Prep U Chapter 66, Chapter 65, and Chapter 67

A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements?

"A secondary headache is associated with an organic cause, such as a brain tumor." pg. 1967

A client preparing to undergo a lumbar puncture states he doesn't think he will be able to get comfortable with his knees drawn up to his abdomen and his chin touching his chest. He asks if he can lie on his left side. Which statement is the best response by the nurse?

"Although the required position may not be comfortable, it will make the procedure safer and easier to perform." pg. 1932

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"Clients and families are the focus of hospice care." pg. chapter 16

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer?

"Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation." pg. pp. 1975-1976.

To evaluate a client's cerebellar function, a nurse should ask:

"Do you have any problems with balance?" pg. 1924

A nurse is preparing a client for lumbar puncture. The client has heard about post-lumbar puncture headaches and asks how to avoid having one. The nurse tells the client that these headches can be avoided by doing which of the following after the procedure?

"Remain prone for 2 to 3 hours." pg. 1854

A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following?

"The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid." pg. 1933

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"You must avoid coughing, sneezing, and blowing your nose." pg. 1958

A community health nurse is conducting a workshop for unlicensed care providers who work in a chain of long-term care facilities. The nurse is teaching the participants about the signs and symptoms of stroke. What signs and symptoms should the nurse identify? Select all that apply.

- Confusion - Sudden numbness - Visual disturbances pg.

An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following?

3 hours pg. 1900

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3 pg. 1937

A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?

3 pg. 1937

A nurse is caring for a client with an injury to the central nervous system. When caring for a client with a spinal cord insult slowing transmission of the motor neurons, the nurse would anticipate a delayed reaction in:

A delayed reaction in response due to the interrupted impulses from the central nervous system pg. 1918

Which of the following neurotransmitters are deficient in myasthenia gravis?

Acetylcholine pg. 1910

The nurse is completing a neurological assessment and uses the whisper test to assess which cranial nerve?

Acoustic pg. 1923

Which cranial nerve is tested by listening to a ticking watch?

Acoustic pg. 1923

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)?

Administering a stool softener as ordered pg. 1948

Which term refers to the inability to recognize objects through a particular sensory system?

Agnosia pg. 1925

Which term refers to the failure to recognize familiar objects perceived by the senses?

Agnosia pg. 1975

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An absence seizure pg. 1960

A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the priority medical treatment to include which of the following?

Anticoagulant therapy pg. 1976

Which medication classification is used preoperatively to decrease the risk of postoperative seizures?

Anticonvulsants pg. p. 1954-1955.

Which term refers to the inability to coordinate muscle movements, resulting in difficulty walking?

Ataxia pg. 1924

Lesions in the temporal lobe may result in which type of agnosia?

Auditory pg. 1925

Which phase of a migraine headache usually lasts less than an hour?

Aura pg. 1967

Which positions is used to help reduce intracranial pressure (ICP)?

Avoiding flexion of the neck with use of a cervical collar pg. 1948

A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply.

Bradycardia, bradypnea, and hypertension pg. 1943

A patient who has suffered a stroke is unable to maintain respiration and is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breathe?

Brain Stem pg. 1912

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?

Brain tumor pg. 2054

The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart?

CN II pg. 1923

A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?

Call the health care provider immediately. pg.

A client is prescribed warfarin. Client teaching has included instructions to maintain a diet rich in foods that contain vitamin K. What sources of food should the nurse instruct the client to eat?

Cereals, soybeans, and spinach

A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom?

Cerebral aneurysm pg. 1973

The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm?

Cerebral angiography pg. 1930

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Change in level of consciousness pg. 1943

A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis?

Chewing pg. 2048

The critical care nurse is giving report on a client they are caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the on-coming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate?

Comatose pg.

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode?

Compliance with the prescribed medication regimen pg. 1965

There are 12 pairs of cranial nerves. Only three are sensory. Select the cranial nerve that is affected with decreased visual fields.

Cranial nerve II pg. 1915

A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like the person in part B of the accompanying image. Which posturing is the patient exhibiting? (Plantar flexed, flexed, pronated, extended, adducted)

Decerebrate pg. pp. 1937-1938. (Decorticate: Plantar flexed, internally rotated, flexed elbows, flexed hands, adducted)

A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP?

Decerebrate posturing and loss of corneal reflex pg. 1952

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Decreased muscle spasms in the lower extremities

Low levels of the neurotransmitter serotonin lead to which of the following disease processes?

Depression pg. 1910

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?

Elevated 30 degrees pg. pp. 1955-1956.

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client?

Elevating the head of the bed to 30 degrees pg. 1984

A client has undergone a lumbar puncture as part of a neurological assessment. The client is put under the care of a nurse after the procedure. Which important postprocedure nursing intervention should be performed to ensure the client's maximum comfort?

Encourage the client to drink liberal amounts of fluids pg. 1931

The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client?

Establishing eye contact pg. 1958

How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)? pg.

Every 15 minutes pg.

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Explaining hospice care and services pg. 2059

The trochlear nerve controls which function?

Eye muscle movement pg. 1915

A nurse is caring for a client with deteriorating neurologic status. The nurse is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate?

Flaccidity pg. 1909, 1919.

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action?

Form words that are understandable or comprehend spoken words pg. 1974

A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?

Frontal pg. 1975

During assessment of cognitive impairment, post-stroke, the nurse documents that the patient was experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?

Frontal pg. 1975

Which is a nonmodifiable risk factor for ischemic stroke?

Gender pg. 1976

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure?

Generalized pg. 1959

A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position?

Head of the bed elevated 45 degrees pg. 1931

A client undergoes cerebral angiography for evaluation after an intracranial computed tomography scan revealed a subarachnoid hemorrhage. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?

Hemiplegia, seizures, and decreased level of consciousness (LOC) pg. 1976

A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?

Heparin sodium pg. 1979

Which term will the nurse use when referring to blindness in the right or left half of the visual field in both eyes?

Homonymous hemianopsia pg.

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?

Lateral recumbent, with chin resting on flexed knees pg. 1932

A 53-year-old man presents to the emergency department with a chief complaint of inability to form words, and numbness and weakness of the right arm and leg. Where would you locate the site of injury?

Left frontoparietal region pg. 1911

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Mannitol pg. 1957

The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?

Moving the head and chin toward the chest pg. 1909

A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for?

Noncontrast computed tomogram pg. 1976

Which of the following is the initial diagnostic in suspected stroke?

Noncontrast computed tomography (CT) pg. 1976

Which is the initial diagnostic test for a stroke?

Noncontrast computed tomography pg. 1976

A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate?

Notify the physician of a possible cerebrospinal fluid leak. pg. 1957

A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain?

Occipital pg. 1911

A nurse is completing a neurological assessment and determines that the client has significant visual deficits. A brain tumor is considered. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit?

Occipital pg. 1911

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?

Parasympathetic pg. 1916

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Parkinson's disease. pg. pp. 2064-2065.

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Pituitary carcinoma pg. 1958

A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture?

Position the client flat for at least 3 hours. pg. 1931-1933.

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?

Provide thickened commercial beverages and fortified cooked cereals. pg. 1984

Which set of symptoms characterize Korsakoff syndrome?

Psychosis, disorientation, delirium, insomnia, and hallucinations pg. 1991

The geriatric advanced practice nurse (APN) is doing client teaching with a client who has had a cerebrovascular accident (CVA) and the client's family. One concern the APN addresses is a potential for falls related to the CVA and resulting muscle weakness. What would be most important for the APN to include in teaching related to this concern?

Remove throw rugs and electrical cords from home environment. pg. 1983

A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis?

Risk for aspiration pg. 1923

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?

Semi-Fowler's pg. 1991 The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.

Which neurotransmitter demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways?

Serotonin pg. 1910

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:

Severe headache and early change in level of consciousness pg. pp. 1896, 1911.

A patient has been diagnosed with damage to Broca's area of the left frontal lobe. To document the extent of damage, the nurse would assess the patient's:

Speech pg. 1911

A client who has sustained a head injury to the parietal lobe cannot identify a familiar object by touch. The nurse knows that this deficit is which of the following?

Tactile agnosia pg. 1846-1847.

Which cerebral lobe contains the auditory receptive areas?

Temporal pg. 1911

The nurse is performing a neurological assessment of a client who has sustained damage to the frontal cortex. Which of the following deficits will the nurse look for during assessment?

The inability to tell how a mouse and a cat are alike pg. 1921

When developing a care plan for a client who has recently suffered a stroke, a nurse includes the nursing diagnosis Risk for imbalanced body temperature. What is the rationale for this diagnosis?

The stroke may have impacted the body's thermoregulation centers. pg.

A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following?

Thrombolytic therapy has a time window of only 3 hours. pg. 1977

A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?

Transient ischemic attack pg.

A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain?

V pg. 1923

The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of cranial nerve:

VIII pg. 1914

The nurse plays a critical role in the initial work-up of a patient with acute stroke symptoms. An immediate decision is to determine if the stroke is ischemic or hemorrhagic. Although there is overlap in some motor, sensory, and cognitive changes, hemorrhagic strokes can be identified by some specific signs. Which of the following signs are consistent with a hemorrhagic stroke? Select all that apply.

Vomiting Seizures Sudden, severe headache pg. p. 1989-1990.

A client is scheduled for standard EEG testing to evaluate a possible seizure disorder. Which nursing intervention should the nurse perform before the procedure?

Withhold anticonvulsant medications for 24 to 48 hours before the exam

The nurse is performing a neurologic assessment on a client diagnosed with a stroke and cannot elicit a gag reflex. This deficit is related to which of the following cranial nerves?

X pg. 1845

A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects in the body systems, the nurse anticipates that the liver will:

convert glycogen to glucose for immediate use. pg. 1917

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?

decerebrate. pg. 1938

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:

diminished responsiveness. pg. 1943

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ensure that no patient care equipment containing metal enters the room where the MRI is located pg. 1929

After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an:

evaluation of the corneal reflex response. pg. 1927

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flaccid muscle paralysis. pg. 1918

The nurse is caring for a client in the emergency department with a diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the client's face and torso. The nurse would provide further instruction after seeing that the nurse aide:

moved the client's head to clean behind the ears. pg. 2000, 2013

A nurse is completing a neurological assessment and determines that the client has significant visual deficits. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit?

occipital pg. 1920

The nurse has completed evaluating the client's cranial nerves. The nurse documents impairment of the right cervical nerves (CN IX and CN X). Based on these findings, the nurse should instruct the client to

refrain from eating or drinking for now. pg. 1923

During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to:

support the joint where the tendon is being tested. pg. 1925

The nurse is caring for a client newly diagnosed with multiple sclerosis who is overwhelmed by learning about the disease. The client indicates understanding that there is a disruption in the covering of axons but does not remember what the covering is called. The nurse should tell the client:

that the covering is called myelin and that it can be discussed further at the next meeting. pg. 1910

A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in

thought content. pg. 1922, 1928.

A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure?

unequal response pg. 1939

Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply.

• Cloudy cerebral spinal fluid • Purpura of hands and feet pg. 2027

A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse?

"Emotional lability is common after a stroke, and it usually improves with time." pg. 1985

A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first?

Assess the client for medication allergies. 1929

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Lethargy and stupor pg. 1944

A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following?

"There is a strong familial tendency." pg. 1967

A client with hypercholesterolemia is receiving Lipitor (atorvastatin) to prevent high cholesterol and stroke. The order is for Lipitor 40 mg PO daily. The medication is supplied in 80 mg tabs. How many tabs will the nurse administer to the client? Enter the correct number ONLY.

0.5 tabs

Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?

Apraxia pg. 1975

If warfarin is contraindicated as a treatment for stroke, which medication is the best option?

Aspirin pg. 1976

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to do perform which action?

Form words that are understandable or comprehend the spoken word pg. 1974

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?

Frequent neurologic checks pg.

When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?

Increased intracranial pressure (ICP) pg. 1943

A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?

Increased urine output pg. 1990

A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication?

Lamictal pg. 1963

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?

Left visual field deficit pg. 1975

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings?

Left-sided cerebrovascular accident (CVA) pg.

Which of the following is accurate regarding a hemorrhagic stroke?

Main presenting symptom is an "exploding headache." pg. 1973

The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important?

Maintaining a patent airway pg. 1989

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Maintaining a safe environment pg. 2067

A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome?

Maintains a patent airway pg. 1947

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?

Maintenance of a patent airway pg. 1938

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?

Mannitol(Osmitrol) pg. 2000

A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following?

Monro-Kellie pg. 1942

A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator?

More than 200 ml/hr pg. 1951

The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the

Place patient in supine position with head slightly elevated. pg. 1955

A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke?

Severe headache pg. 1989

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?

She is taking coumadin. pg. 1977

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?

Shivering pg. 1947

After a seizure, the nurse should place the patient in which of the following positions to prevent complications?

Side-lying, to facilitate drainage of oral secretions pg. 1960

Because of the pain in her facial muscles and jaws a young female client with Bell's palsy is upset because she is unable to communicate properly. What advice can be given to the client to improve her speech?

Speak slowly and in short sentences.

A client with a neurological disorder has difficulty swallowing. The nurse should take special care with the client's diet because of a potential risk of imbalanced nutrition. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing?

Help the client sit upright when eating and feed slowly pg. 1984

The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring?

Increased ICP pg. 1956

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 nursing diagnoses would be the first priority for the plan of care?

Ineffective airway clearance related to altered LOC pg. 1859

To meet the sensory needs of a client with viral meningitis, the nurse should:

minimize exposure to bright lights and noise. pg. 2027