AH Final PrepU
A family member brings the client to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurse's best answer? "Have your heart checked regularly." "Stop smoking as soon as possible." "Get medication to bring down your sodium levels." "Eat a nutritious diet."
"Stop smoking as soon as possible."
The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps: 1. Change in pH occurs 2. Blood flow decreases 3. A switch to anaerobic respiration occurs 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated Which of the following options is the correct order in which the ischemic cascade steps occur?
2, 3, 6, 1, 4, 5
A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time? 2:00 p.m. 3:00 p.m. 4:00 p.m. 7:00 p.m.
4:00 p.m Explanation: Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset. Therefore, since symptom onset was 1:00 pm, the window of opportunity ends at 4:00 pm.
The nurse is caring for a client in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is the normal range of intracranial pressure (ICP) for the client? 5 to 15 mm Hg 10 to 20 mm Hg 15 to 25 mm Hg 20 to 30 mm Hg
5 to 15 mm Hg
A preceptor discussing stroke with a new nurse on the unit would tell the new nurse that which cardiac dysrhythmia is associated with cardiogenic embolic strokes? Ventricular tachycardia Atrial fibrillation Supraventricular tachycardia Bundle branch block
A preceptor discussing stroke with a new nurse on the unit would tell the new nurse that which cardiac dysrhythmia is associated with cardiogenic embolic strokes? Atrial fibrillation
A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school? Generalized seizure Absence seizure Focal seizure Unclassified seizure
Absence seizure
A client is recovering from intracranial surgery performed approximately 24 hours ago and is reporting a headache that the client rates at 8 on a 10-point pain scale. What nursing action is most appropriate? Administer morphine sulfate as prescribed. Reposition the client in a prone position. Apply a hot pack to the client's scalp. Implement distraction techniques.
Administer morphine sulfate as prescribed
A clinic nurse is caring for a client diagnosed with migraine headaches. During the client teaching session, the client questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the client about the effects of alcohol? Alcohol causes hormone fluctuations. Alcohol causes vasodilation of the blood vessels. Alcohol has an excitatory effect on the CNS. Alcohol diminishes endorphins in the brain.
Alcohol causes vasodilation of the blood vessels.
Which is a late sign of increased intracranial pressure (ICP)? Irritability Slow speech Altered respiratory patterns Headache
Altered respiratory patterns
The ED nurse is receiving a client handoff report at the beginning of the nursing shift. The departing nurse notes that the client with a head injury shows Battle sign. The incoming nurse expects which to observe clinical manifestation? A bloodstain surrounded by a yellowish stain on the head dressing An area of bruising over the mastoid bone Escape of cerebrospinal fluid from the client's ear Escape of cerebrospinal fluid from the client's nose
An area of bruising over the mastoid bone
A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as? An epidural hematoma An extradural hematoma An intracerebral hematoma A subdural hematoma
An intracerebral hematoma
The nurse is taking care of a client with a headache. The nurse can take which measure to assist the client in reducing the pain associated with the headache? Apply warm or cool cloths to the forehead or back of the neck. Encouraging the client to participate in stimulating activities. Administer prescribed medications when pain intensifies. Use pressure-relieving pads or a similar type of mattress.
Apply warm or cool cloths to the forehead or back of the neck
A client diagnosed with Bell palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions? Applying a protective eye shield at night Chewing on the affected side to prevent unilateral neglect Avoiding the use of analgesics whenever possible Avoiding brushing the teeth
Applying a protective eye shield at night
The nurse is caring for a patient with GBS in the intensive care unit and is assessing the patient for autonomic dysfunction. What interventions should be provided in order to determine the presence of autonomic dysfunction? Assess the respiratory rate and oxygen saturation. Assess the blood pressure and heart rate. Assess the peripheral pulses. Listen to the bowel sounds.
Assess the blood pressure and heart rate. Explanation: The nurse assesses the blood pressure and heart rate frequently to identify autonomic dysfunction so that interventions can be initiated quickly if needed.
Which nursing intervention is the priority for a client in myasthenic crisis? Assessing respiratory effort Administering intravenous immunoglobin (IVIG) per orders Preparing for plasmapheresis Ensuring adequate nutritional support
Assessing respiratory effort
A client who is diagnosed with meningitis has a history of seizure activity. Which action(s) should the nurse implement to decrease the client's risk for injury during seizure activity? Select all that apply. Assist the client to the floor. Move objects away from the client. Inspect the client's oral cavity and teeth. Loosen clothing around the client's neck. Physically restrain the client's movements.
Assist the client to the floor. Move objects away from the client. Loosen clothing around the client's neck.
A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect? Autonomic dysreflexia Thrombophlebitis Orthostatic hypotension Spinal shock
Autonomic dysreflexia
A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture? Simple Comminuted Depressed Basilar
Basilar
Which of the following types of skull fractures may be evident by Battle's sign? Basilar Simple Comminuted Depressed
Basilar
A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication? Acute pain Septicemia Bleeding Seizures
Bleeding
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 Hypertension Tachycardia Pupillary constriction
Bradycardia Bradypnea Hypertension
A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client? Respiratory distress and projectile vomiting Bradycardia and hypertension Tachycardia and agitation Third-spacing and hyperthermia
Bradycardia and hypertension
The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for? Hypophysectomy Application of Halo traction Burr holes Insertion of Crutchfield tongs
Burr holes
A client with a spinal cord injury has full head and neck control when the injury is at which level? C1 C2 to C3 C4 C5
C5
A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? Sit with the client for a few minutes. Administer an analgesic. Inform the nurse manager. Call the physician immediately.
Call the physician immediately
A patient who just suffered a hemorrhagic stroke is brought to the emergency department by ambulance. What should be the nurse's primary assessment focus? Cardiac and respiratory status Seizure activity Urinary output Fluid and electrolyte balance
Cardiac and respiratory status
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? Large artery thrombosis Cerebral aneurysm Cardiogenic emboli Small artery thrombosis
Cerebral aneurysm
When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? Check the equipment. Contact the physician to review the care plan. Continue the assessment because no actions are indicated at this time. Document the reading because it reflects that the treatment has been effective.
Check the equipment
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. Epistaxis (nosebleed) Confusion Sudden numbness Sudden ear pain Visual disturbances
Confusion Sudden numbness Visual disturbances
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 Loss of gag reflex and mental confusion Complaints of headache and lack of pupillary response Mental confusion and pupillary changes
Decerebrate posturing and loss of corneal reflex
A nursing student is writing a care plan for a newly admitted client who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the client's plan of care? Adult failure to thrive Post-trauma syndrome Hyperthermia Disturbed sensory perception
Disturbed sensory perception
The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began? Shortness of breath Sensitivity to bright light Muscle spasms Drooping eyelids
Drooping eyelids
The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign? Ecchymosis over the mastoid Bruising under the eyes Drainage of cerebrospinal fluid from the nose Drainage of cerebrospinal fluid from the ears
Ecchymosis over the mastoid
Which nursing intervention is most helpful when addressing the priority nursing diagnosis of Impaired Physical Mobility related to damage of brain tissue as evidenced by visual deficits and absence of portions of the visual field? Place patient in a room near the nursing station. Announce yourself when approaching the client. Ensure a clutter-free walkway. Instruct on adaptive plates with rims.
Ensure a clutter-free walkway.
A nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which goal is appropriate? Establishing an intermittent catheterization routine every 4 hours Managing spasticity with range-of-motion exercises and medications Establishing an ambulation program using short leg braces Preventing autonomic dysreflexia by preventing bowel impaction
Establishing an intermittent catheterization routine every 4 hours
A client is brought by ambulance to the ED after experiencing what the family thinks is a stroke. The nurse caring for this client is aware that which is an absolute contraindication for thrombolytic therapy? Evidence of hemorrhagic stroke Blood pressure of ≥ 180/110 mm Hg Evidence of stroke evolution Previous thrombolytic therapy within the past 12 months
Evidence of hemorrhagic stroke
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 Occipital Parietal Temporal
Frontal
When preparing to discharge a client home, the nurse has met with the family and warned them that the client may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? Frustration around changes in function and communication Unmet physiologic needs Changes in brain activity during sleep and wakefulness Temporary changes in metabolism
Frustration around changes in function and communication
A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? Unclassified seizure Absence seizure Generalized seizure Focal seizure
Generalized seizure
A client is demonstrating an altered level of consciousness from a traumatic brain injury. Which assessment will the nurse use as a sensitive indicator of neurologic function? Cerebellar function Glasgow Coma Scale Cranial nerve function Mental status evaluation
Glasgow Coma Scale
Which is the most common motor dysfunction seen in clients diagnosed with stroke? Ataxia Diplopia Hemiplegia Hemiparesis
Hemiplegia
A client diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the client and family needs to begin as soon as the client is settled on the unit and will continue until the client is discharged. What will family education need to include? How to differentiate between hemorrhagic and ischemic stroke Risk factors for ischemic stroke How to correctly modify the home environment Techniques for adjusting the client's medication dosages at home
How to correctly modify the home environment
The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is: Obesity Dyslipidemia Smoking Hypertension
Hypertension
A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms? impaired cerebral circulation cardiac disease diabetes insipidus hypertension
Impaired cerebral circulation
A nurse is providing care to a client who has had a stroke. Which symptoms are consistent with left-sided stroke? expressive aphasia, defects in the right visual fields, problems with abstract thinking impulsive behavior, poor judgment, deficits in left visual fields problems with abstract thinking, impairment of short-term memory, poor judgment cautious behavior, deficits in left visual fields, misjudgment of distances
Impulsive behavior, poor judgment, deficits in left visual fields
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 Exacerbation of uncontrolled hypertension Infection Increase in cerebral perfusion pressure
Increased ICP
A fall during a rock climbing expedition this morning has caused a 28-year-old woman to develop an epidural hematoma. Immediate treatment is being organized by the emergency department team because this woman faces a risk of serious neurological damage as a result of: Decreased intravascular volume Increased intracranial pressure (ICP) Ischemic cerebrovascular accident (CVA) Brain tissue necrosis
Increased intracranial pressure (ICP)
The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate action? Inform the care team and assess for further signs of possible increased ICP. Administer bronchodilators as prescribed and monitor the client's LOC. Increase the client's bed height and reassess in 30 minutes. Administer a bolus of normal saline as prescribed.
Inform the care team and assess for further signs of possible increased ICP
A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? Positioning the client to prevent airway obstruction Keeping the client in one position to decrease bleeding Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess Maintaining the client in a quiet environment
Keeping the client in one position to decrease bleeding Explanation: The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of re-bleeding.
What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke? Left visual field deficit Aphasia Slow, cautious behavior Altered intellectual ability
Left visual field deficit
The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? Select all that apply. Loosening constrictive clothing Opening the patient's jaw and inserting a mouth gag Positioning the patient on his or her side with head flexed forward Providing for privacy Restraining the patient to avoid self injury
Loosening constrictive clothing Positioning the patient on his or her side with head flexed forward Providing for privacy
The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment? Computed tomography (CT) scan Lumbar puncture Magnetic resonance imaging (MRI) Venous Doppler studies
Lumbar puncture
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? Positioning to prevent complications Maintenance of a patent airway Assessment of pupillary light reflexes Determination of the cause
Maintenance of a patent airway
A client with increased intracranial pressure (ICP) has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? Encephalitis Cerebral spinal fluid leak Meningitis Catheter occlusion
Meningitis
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? Administering zolpidem tartrate (Ambien) Assessing laboratory test results as ordered Placing the client in Trendelenburg's position Monitoring the patency of an indwelling urinary catheter
Monitoring the patency of an indwelling urinary catheter
Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord? Parkinson disease Huntington disease Creutzfeldt-Jakob disease Multiple sclerosis
Multiple sclerosis
During a client's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help clients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply. National Institutes of Health Stroke Scale (NIHSS) score Race LOC at time of admission Gender Age
National Institutes of Health Stroke Scale (NIHSS) score LOC at time of admission Age
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? 12-lead electrocardiogram Carotid ultrasound study Noncontrast computed tomogram Transcranial Doppler flow study
Noncontrast computed tomogram
The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of "ineffective cerebral tissue perfusion." What would be an expected outcome that the nurse would document for this diagnosis? Copes with sensory deprivation. Registers normal body temperature. Pays attention to grooming. Obeys commands with appropriate motor responses.
Obeys commands with appropriate motor responses Explanation: An expected outcome of the diagnosis of ineffective cerebral tissue perfusion in a patient with increased intracranial pressure (ICP) would include obeying commands with appropriate motor responses. Vitals signs and neurologic status are assessed every 15 minutes to every hour. Coping with sensory deprivation would relate to the nursing diagnosis of "disturbed sensory perception." The outcome of "registers normal body temperature" relates to the diagnosis of "potential for ineffective thermoregulation." Body image disturbance would have a potential outcome of "pays attention to grooming."
A client with a spinal cord injury develops an excruciating headache and profuse diuresis. Which action will the nurse take first? Place in a seated position. Palpate the bladder for distention. Asses the skin for areas of pressure. Examine the rectum for a fecal mass.
Place in a seated position. Explanation: Autonomic dysreflexia, also known as autonomic hyperreflexia, is an acute life-threatening emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in people without spinal cord injury (SCI). It occurs only after spinal shock has resolved. This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis above the spinal level of the lesion (most often of the forehead), nausea, nasal congestion, and bradycardia. The first action to take is to place the client in a seated position to lower the blood pressure. Next, the bladder can be assessed for distention, the skin assessed for areas of pressure, and the rectum assessed for a fecal mass, which can all be the reasons for the onset of the symptoms.
A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety? Place the client in a side-lying position. Pad the client's bed rails. Administer antianxiety medications as ordered. Reassure the client and family members.
Place the client in a side-lying position
After having a stroke, a patient has cognitive deficits. What are the cognitive deficits the nurse recognizes the patient has as a result of the stroke? Select all that apply. Poor abstract reasoning Decreased attention span Short- and long-term memory loss Expressive aphasia Paresthesias
Poor abstract reasoning Decreased attention span Short- and long-term memory loss
Nursing care during the immediate recovery period from an ischemic stroke should normally prioritize which intervention? Positioning the client to avoid intercranial pressure (ICP) Maximizing partial pressure of carbon dioxide (PaCO2) Administering hypertonic intravenous (IV) solution Initiating early mobilization
Positioning the client to avoid intercranial pressure (ICP)
The ED is notified that a 6-year-old child is in transit with a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the primary goal of initial therapy? Promoting adequate circulation Treating the child's increased ICP Assessing secondary brain injury Preserving brain homeostasis
Preserving brain homeostasis
Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition? Examine the skin for any area of pressure or irritation. Examine the rectum for a fecal mass. Empty the bladder immediately. Raise the head of the bed and place the patient in a sitting position.
Raise the head of the bed and place the patient in a sitting position.
A client experiences a seizure while hospitalized for appendicitis. During the postictal phase, the client is yelling and swings a closed fist at the nurse. Which is the appropriate action by the nurse? Place the client in wrist restraints. Reorient the client while gently holding their arms. Administer lorazepam per orders. Apply oxygen via nasal cannula.
Reorient the client while gently holding their arms Explanation: Some clients during the postictal phase will become confused and agitated. This reaction is not intentional, and most clients do not later remember becoming agitated. The nurse should attempt to calm and reorient the client, while also gently holding the arms to prevent the client from hitting, thereby preventing the client from doing injury to self or others. The nurse should always use restraints as a last resort; therefore, the nurse should try to reorient the client before applying wrist restraints. Lorazepam is not indicated for postictal agitation. It may be administered to prevent future seizures. Oxygen is not indicated for this client.
A community health nurse is performing a home visit to a patient with amyotrophic lateral sclerosis (ALS). The nurse should prioritize assessments related to which of the following? Respiratory function Potential skin breakdown Cardiac function Cognition
Respiratory function
When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP? Rising blood pressure and bradycardia Hypotension and bradycardia Hypotension and tachycardia Hypertension and narrowing pulse pressure
Rising blood pressure and bradycardia
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? High-Fowler's Prone Supine Semi-Fowler's
Semi-Fowler's
A client with Parkinson disease is undergoing a swallowing assessment because the client has recently developed adventitious lung sounds. The client's nutritional needs should be met by what method? Total parenteral nutrition (TPN) Provision of a low-residue diet Semisolid food with thick liquids Minced foods and a fluid restriction
Semisolid food with thick liquids
A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention? Capillary refill of 2 seconds Shivering Cool, dry skin Urine output of 100 mL/hr
Shivering Explanation: Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption. A capillary refill of 2 seconds, urine output of 100mL/hr, and cool, dry skin are expected findings.
Which is indicative of a right hemisphere stroke? Aphasia Spatial-perceptual deficits Slow, cautious behavior Altered intellectual ability
Spatial-perceptual deficits
Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? Epidural Subdural Intracerebral Cerebral
Subdural
Which condition occurs when blood collects between the dura mater and arachnoid membrane? Intracerebral hemorrhage Epidural hematoma Extradural hematoma Subdural hematoma
Subdural hematoma
Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? T6 S2 L4 T10
T6
The nurse is preparing discharge teaching for a patient who is being discharged after hospitalization for a hemorrhagic stroke. What should be included in the discharge teaching for this patient? Intermittent seizures can be expected. Take ibuprofen for complaints of a serious headache. Take antihypertensive medication as ordered. Drowsiness is normal for the first week after discharge.
Take antihypertensive medication as ordered
The nurse is providing care for a client who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the client has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following? The ability of the client to follow instructions during the seizure. The success or failure of the care team to physically restrain the client. The client's ability to explain his seizure during the postictal period. The client's activities immediately prior to the seizure.
The client's activities immediately prior to the seizure
When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? The day before the patient is discharged After the patient has passed the acute phase of the stroke After the nurse has received the discharge orders The day the patient has the stroke
The day the patient has the stroke
A woman has been brought to the emergency department (ED) by her distraught husband who believes that she has had a stroke. A rapid assessment by the care team confirms that the husband's suspicions are likely accurate, and the woman is being screened for the possible administration of recombinant tissue plasminogen activator (r tPA). Which of the following factors would contraindicate the use of tPA? The woman's stroke has a hemorrhagic etiology. The woman is older than 80 years of age. The woman has previously had a stroke. The woman has hypertension and type 1 diabetes.
The woman's stroke has a hemorrhagic etiology
An osmotic diuretic, such as mannitol, is given to the patient with increased intracranial pressure (ICP) for which of the following actions? To dehydrate the brain and reduce cerebral edema To control fever To control shivering To reduce cellular metabolic demands
To dehydrate the brain and reduce cerebral edema
A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy (CEA). The nurse explains that this procedure will be done for what purpose? To decrease cerebral edema To prevent seizure activity that is common following a TIA To remove atherosclerotic plaques blocking cerebral flow To determine the cause of the TIA
To remove atherosclerotic plaques blocking cerebral flow
A 70-year-old woman is being treated at home for Parkinson's disease (PD), a health problem that she was diagnosed with 18 months ago. The nurse who is participating in the woman's care should be aware that her initial symptoms most likely consisted of: Increasing forgetfulness and confusion Tremors and muscle rigidity Visual disturbances and muscle weakness Fatigue and respiratory difficulties
Tremors and muscle rigidity
A client with meningitis has a history of seizures. Which activity should the nurse do while the client is actively seizing? Place a cooling blanket beneath the client Provide oxygen or anticonvulsants, whichever is available Turn the client to the side during a seizure and do not restrain movements Suction the client's mouth and pharynx
Turn the client to the side during a seizure and do not restrain movements
A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant? Warm, dry skin Urine output of 40 ml/hour Soft, nondistended abdomen Uneven, labored respirations
Uneven, labored respirations
The nurse is caring for a client diagnosed with Parkinson disease. The client is having increasing problems with rising from the sitting to the standing position. What should the nurse suggest to the client to use that will aid in getting from the sitting to the standing position as well as aid in improving bowel elimination? Use of a bedpan Use of a raised toilet seat Sitting quietly on the toilet every 2 hours Following the outlined bowel program
Use of a raised toilet seat
A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms? Mannitol Furosemide (Lasix) Vasopressin Phenobarbital
Vasopressin
A client who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following? Preparation for emergency craniotomy Watchful waiting and close monitoring Administration of inotropic drugs Fluid resuscitation
Watchful waiting and close monitoring
A patient is diagnosed with amyotrophic lateral sclerosis, also known as ALS or Lou Gehrig's disease. The nurse understands that the symptoms of the disease will begin in what way? Ascending paralysis Numbness and tingling in the lower extremities Weakness starting in the muscles supplied by the cranial nerves Jerky, uncontrolled movements in the extremities
Weakness starting in the muscles supplied by the cranial nerves
Which of the following findings in the patient who has sustained a head injury indicate increasing intracranial pressure (ICP)? Increased pulse Decreased respirations Widened pulse pressure Decreased body temperature
Widened pulse pressure
A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified? acute chronic subacute intracerebral
acute
A client had a long and successful ice hockey career but has been forced to retire due to symptoms of depression, memory loss, and difficulty with gait and balance. The neurologist believes the most likely cause of these symptoms is: chronic traumatic encephalopathy. concussion. contusion. cerebral hematoma.
chronic traumatic encephalopathy
A client receives a diagnosis of concussion. While speaking with the client, the nurse learns that this is the client's third head injury. This information is of particular significance because it puts the client at risk for: chronic traumatic encephalopathy. a blood clot. ALS. stroke.
chronic traumatic encephalopathy
While snowboarding, a client fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be? concussion laceration contusion skull fracture
concussion
What is one of the earliest signs of increased ICP? decreased level of consciousness (LOC) headache Cushing triad coma
decreased level of consciousness (LOC)
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: pupillary changes. diminished responsiveness. decreasing blood pressure. elevated temperature.
diminished responsiveness
The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur? Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes. After administration of the medication, there will be no change in the status of the ptosis or facial weakness. The patient will have recovery of symptoms for at least 24 hours after the administration of the Tensilon. Eight hours after administration, the acetylcholinesterase begins to regenerate the available acetylcholine and will relieve symptoms.
hirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes
Medical management of a client with a cerebral aneurysm does not include: thrombolytic therapy. anticonvulsants. barbiturates. corticosteroids.
thrombolytic therapy
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 equal response rapid response constricted response
unequal response
A client suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure? vasodilation vasoconstriction hypertension increased PaO
vasodilation
A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client reports a headache. reports generalized weakness. sleeps for short periods of time. vomits.
vomits
