, and atherosclerosis are related to cerebrovascular disease, and not in the case of carotid artery surgery. Sexual history and motor and sensory responses are not important assessments to be performed for such clients.
The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe? a) Numbness and vomiting b) Headache and nuchal rigidity c) Hyporeflexia in the lower extremities d) Ptosis and diplopia
Headache and nuchal rigidity Correct Explanation: Headache and fever are the initial symptoms of meningitis. Nuchal rigidity can be an early sign. Photophobia is also a well-recognized sign in meningitis. Ptosis and diplopia are usually seen with myasthenia gravis. Hyporeflexia in the legs is seen with Guillain-Barre syndrome.
A nurse is providing education to a community group about ischemic strokes. One group member asks if there are ways to reduce the risk for stroke. Which of the following is a risk factor that can be modified? a) Male gender b) Hypertension c) Advanced age d) African-American race
Hypertension Correct Explanation: Modifiable risk factors for ischemic stroke include hypertension, atrial fibrillation, hyperlipidemia, diabetes mellitus, smoking, asymptomatic carotid stenosis, obesity, and excessive alcohol consumption. Non-modifiable risk factors include advanced age, gender, and race.
A nurse is caring for an older client who has had a hemorrhagic stroke. The client has exhibited impulsive behavior and, despite reminders from the nurse, doesn't recognize his limitations. Which priority measure should the nurse implement to prevent injury? a) Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed. b) Encourage the family to reprimand the client if he doesn't ask for help with transfers and mobility. c) Ask a physician to order a vest and wrist restraints. d) Encourage the client to do as much as possible without assistance, and to use the call light only in emergencies.
Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed. Correct Explanation: The bed alarm will alert staff that the client is attempting to transfer, so they can come to assist. The nurse shouldn't encourage the family to reprimand the client. Instead, the nurse should ask the family to encourage the client to request assistance. The nurse should encourage the client to use the call light in all situations, not just emergencies. A vest and wrist restraints aren't appropriate unless less-restrictive measures have failed and the client is a danger to himself or others
The diagnosis of multiple sclerosis is based upon which of the following tests? a) CSF electrophoresis b) MRI c) Evoked potential studies d) Neuropsychological testing
MRI Correct Explanation: The diagnosis of MS is based on the presence of multiple plaques in the CNS observed with MRI. Electrophoresis of CSF identifies the presence of oligoclonal banding. Evoked potential studies can help define the extent of the disease process and monitor changes. Neuropsychological testing may be indicated to assess cognitive impairment
A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority? a) Positioning to prevent complications b) Maintenance of a patent airway c) Assessment of pupillary light reflexes d) Determination of the cause
Maintenance of a patent airway Correct Explanation: The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.
The nurse is educating a client with myasthenia gravis about medications. The nurse is sure to include which of the following? a) Medications must be taken on time. b) Medications are best taken while the client is in a reclining position. c) There is no conflict with the disorder and dental work. d) Medications can be taken whenever convenient.
Medications must be taken on time. Correct Explanation: If medications are not taken on time, exacerbations may occur, making it impossible for the client to take the medication orally. Medications must always be taken with the client upright to avoid aspiration. Procaine (Novocain) should be avoided and the client's dentist must be informed.
Which of the following is the initial diagnostic in suspected stroke? a) CT with contrast b) Cerebral angiography c) Noncontrast computed tomography (CT) d) Magnetic resonance imaging (MRI)
Noncontrast computed tomography (CT) Explanation: An initial head CT scan will determine whether or not the patient is experiencing a hemorrhagic stroke. An ischemic infarction will not be readily visible on initial CT scan if it is performed within the first few hours after symptoms onset; however, evidence of bleeding will almost always be visible.
Which of the following cranial nerves is responsible for muscles that move the eye and lid? a) Facial b) Trigeminal c) Oculomotor d) Vestibulocochlear
Oculomotor Correct Explanation: The oculomotor (III) cranial nerve is also responsible for pupillary constriction and lens accommodation. The trigeminal (V) cranial nerve is responsible for facial sensation, corneal reflex, and mastication. The vestibulocochlear (VII) cranial nerve is responsible for hearing and equilibrium. The facial (VII) nerve is responsible for salivation, tearing, taste, and sensation in the ear.
The pre-nursing class is learning about the nervous system in their anatomy class. What part of the nervous system would the students learn is responsible for digesting food and eliminating body waste? a) Central b) Peripheral c) Sympathetic d) Parasympathetic
Parasympathetic Correct Explanation: The parasympathetic division of the autonomic nervous system works to conserve body energy and is partly responsible for slowing heart rate, digesting food, and eliminating body wastes.
A nurse conducts the Romberg test on a patient by asking the patient to stand with feet close together and eyes closed. As a result of this posture, the patient suddenly sways to one side and is about to fall when the nurse intervenes and saves the patient from being injured. In which of the following ways should the patient's action be interpreted by the nurse? a) Negative Romberg test, indicating a problem with vision b) Positive Romberg test, indicating a problem with level of consciousness (LOC) c) Negative Romberg test, indicating a problem with body mass d) Positive Romberg test, indicating a problem with equilibrium
Positive Romberg test, indicating a problem with equilibrium Correct Explanation: If the patient sways and tends to fall during the Romberg test, it indicates a positive Romberg test. This means the patient has a problem with equilibrium. The examiner or the nurse stands fairly close to the patient during the test to prevent the patient from falling. The Romberg test is used to assess the motor function of the patient, including muscle movement, size, tone, strength, and coordination. However, the Romberg test is not used to assess the LOC, body mass, or vision of the patient.
The nurse is providing diet-related advice to a male patient following a cerebrovascular accident (CVA). The patient wants to minimize the volume of food and yet meet all nutritional elements. Which of the following suggestions should the nurse give to the patient about controlling the volume of food intake? a) Provide thickened commercial beverages and fortified cooked cereals. b) Always serve hot or tepid foods. c) Include dry or crisp foods and chewy meats. d) Provide a high-fat diet.
Provide thickened commercial beverages and fortified cooked cereals. Correct Explanation: Patients with CVA or other cerebrovascular disorders should lose weight and therefore should minimize their volume of food consumption. To ensure this, the nurse may provide thickened commercial beverages, fortified cooked cereals, or scrambled eggs. Patients should avoid eating high-fat foods, and serving foods hot or tepid will not minimize the volume consumed by the patient. Foods such as peanut butter, bread, tart foods, dry or crisp foods, and chewy meats should also be avoided because they cause choking.
Which of the following is the first-line therapy for myasthenia gravis (MG)? a) Deltasone (Prednisone) b) Lioresal (Baclofen) c) Pyridostigmine bromide (Mestinon) d) Azathioprine (Imuran)
Pyridostigmine bromide (Mestinon) Correct Explanation: Mestinon, an anticholinesterase medication, is the first-line therapy in MG. It provides symptomatic relief by inhibiting the breakdown of acetylcholine and increasing the relative concentration of available acetylcholine at the neuromuscular junction. If Mestinon does not improve muscle strength and control fatigue, the next agents used are immunosuppressant agents. Imuran is an immunosuppressive agent that inhibits T lymphocytes and reduces acetylcholine receptor antibody levels. Baclofen is used in the treatment of spasticity in MG.
A nurse is completing discharge teaching for the client who has left-sided hemiparesis following a stroke. When investigating the client's home environment, the nurse should focus on which nursing diagnosis? a) Diarrhea b) Ineffective coping c) Noncompliance d) Risk for injury
Risk for injury Correct Explanation: Because of decreased physical mobility, a client with recent left-sided hemiparesis is at risk for falls in the home setting. His ability to cope with the stroke is important, but investigating the home environment doesn't provide information about this nursing diagnosis. Diarrhea and Noncompliance aren't related to the client's home environment.
Within our brains, cerebrospinal fluid (CSF) is manufactured in the ventricles and constantly circulates around the brain and spinal cord. The CSF functions as a cushion to protect structures and maintain relatively consistent intracranial pressure. Where does CSF circulate? a) Arachnoid space b) Subpial space c) Subdural space d) Subarachnoid space
Subarachnoid space Correct Explanation: The ventricles manufacture and absorb cerebrospinal fluid (CSF), which constantly circulates in the subarachnoid space of the brain and spinal cord.
A client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis? a) The client hangs the left arm over the side of the wheelchair. b) The client leaves the side rails down. c) The client uses a mirror to inspect the skin. d) The client repositions only after being reminded to do so.
The client uses a mirror to inspect the skin. Correct Explanation: The client demonstrates understanding of safety measures related to paralysis when he uses a mirror to inspect his skin. The mirror enables the client to inspect all areas of the skin for signs of breakdown without the help of staff or family members. The client should keep the side rails up to help with repositioning and to prevent falls. The paralyzed client should take responsibility for repositioning or for reminding the staff to assist with it, if needed. A client with left-side paralysis may not realize that the left arm is hanging over the side of the wheelchair. However, the nurse should call this position to the client's attention because the arm can get caught in the wheel spokes or develop impaired circulation from being in a dependent position for too long.
A client is diagnosed with meningococcal meningitis. The 22-year-old client shares an apartment with one other person. What would the nurse expect as appropriate care for the client's roommate? a) No treatment unless the roommate begins to show symptoms b) Bedrest at home for 72 hours c) Admission to the nearest hospital for observation d) Treatment with antimicrobial prophylaxis as soon as possible
Treatment with antimicrobial prophylaxis as soon as possible Correct Explanation: People in close contact with clients who have meningococcal meningitis should be treated with antimicrobial chemoprophylaxis, ideally within 24 hours after exposure.
A client has just been diagnosed with an aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client? a) Include peanut butter, bread, or tart foods in the diet. b) Take opioid analgesics. c) Avoid heavy lifting. d) Take an herbal form of feverfew.
Avoid heavy lifting. Correct Explanation: A client with an aneurysm should be advised to avoid heavy lifting, extreme emotional situations, or straining of stools because they may increase intracranial pressure and thereby headaches. Such clients should be advised against taking opioid analgesics or including peanut butter, bread, or tart foods in the diet, because these foods cause choking. Herbal medications should be taken only in consultation with the physician.
An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following reasons? a) She is not within the treatment time window. b) She had surgery 6 weeks ago. c) She is taking coumadin. d) She is taking digoxin.
She is taking coumadin. Correct Explanation: To be eligible for thrombolytic therapy, the client cannot be taking coumadin. Initiation of thrombolytic therapy must be within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetelol do not prohibit thrombolytic therapy.
A nurse is preparing a client for a computed tomography (CT) scan that requires infusion of radiopaque dye. Which question is the most important for the nurse to ask? a) "When did you last have something to eat or drink?" b) "How much do you weigh?" c) "Are you allergic to seafood or iodine?" d) "When did you last take any medication?"
"Are you allergic to seafood or iodine?" Correct Explanation: Seafood and the radiopaque dye used in CT contain iodine. To prevent an allergic reaction to the radiopaque dye, the nurse should ask the client about allergies to seafood or iodine before the CT scan. Because fasting is unnecessary before a CT scan, the nurse doesn't need to obtain information about the client's last food and fluid intake. The client's last dose of medication and current weight also are irrelevant.
Which of the following diagnostic studies provides visualization of cerebral blood vessels? a) Computer-assisted stereotactic biopsy b) Cytologic studies of cerebrospinal fluid (CSF) c) Positron emission tomography (PET) d) Cerebral angiography
Cerebral angiography Correct Explanation: Cerebral angiography provides visualization of cerebral blood vessels and can localize most cerebral trauma. A PET scan measures the brain's activity and is useful in differentiating tumor from scar tissue or radiation necrosis. Cytologic studies of the cerebral spinal fluid (CSF) may be performed to detect malignant cells because central nervous system tumors can shed cells into the CSF. Computer-assisted stereotactic biopsy is being used to diagnose deep-seated brain tumors.
You are taking care of a client who is taking an anticonvulsant. Why should you advise the client not to stop taking the drug abruptly? a) It may trigger status epilepticus. b) It may cause alopecia. c) It may cause severe and ugly skin rashes. d) It may cause loss in appetite.
It may trigger status epilepticus. Explanation: Abrupt withdrawal of any anticonvulsant may cause status epilepticus or continuous seizure activity. Therefore, the drug should be withdrawn gradually and not abruptly. Abrupt withdrawal of any anticonvulsant does not cause loss of appetite, alopecia, or rashes.
Which of the following is an inaccurate manifestation of Cushing's triad? a) Hypertension b) Tachycardia c) Bradypnea d) Bradycardia
Tachycardia Correct Explanation: Cushing's triad is manifested by bradycardia, hypertension, and bradypnea. Tachycardia is not a component of the triad.
A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take? a) Face the client and establish eye contact. b) Talk in a louder than normal voice. c) Keep the television on while she speaks. d) Use one long sentence to say everything that needs to be said.
Face the client and establish eye contact. Correct Explanation: When speaking with a client who has aphasia, the nurse should face the client and establish eye contact. The nurse should use short phrases, not one long sentence, and give the client time between phrases to understand what is being said. Keeping extraneous and background noise such as the television to a minimum helps the client concentrate on what is being said. It isn't necessary to speak in a louder or softer voice than normal
Which of the following terms is used to describe the fibrous connective tissue that covers the brain and spinal cord? a) Meninges b) Arachnoid mater c) Dura mater d) Pia mater
Meninges Correct Explanation: The meninges have three layers, the dura mater, arachnoid mater, and pia mater. The dura mater is the outmost layer of the protective covering of the brain and spinal cord. The arachnoid is the middle membrane of the protective covering of the brain and spinal cord. The pia mater is the innermost membrane of the protective covering of the brain and spinal cord.
The nurse is completing a neurological assessment and uses the whisper test to assess which cranial nerve? a) Olfactory b) Facial c) Vagus d) Acoustic
Acoustic Correct Explanation: Clinical examination of the acoustic nerve can be done by the whisper test. Having the patient say "ah" tests the vagus nerve. Observing for symmetry when the patient performs facial movements tests the facial nerve. The olfactory nerve is tested by having the patient identify specific odors.
A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapherisis and explains this in which of the following statements? a) The thymus gland is removed. b) Immune globulin is given intravenously. c) Mestinon therapy is initiated. d) Antibodies are removed from the plasma.
Antibodies are removed from the plasma. Correct Explanation: Plasmapheresis is a technique in which antibodies are removed from plasma and the plasma is returned to the client. The other three choices are appropriate treatments for myasthenia gravis, but are not related to plasmapheresis.
Which of the following cerebral lobes is the largest and controls abstract thought? a) Occipital b) Temporal c) Parietal d) Frontal
Frontal Correct Explanation: The frontal lobe also controls information storage or memory and motor function. The temporal lobe contains the auditory receptive area. The parietal lobe contains the primary sensory cortex, which analyzes sensory information and relays interpretation to the thalamus and other cortical areas. The occipital lobe is responsible for visual interpretation.
A patient with neurological disorder has difficulty swallowing. The nurse should take special care of the patient's diet because of a potential risk of imbalanced nutrition in the patient. Which of the following measures may be taken by the nurse to ensure that the patient's diet allows for easy swallowing? a) Instruct the patient to lie on the bed when eating b) Offer liquids frequently in large quantities c) Allow optimum physical activity before meals to expedite digestion d) Help the patient sit upright when eating and feed slowly
Help the patient sit upright when eating and feed slowly Correct Explanation: A patient who has impaired swallowing should be helped to eat food with texture. The nurse should help such a patient sit upright, flex the patient's chin toward the chest, and feed slowly. These measures promote easy swallowing of food and reduce the risk of aspiration or airway obstruction. The patient should be allowed to rest before meals because fatigue may interfere with coordination and following instructions. Liquids should be offered frequently but in small quantities.
Which of the following terms refers to blindness in the right or left halves of the visual fields of both eyes? a) Scotoma b) Homonymous hemianopsia c) Diplopia d) Nystagmus
Homonymous hemianopsia Correct Explanation: Homonymous hemianopsia occurs with occipital lobe tumors. Scotoma refers to a defect in vision in a specific area in one or both eyes. Diplopia refers to double vision or the awareness of two images of the same object occurring in one or both eyes. Nystagmus refers to rhythmic, involuntary movements or oscillations of the eyes.
A nurse is planning discharge for a client who experienced right-sided weakness caused by a stroke. During his hospitalization, the client has been receiving physical therapy, occupational therapy, and speech therapy daily. The family voices concern about rehabilitation after discharge. How should the nurse intervene? a) Suggest that the family members speak with the physician about their concerns. b) The nurse should do nothing because she is responsible only for inpatient care. c) Inform the case manager of the family's concern and provide information about the client's current clinical status so appropriate resources can be provided after discharge. d) Contact the appropriate agencies so that they can provide care after discharge.
Inform the case manager of the family's concern and provide information about the client's current clinical status so appropriate resources can be provided after discharge. Explanation: As the coordinator of care, the nurse must assess the client's needs and initiate referrals for the appropriate health team members to coordinate services needed after discharge. The nurse isn't responsible for contacting agencies to provide care after discharge. Simply providing information about the family's concerns doesn't ensure that services will be arranged for the client after discharge. Alerting the physician is helpful; however, that step doesn't ensure that the necessary services will be provided after discharge. Doing nothing is irresponsible.
Which lobe of the brain is responsible for spatial relationships? a) Frontal b) Parietal c) Occipital d) Temporal
Parietal Correct Explanation: The parietal lobe is responsible for spatial relationships. The frontal lobe also controls information storage or memory and motor function. The temporal lobe contains the auditory receptive area. The occipital lobe is responsible for visual interpretation.
A client with amyotrophic lateral sclerosis (ALS) tells the nurse, "Sometimes I feel so frustrated. I can't do anything without help!" This comment best supports which nursing diagnosis? a) Ineffective denial b) Powerlessness c) Anxiety d) Risk for disuse syndrome
Powerlessness Correct Explanation: The client's comment best supports a nursing diagnosis of Powerlessness because ALS may lead to locked-in syndrome, characterized by an active and functioning mind locked in a body that can't perform even simple daily tasks. Although Anxiety and Risk for disuse syndrome may be diagnoses associated with ALS, the client's comment specifically refers to an inability to act autonomously. A diagnosis of Ineffective denial would be indicated if the client didn't seem to perceive the personal relevance of symptoms or danger.
A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order: a) Doppler scanning. b) quantitative spectral phonoangiography. c) Doppler ultrasonography. d) electromyography (EMG).
electromyography (EMG). Correct Explanation: To help confirm ALS, the physician typically orders EMG, which detects abnormal electrical activity of the involved muscles. To help establish the diagnosis of ALS, EMG must show widespread anterior horn cell dysfunction with fibrillations, positive waves, fasciculations, and chronic changes in the potentials of neurogenic motor units in multiple nerve root distribution in at least three limbs and the paraspinal muscles. Normal sensory responses must accompany these findings. Doppler scanning, Doppler ultrasonography, and quantitative spectral phonoangiography are used to detect vascular disorders, not muscular or neuromuscular abnormalities.
A physician orders aspirin, 325 mg P.O. daily for a client who has experienced a transient ischemic attack (TIA). The nurse should teach the client that the physician has ordered this medication to: a) control headache pain. b) prevent intracranial bleeding. c) enhance the immune response. d) reduce the chance of blood clot formation.
reduce the chance of blood clot formation. Correct Explanation: TIAs are considered forerunners of stroke. Because strokes may result from clots in cerebral vessels, physicians order aspirin to prevent clot formation by reducing platelet agglutination. A 325-mg dose of aspirin is inadequate to relieve headache pain in an adult. Aspirin doesn't affect the body's immune response. Intracranial bleeding isn't associated with TIAs, and aspirin probably would worsen any existing bleeding.
A physician has ordered home health and physical therapy for an older adult who will be discharged home following an acute stroke. The nurse's discharge teaching should include instructions about: a) reporting specific signs and symptoms to the physician, discharge medications, and dietary concerns. b) calling the home health nurse with any questions instead of bothering the physician and therapist. c) the daily exercise routine for the physical therapist to follow. d) avoiding any social activity until the effects of the stroke have reversed.
reporting specific signs and symptoms to the physician, discharge medications, and dietary concerns. Correct Explanation: The nurse should tell the client what signs and symptoms to report to the physician, what medications he is being discharged with and how to take them, and what dietary changes he needs to implement. The nurse shouldn't instruct the client to call the home health nurse with all questions because certain situations or concerns require physician intervention. The nurse shouldn't encourage the client to avoid social activity; isolation may result in depression. Although effects of a stroke don't always reverse, the nurse should encourage the client to be as independent as possible. The physical therapist will provide information on exercises the client can do at home.
