Nurselabs - Neuro Exam 2

Emergency medical technicians transport a 27-year-old ironworker to the emergency department. They tell the nurse, "He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he's comatose. We intubated him and he's maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual resuscitation bag." Which intervention by the nurse has the highest priority? A. Assessing the left leg. B. Assessing the pupils. C. Placing the client in Trendelenburg's position. D. Assessing level of consciousness.

A. Assessing the left leg. In the scenario, airway and breathing are established so the nurse's next priority should be circulation. With a compound fracture of the femur, there is a high risk of profuse bleeding; therefore, the nurse should assess the site. Monitor vital signs. Note signs of general pallor, cyanosis, cool skin, changes in mentation. Inadequate circulating volume compromises systemic tissue perfusion.

The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following? A. Giving the client thin liquids. B. Thickening liquids to the consistency of oatmeal. C. Placing food on the unaffected side of the mouth. D. Allowing plenty of time for chewing and swallowing.

A. Giving the client thin liquids. Before the client with dysphagia is started on a diet, the gag and swallow reflexes must have returned. Review individual pathology and ability to swallow, noting extent of the paralysis: clarity of speech, tongue involvement, ability to protect airway, episodes of coughing, presence of adventitious breath sounds. Weigh periodically as indicated. Nutritional interventions and choices of feeding route are determined by these factors.

A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test? A. Immobilize the neck before the client is moved onto a stretcher. B. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. C. Place a cap on the client's head. D. Administer a sedative as ordered.

B. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. Because CT commonly involves the use of a contrast agent, the nurse should determine whether the client is allergic to iodine, contrast dyes, or shellfish. In some patients, contrast agents may cause allergic reactions, or in rare cases, temporary kidney failure. IV contrast agents should not be administered to patients with abnormal kidney function since they may induce a further reduction of kidney function, which may sometimes become permanent.

The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid? A. Head midline B. Head turned to the side C. Neck in neutral position D. Head of bed elevated 30 to 45 degrees

B. Head turned to the side The head of the client with increased intracranial pressure should be positioned so the head is in a neutral midline position. The nurse should avoid flexing or extending the client's neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.

The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition: A. The client has complete bilateral paralysis of the arms and legs. B. The client has weakness on the right side of the body, including the face and tongue. C. The client has lost the ability to move the right arm but can walk independently. D. The client has lost the ability to move the right arm but can walk independently.

B. The client has weakness on the right side of the body, including the face and tongue. Hemiparesis is a weakness of one side of the body that may occur after a stroke. Complete hemiparesis is a weakness of the face and tongue, arm, and leg on one side. Complete bilateral paralysis does not occur in this condition.

A female 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 leaves the side rails down. B. The client uses a mirror to inspect the skin. C. The client repositions only after being reminded to do so. D. The client hangs the left arm over the side of the wheelchair.

B. The client uses a mirror to inspect the skin. Using a mirror enables the client to inspect all areas of the skin for signs of breakdown without the help of staff or family members. Inspect skin daily. Observe for pressure areas, and provide meticulous skincare. Teach the patient to inspect skin surfaces and to use a mirror to look at hard-to-see-areas. Altered circulation, loss of sensation, and paralysis potentiate pressure sore formation. This is a lifelong consideration.

The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. This test assesses which of the following? A. Cerebellar function B. Intellectual function C. Cerebral function D. Sensory function

C. Cerebral function The mental status examination assesses functions governed by the cerebrum. Some of these are orientation, attention span, judgment, and abstract reasoning. Cerebrum is the largest part of the brain and is composed of right and left hemispheres. It performs higher functions like interpreting touch, vision, and hearing, as well as speech, reasoning, emotions, learning, and fine control of movement.

Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia. Which of the following actions by the nurse would be least helpful to the client? A. Speaking to the client at a slower rate. B. Allowing plenty of time for the client to respond. C. Completing the sentences that the client cannot finish. D. Looking directly at the client during attempts at speech.

C. Completing the sentences that the client cannot finish. Clients with aphasia after brain attack (stroke) often fatigue easily and have a short attention span. The nurse would avoid shouting (because the client is not deaf), appearing rushed for a response, and letting family members provide all the responses for the client.

A female client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain? A. Diencephalon B. Medulla C. Midbrain D. Cortex

C. Midbrain Decerebrate posturing, characterized by abnormal extension in response to painful stimuli, indicates damage to the midbrain. Decerebrate posturing can be seen in patients with large bilateral forebrain lesions with progression caudally into the diencephalon and midbrain. It can also be caused by a posterior fossa lesion compressing the midbrain or rostral pons.

A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA? A. Caucasian race B. Female sex C. Obesity D. Bronchial asthma

C. Obesity Obesity is a risk factor for CVA. Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, oral contraceptive use, emotional stress, family history of CVA, and advancing age.

For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: A. Prevent respiratory alkalosis. B. Lower arterial pH. C. Promote carbon dioxide elimination. D. Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg.

C. Promote carbon dioxide elimination. The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Hypercarbia lowers serum pH and can increase cerebral blood flow contributing to rising ICP, hence hyperventilation to lower pCO2 to around 30 mm Hg can be transiently used.

The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting mostsuccessfully if the client: A. Gets angry with family if they interrupt a task. B. Experiences bouts of depression and irritability. C. Has difficulty with using modified feeding utensils. D. Consistently uses adaptive equipment in dressing self.

D. Consistently uses adaptive equipment in dressing self Clients are evaluated as coping successfully with lifestyle changes after a brain attack (stroke) if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions.

During recovery from a cerebrovascular accident (CVA), a female client is given nothing by mouth, to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once each shift. This assessment evaluates: A. Cranial nerves I and II. B. Cranial nerves III and V. C. Cranial nerves VI and VIII. D. Cranial nerves IX and X.

D. Cranial nerves IX and X. Swallowing is a motor function of cranial nerves IX and X. Cranial nerve IX (glossopharyngeal nerve), is responsible for motor (SVE) innervation of the stylopharyngeus and the pharyngeal constrictor muscles by the nucleus ambiguus. Damage to the recurrent laryngeal branch of the vagus nerve can result in vocal hoarseness or acute dyspnea with bilateral avulsion.

A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority for this client's plan of care? A. Disturbed sensory perception (visual) B. Self-care deficit: Dressing/grooming C. Impaired verbal communication D. Risk for injury

D. Risk for injury Because the client is disoriented and restless, the most important nursing diagnosis is risk for injury. Provide for safety needs (e.g., supervision, side rails, seizure precautions, placing call bell within reach, positioning needed items within reach/clearing traffic paths, ambulating with devices). This is to prevent untoward incidents and to promote safety.

A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid: A. Is clear and tests negative for glucose. B. Is grossly bloody in appearance and has a pH of 6. C. Clumps together on the dressing and has a pH of 7. D. Separates into concentric rings and tests positive for glucose.

D. Separates into concentric rings and tests positive for glucose. Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.