Cerebrovascular 2800 PrepU
A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. This CPP reading is considered high. low. within normal limits. inaccurate.
2... 70-100 is normal range
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
4... HTN is most important risk factor for stroke...
A client with epilepsy is having a seizure. What intervention should the nurse do after the seizure? Keep the client on one side. Place a cooling blanket beneath the client. Help the client sit up. Pry the client's mouth open to allow a patent airway.
1..,. The nurse will need to keep the client on one side to prevent aspiration. Make sure the airway is patent. On awakening, reorient the client to the environment. If the client is confused or wandering, guide the client gently to a bed or chair. If the client becomes agitated after a seizure (postictal), stay a distance away, but close enough to prevent injury until the client is fully aware. The client does not need a cooling blanket after a seizure. The client's temperature should not be elevated from the seizure. The nurse should not pry the client's mouth open after a seizure so that the airway remains open. Reference:
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)? Every 15 minutes Every 30 minutes Every 45 minutes Every hour
1... Neurological assessment and vital signs (except temperature) should be taken every 15 minutes initially while the patient is receiving tPA infusion.
Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? Intracranial hemorrhage Ischemic stroke Age 18 years or older Systolic blood pressure less than or equal to 185 mm Hg
1... Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA. Clinical diagnosis of ischemic stroke, age 18 years or older, and a systolic blood pressure less than or equal to 185 mm Hg are eligibility criteria.
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? 2:30 p.m. 3:00 p.m. 4:00 p.m. 5:30 p.m.
3... There is a three hour time window for tPA so the time would be by 4pm
The nursing instructor is discussing disorders of the hematopoietic system with the pre-nursing pathophysiology class. What disease would the instructor list with a primary characteristic of erythrocytosis? Polycythemia vera Sickle cell disease Aplastic anemia Pernicious anemia
4... Polycythemia vera is associated with a rapid proliferation of blood cells produced by the bone marrow. In sickle cell disease, HbS causes RBCs to assume a sickled shape under hypoxic conditions. Aplastic anemia has a deficiency of erythrocytes. The other options do not have the characteristics of erythrocytosis.
A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? Elevate the head of the bed. Complete a head-to-toe assessment. Administer morning dose of anticonvulsant. Administer Percocet as ordered.
1... The first action would be to elevate the head of the bed to promote venous drainage of blood and cerebral spinal fluid (CSF). Then, a neurological assessment would be completed to determine if any other assessment findings are significant of increasing intracranial pressure (ICP). The administering of routine ordered drugs is not a priority, and narcotic analgesics would be avoided in clients with ICP issues.
A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is: 170 mm Hg/105 mm Hg 175 mm Hg/100 mm Hg 185 mm Hg/110 mm Hg 190 mm Hg/120 mm Hg
4... Elevated blood pressure (systolic >185; diastolic >110 mm Hg) is a contraindication to tPA.
Which term refers to the failure to recognize familiar objects perceived by the senses? Agnosia Agraphia Apraxia Perseveration
1... Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to disturbances in writing intelligible words. Apraxia refers to an inability to perform previously learned purposeful motor acts on a voluntary basis. Perseveration is the continued and automatic repetition of an activity, word, or phrase that is no longer appropriate.
The nurse is currently planning the care of a patient with multiple myeloma who is experiencing bone destruction. When reviewing the patient's most recent blood work, what value would the nurse pay particular attention to? Hypercalcemia Hyperproteinemia Elevated serum viscosity Elevated red blood cell (RBC) count
1.... Hypercalcemia may occur when bone destruction occurs due to the disease process. Elevated serum viscosity occurs because plasma cells excrete excess immunoglobulin. RBC count will be decreased. Hyperproteinemia would not be present.
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
2... A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache.
Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? Intracranial hemorrhage Ischemic stroke Age 18 years or older Systolic blood pressure less than or equal to 185 mm Hg
1... Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA. Clinical diagnosis of ischemic stroke, age 18 years or older, and a systolic blood pressure less than or equal to 185 mm Hg are eligibility criteria.
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? Transient ischemic attack (TIA) Left-sided cerebrovascular accident (CVA) Right-sided cerebrovascular accident (CVA) Completed Stroke
2... When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.
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. A ruptured intracranial aneurysm must quickly be repaired. Intracranial pressure is increased by a space-occupying bleed. A ruptured arteriovenous malformation will cause deficits until it is stopped.
1... Currently approved thrombolytic therapy for ischemic strokes has a treatment window of only 3 hours after the onset of symptoms. Urgency is needed on the part of the public for rapid entry into the medical system. The other three choices are related to hemorrhagic strokes.
The nurse is interacting with a family that has been caring for a client with cancer for several months. What are the best interventions to assist in relieving caregiver stress in this family? Select all that apply. Educate the family about medications and side effects. Allow family members to express feelings. Suggest support for household maintenance. Suggest the prescription of antianxiety medications. Suggest the family go to church more often.
1,2,3... Family members benefit from increased education on what to expect. Allowing family members to express their feelings has also been shown to relieve stress. Supporting the caregiver and family with help in household duties will also help the overburdened family. Antianxiety medications and church attendance have not been shown to reduce caregiver stress. Reference:
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? Left-sided stroke Right-sided stroke Cerebral aneurysm Transient ischemic attack
4... A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm.
Which term refers to an abnormal decrease in white blood cells, red blood cells, and platelets? Pancytopenia Anemia Leukopenia Thrombocytopenia
1... Pancytopenia may be congenital or acquired. Anemia refers to decreased red cell mass. Leukopenia refers to a less-than-normal amount of WBCs in circulation. Thrombocytopenia refers to a lower-than-normal platelet count.
A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. 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 prevent a stroke by removing atherosclerotic plaques blocking cerebral flow To determine the cause of the TIA
3... The main surgical procedure for select patients with TIAs is carotid endarterectomy, the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extra cranial arteries. An endarterectomy does not decrease cerebral edema, prevent seizure activity, or determine the cause of a TIA.
Which term will the nurse use when referring to blindness in the right or left half of the visual field in both eyes? Scotoma Diplopia Nystagmus Homonymous hemianopsia
4... 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 patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? Implement distraction techniques. Administer an analgesic. Inform the nurse-manager. Call the health care provider immediately.
4... The headache may be an indication that the aneurysm is leaking. The nurse should notify the health care provider immediately. The health care provider will decide whether administration of an analgesic is indicated. Informing the nurse-manager isn't necessary. Sitting with the patient is appropriate, once the health care provider has been notified of the change in the patient's condition.
The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? Select all that apply. 1. Facial edema in the morning 2. Weight loss of 20 lb (9 kg) in 1 month 3. Serum calcium level of 12 mg/dL (3.0 mmol/L) 4. Serum sodium level of 136 mg/dL (136 mmol/L) 5. Serum potassium level of 3.4 mg/dL (3.4 mmol/L) 6. Numbness and tingling of the lower extremities
1,3,6... Rationale: Oncological emergencies include sepsis, disseminated intravascular coagulation, syndrome of inappropriate antidiuretic hormone, spinal cord compression, hypercalcemia, superior vena cava syndrome, and tumor lysis syndrome. Blockage of blood flow to the venous system of the head resulting in facial edema is a sign of superior vena cava syndrome. A serum calcium level of 12 mg/dL (3.0 mmol/L) indicates hypercalcemia. Numbness and tingling of the lower extremities could be a sign of spinal cord compression. Mild hypokalemia and weight loss are not oncological emergencies. A sodium level of 136 mg/dL (136 mmol/L) is a normal level. Test-Taking Strategy: Note the subject, an oncological emergency. Recalling the signs and symptoms of oncological emergencies will help you identify the correct options. Also, recalling the normal calcium, potassium, and sodium levels will direct you to the correct options.
An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetelol. What factor poses a threat to the client for thrombolytic therapy? International normalized ratio greater than 2 Two hour time period of the stroke Taking digoxin Surgery 6 weeks ago
1... The client is at risk for further bleeding if the international normalized ratio is greater than 2. Thrombolytic therapy must be initiated 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 client who is being treated for AML has bruises on both legs. What is the nurse's mostappropriate action? Ask the client whether they have recently fallen. Evaluate the client's INR. Keep the client on bed rest. Evaluate the client's platelet count.
4... Complications of AML include bleeding. The risk of bleeding correlates with the level and duration of platelet deficiency. Major hemorrhages may develop when the platelet count drops to less than 10,000/mm3. The bleeding is usually unrelated to falling. Keeping the client on bed rest will not prevent bleeding when the client has a low platelet count. Assessment for other areas of bleeding is also a priority intervention.
The nurse is caring for a client diagnosed with a subarachnoid hemorrhage resulting from a leaking aneurysm. The client is awaiting surgery. Which nursing interventions would be appropriate for the nurse to implement? SELECT ALL THAT APPLY>>> Permit friends to visit often. Provide a dimly lit environment. Elevate the head of bed 30 degrees. Ambulate the client every hour. Administer docusate per order.
2, 3, 5.... Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in intracranial pressure (ICP), and prevent further bleeding. The patient is placed on immediate and absolute bed rest in a quiet, nonstressful environment, because activity, pain, and anxiety elevate blood pressure, which increases the risk for bleeding. Visitors, except for family, are restricted. Dim lighting is helpful because photophobia (visual intolerance of light) is common. The head of the bed is elevated 15 to 30 degrees to promote venous drainage and decrease ICP. No enemas are permitted, but stool softeners (Colace) and mild laxatives are prescribed. Both prevent constipation, which would cause an increase in ICP, as would enemas.
A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to: hold the client's arm still to keep him from hitting anything. carefully move the client to a flat surface and turn him on his side. allow the client to remain in the chair but move all objects out of his way. place an oral airway in the client's mouth to maintain an open airway.
2... When caring for a client experiencing a tonic-clonic seizure, the nurse should help the client to a flat non elevated surface and then position him on his side to ensure that he doesn't aspirate and to protect him from injury. These steps help reduce the risk of injury from falling or hitting surrounding objects and help establish an open airway. The client shouldn't be restrained during the seizure. Also, nothing should be placed in his mouth; anything in the mouth could impair ventilation and damage the inside of the mouth.
A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment? Limited attention span and forgetfulness Visual agnosia Lack of deep tendon reflexes Auditory agnosia
3... Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation. Damage to the lower motor neurons may cause decreased muscle tone, flaccid muscle paralysis, and a decrease in or loss of reflexes.
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. 1. The client is aphasic. 2. The client has weakness on the right side of the body. 3. The client has complete bilateral paralysis of the arms and legs. 4. The client has weakness on the right side of the face and tongue. 5. The client has lost the ability to move the right arm but is able to walk independently. 6. The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself without assistance
1,2,4...hemiparesis=weakness hemiplegia=paralysis Rationale: Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic, unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating. Test-Taking Strategy: Focus on the subject, right-sided hemiparesis. Recalling that hemiparesis indicates weakness on one side of the body and focusing on the subject will direct you to the correct option. Also, noting the word complete in the question will assist you in answering correctly.
As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement? 1. "I should avoid blowing my nose." 2. "I may need a platelet transfusion if my platelet count is too low." 3. "I'm going to take aspirin for my headache as soon as I get home." 4. "I will count the number of pads and tampons I use when menstruating."
3... Rationale: During the period of greatest bone marrow suppression (the nadir), the platelet count may be low, less than 20,000 cells mm3 (20.0 × 109/L). The correct option describes an incorrect statement by the client. Aspirin and nonsteroidal antiinflammatory drugs and products that contain aspirin should be avoided because of their antiplatelet activity. Options 1, 2, and 4 are correct statements by the client to prevent and monitor bleeding. Test-Taking Strategy: Note the strategic words, further teaching is needed. Recalling the effects of bone marrow suppression will direct you to the correct option.
The client was admitted to the Emergency Department after an accident with a chain saw. The client is exhibiting signs and symptoms of acute hypovolemic anemia from severe blood loss. What signs and symptoms would the nurse assess for? Malabsorption disorders Postural hypotension Fatigue Reduced urine output
4... Acute hypovolemic anemia from severe blood loss is evidenced by the signs and symptoms of hypovolemic shock, which include reduced urine output. The symptoms of chronic hypovolemic anemia include fatigue and postural hypotension. Clients with malabsorption disorders are at great risk of iron deficiency anemia.
When the nurse observes that the client has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the client's posture as normal. flaccid. decorticate. decerebrate.
4... Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The client has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing the client has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.