Chapter 45 Care of Critically Ill Patients with Neurologic Problems
The client is considering treatments for a malignant brain tumor. Which statement by the client indicates a need for further instruction by the nurse? "A combination of treatments might be necessary." "In a craniotomy, holes are cut in the skull to access the tumor." "Antibiotics will help minimize the size of the tumor." "The goal is to decrease tumor size and improve survival time."
"Antibiotics will help minimize the size of the tumor."
The daughter of the client who has had a stroke asks the nurse for additional resources. What is the nurse's best response? "Call hospice." "Check the Internet." "Go to the National Stroke Association website." "Please check with the charge nurse at the desk. He has all the information."
"Go to the National Stroke Association website."
The nurse is teaching the client and family about home care after a stroke. Which statement made by the client's spouse indicates a need for further teaching? "I should spend all my time with my husband in case I'm needed." "My husband may get depressed." "My husband must take his medicine every day to prevent another stroke." "The physical therapist will show us how to use the equipment so my husband can climb the stairs and get into and out of bed."
"I should spend all my time with my husband in case I'm needed."
The client is eating a soft diet while recovering from a stroke. The client reports food accumulating in the cheek of the affected side. What is the nurse's best response? "Next time you eat, try lifting your chin when you swallow." "Let's advance your diet to solid food." "Let's see if the dietitian can help." "Let's see if the speech-language pathologist can help."
"Let's see if the speech-language pathologist can help."
The nurse is teaching the spouse and the client who has had a brain attack about rehabilitation. Which statement by the spouse demonstrates understanding of the nurse's instruction? "My spouse will no longer need to take his blood pressure medication." "Rehabilitation and physical therapy are the same thing." "The home health nurse will help identify changes needed at home." "Frequent stimulation will help with the rehabilitation process."
"The home health nurse will help identify changes needed at home."
The client is being discharged home after surgery for brain cancer. Which statement by the client's spouse indicates an understanding of the nurse's discharge teaching? "I will have to quit my job to care of my spouse." "Life will be back to normal soon." "The case manager will provide home care." "We can find a support group through the local American Cancer Society."
"We can find a support group through the local American Cancer Society."
A patient displays signs of increased ICP, confusion, slurred speech, and unilateral weakness in the upper extremity. Which diagnostic test for this patient does the nurse question? a. Lumbar puncture (LP) b. Computed tomography (CT) c. Positron emission tomography (PET) d. Magnetic resonance imaging (MRI)
A
A patient has been diagnosed with subarachnoid hemorrhage. Which drug does the nurse anticipate will be ordered to control cerebral vasospasm? a. Nimodipine (Nimotop) b. Phenytoin (Dilantin) c. Dexamethasone (Decadron) d. Clopidogrel (Plavix)
A
A patient has sustained a major head injury and the nurse is assessing the patient's neurologic status every 2 hours. What early sign of increased ICP does the nurse monitor for? a. Change in the LOC b. Cheyne-Stokes respirations c. Severe hypertension with widened pulse pressure (Cushing's reflex) d. Dilated and nonreactive pupils
A
A patient is admitted for diagnostic testing for probably encapsulated brain abscess and risk for increased ICP. Which statement about diagnostic testing for this patient is true? a. WBCs may be normal, even if an infection is present b. Blood cultures are the only cultures likely to grow the causative organism c. MRI is useful late in the course of the disease to identify permanent lesions d. The first test performed is a lumbar puncture to determine if the cerebrospinal fluid is cloudy
A
A patient sustained a stroke that affected the right hemisphere of the brain. The patient has visual spatial deficits and deficits of proprioception. After assessing the safety of the patient's home, the home health nurse identifies which environmental feature that represents a potential safety problem for this patient? a. The handrail that borders the bathtub is on f the left-hand side. b. The patient's favorite chair faces the front door of the house. c. The patient's bedside table is on the right-hand side of the bed. d. Family has relocated the patient to a ground-floor bedroom.
A
A patient who had a craniotomy develops the postoperative complication of syndrome of inappropriate antidiuretic hormone(SIADH). The patient's sodium level is 126 mEq/L and the serum osmolality is decreased. In light of this development, which physician order does the nurse question? a. Encourage oral fluids b. Normal saline IV at 150Ml/hr c. Strict intake and output d. Daily weights
A
A patient with a right cerebral stroke may have safety issues related to which factor? a. Poor impulse control b. Alexia and agraphia c. Loss of language and analytical skills d. Slow and cautious behavior
A
The nurse has completed teaching a patient about carotid artery angioplasty with stenting (CAS). Which statement by the patient indicates understanding of the purpose of the procedure? a. "The stent opens the blockage enough to establish blood flow" b. "The stent occludes the abnormal artery to prevent bleeding." c. "The stent bypasses the blockage." d. "The stent catches any clot debris."
A
The nurse is caring for a patient admitted with the medical diagnosis of probably epidural hematoma and decreased level of consciousness. During the shift, the patient becomes lucid and is alert and talking. The family reports this is her baseline mental status. What is the nurse's next action? a. Stay with the patient and have the charge nurse alert the physician because this is an ominous sign for the patient. b. Document the patient's exact behaviors, compare to previous nursing entries, and continue the neurologic assessments every 2 hours. c. Point out to the family that the dangerous period has passed, but encourage them to leave so the patient does not become overly fatigued. d. Monitor the patient for the next 48 hours to 2 weeks because a subacute condition may be slowly developing.
A
The nurse is caring for a patient at risk for increased ICP. Which sign is most likely to be the first indication of increased ICP? a. Decline of level of consciousness b. Increase in systolic blood pressure c. Change in pupil size and response d. Abnormal posturing of extremities
A
The nurse is caring for a patient receiving medication therapy to prevent recurrence of stroke. Which medication is pharmacologically appropriate for this purpose? a. Enteric-coated aspirin (Ecotrin) b. Gabapentin (Neurontin) c. Recombinant tissue plasminogen activator (Retavase) d. Bevacizumab (Avastin)
A
The nurse is caring for a patient with a brain tumor. Which drug therapy does the nurse anticipate this patient will receive? a. Glucocorticosteroids for intracranial edema b. Nonsteroidal antiinflammatory drugs (NSAIDS) for pain c. Insulin for diabetes insipidus d. Ticlopidine hydrochloride (Ticlid) for platelet adhesiveness
A
The nurse is caring for an intubated patient with increased ICP. If the patient needs to be suctioned, which nursing action does the nurse take to avoid further aggravating the increased ICP? a. Manually hyperventilate with 100% oxygen before passing the catheter b. Maintain strict sterile technique when performing endotracheal suctioning c. Perform oral suctioning frequently, but do not perform endotracheal suctioning d. Obtain an order for an arterial blood gas before suctioning the patient
A
Which statement is true about respiratory problems in a patient with a major head injury? a. Atelectasis and pneumonia can be prevented by proper pulmonary hygiene b. Suctioning should be avoided because of the increase in ICP c. Neurologic pulmonary edema occurs frequently d. The patient should avoid breathing deeply because of increased ICP
A
Which statement is true for a patient with a basilar skull fracture? a. There is potential for hemorrhage caused by damage to the internal carotid artery. b. There is an increased risk for loss of functioning abilities such as toileting c. There is an increased risk for cytotoxic or cellular edema with loss of consciousness. d. There is potential for decorticate or decerebrate posturing with loss of motor function.
A
The nurse is talking to the family of a stroke patient about home care measures. Which topics does the nurse include in this discussion? (select all that apply) a. Need for caregivers to plan for routine respite care and protection of own health b. Evaluation for potential safety risks such as throw rugs or slippery floors c. Awareness of potential patient frustration associated with communication d. Avoidance of independent transfers by the patient because of safety issues e. Access to health resources such as publications from the American Heart Association f. Referral to hospice and encouragement of family discussion of advance directives.
Abce
The nurse is performing a neurologic assessment on a patient with a suspected stroke. In addition to the level of consciousness (LOC), what is assessed to evaluate cognitive changes that may be occurring? (Select all that apply.) a. Denial of illness b. Proprioceptive dysfunction c. Presence of flaccid paralysis d. Impairment of memory e. Decreased ability to concentrate
Abde
The nurse is preparing to discharge a patient with transient ischemic attacks. What treatment areas does the nurse include in discharge teaching? (Select all that apply.) a. Reduction of high blood pressure b. Drug teaching for aspirin or another antiplatelet drug c. Lifestyle changes such as increased sleep and rest d. Controlling diabetes e. Increased risk for stroke
Abde
A patient with increased ICP is to receive IV mannitol (Osmitrol). Which nursing actions are taken concerning this drug? (Select all that apply.) a. Draw up the drug through a filtered needle. b. Insert a Foley catheter for strict measurement of urine output. c. Monitor serum and urine osmolality on a weekly basis. d. Assess for acute renal failure, weakness, or edema. e. Administer mannitol through a filter in the IV tubing. f. Administer furosemide (Lasix) as an adjunctive therapy.
Abdef
Which patients are at increased risk for stroke? (Select all that apply.) a. 66-year-old man with diabetes mellitus b. 35-year-old healthy woman who uses oral contraceptives c. 47-year -old woman who exercises regularly d. 35-year-old man with history of multiple transient ischemic attacks e. 25-year-old woman with Bell's palsy f. 53-year-old man with chronic alcoholism
Abdf
A patient with a stroke is having some trouble swallowing. Which interventions does the nurse anticipate the speech-language pathologist to suggest after the swallowing evaluation is completed? (Select all that apply.) a. Position the patient upright while eating. b. Administer orange juice using a straw. c. Give small spoonfuls of soft foods such as custard. d. Add powdered thickeners to liquids. e. Provide liquid nutritional supplements between meals for added calories.
Acde
The nurse is performing discharge teaching for the family and patient who has had prolonged hospitalization and rehabilitation therapy for severe craniocerebral trauma after a motor-cycle accident. What elements of instruction does the nurse include? (select all that apply) a. Review seizure precautions b. Stimulate the patient with frequent changes in the environment c. Develop a routine of activities with consistency and structure. d. Attend follow-up appointments with therapists e. Encourage the family to seek respite care if needed. f. Encourage the patient to wear a helmet when riding
Acde
Which symptoms indicate that a patient's stroke has affected the right hemisphere? (select all that apply.) a. Loss of depth perception b. Aphasia c. Denies illness d. Cannot recognize faces e. Loss of hearing f. Depression
Acde
The nurse is performing discharge teaching for a patient who underwent a craniotomy for a brain tumor. What instruction does the nurse include? (select all that apply) a. Suggestions to make the environment safe, such as removing scatter rugs b. Reminder that seizures could occur frequently for the first couple of months c. Information about drugs such as dose, administration, and side affects d. Directions about how and when to contact emergency services or the physician e. Advice about which over-the-counter products are safe to use f. Referral to a resource such as the American Brain Tumor Association
Acdf
Which are common causes of acquired hypoxic-anoxic brain injury? (select all that apply) a. Cardiac arrest b. Kidney failure c. Asphyxiation from attempted suicide d. Brain attack (stroke) e. Drug overdose f. Severe asthma
Acef
The nurse is evaluating the collaborative care of the stroke client. What is the most important goal for this client? Achieving the highest level of functioning Increasing cerebral perfusion Preventing further injury Preventing respiratory distress
Achieving the highest level of functioning
The client hospitalized for hypertension presses the call light and reports "feeling funny." When the nurse gets to the room, the client is slurring words and has right-sided weakness. What does the nurse do next? Assesses airway, breathing, and circulation Calls the provider Performs a neurologic check Assists the client to a sitting position
Assesses airway, breathing, and circulation
A patient has been diagnosed with a large lesion of the parietal lobe and demonstrates loss of sensory function. Which nursing intervention is applicable for this patient? a. Play music for the patient for at least 30 minutes each day. b. Teach the patient to test the water temperature used for bathing c. Position the patient reclining in bed or in a chair for meals d. Use a picture of the patient's spouse and ask the patient to state the spouse's name.
B
A patient has sustained a traumatic brain injury. Which nursing intervention is best for this patient? a. Assess vital signs every 8 hours b. Position to avoid extreme flexion c. Increase fluid intake for the first 48 hours d. Administer glucocorticoids
B
A patient received rtPA for the treatment of ischemic stroke and the physician ordered an IV sodium heparin infusion. In relation to the drug therapy, what does the nurse monitor for? a. Elevated prothrombin level b. Bleeding gums or bruising c. Nausea and vomiting d. Elevated hematocrit or hemoglobin
B
A patient with an ischemic stroke is placed on a cardiac monitor. Which cardiac dysrhythmia places the patient at risk for emboli? a. Sinus bradycardia b. Atrial fibrillation c. Sinus tachycardia d. First-degree heart block
B
A priority problem for a patient who was admitted for a brain attack is the potential for aspiration. Which intervention is best to delegate to the UAP? a. Monitor the patient for and notify the charge nurse of any occurrence of coughing, choking, or difficulty breathing. b. Elevate the head of the bed as appropriate and slowly feed small spoonfuls of pudding, pausing between each spoonful. c. Assess the swallow reflex by placing the index finger and thumb on either side of the Adam's apple. d. Give the patient a class of water before feeding solid foods and have oral suction ready at the bedside.
B
A stroke patient is at risk for increased intracranial pressure (ICP) and is receiving oxygen 2 L via nasal cannula. The nurse is reviewing arterial blood gas (ABG) results. Which ABG value is of greatest concern for this patient? a. pH 7.32 b. Paco₂ of 60 mm Hg c. Pao₂ of 95 mm Hg d. HCO₃ of 28 mEq/L
B
In planning care for a patient with increased ICP, what does the nurse do to minimize ICP? a. Gives the bath, changes the linens, and does passive ROM exercises to hands/fingers then allows the patient to rest b. Gives the bath, allows the patient to rest, changes the linens, allows the patient to rest, and then performs passive ROM exercises to hands/fingers c. Defers the bath, changes the linens, and does passive ROM exercises to extremities until the danger of increased ICP as passed. d. Contacts the physician for specific orders about all activities related to the care of the patient that might cause increased ICP.
B
The nurse is giving a discharge instructions to the mother of a child who bumped her head on a table. Which statement by the mother indicates an understanding of instructions? a. "I should not let her fall asleep" b. She may have nausea or headache for the first 24 hours" c. "She should gently blow her nose and I'll observe for bleeding" d. "She can run and play as she usually does"
B
The nurse is providing education for a patient with a brain tumor. What educational elements does the nurse include? a. Instructions to avoid physical activity b. Instructions to avoid over-the-counter drugs c. Advice that seizures will occur in the immediate postoperative period d. Information about dietary changes to prevent recurrence of the tumor
B
The nurse notices that a patient seems to be having trouble swallowing. Which intervention does the nurse employ for this patient? a. Limit the diet to clear liquids given through a straw. b. Keep the patient on NPO status until swallowing is assessed. c. Monitor the patient's weight and compare to baseline. d. Sit with the patient while the patient eats and observe for swallowing difficulties.
B
The nurse observes that a patient who had surgery for a benign hemangioblastoma has bilateral periorbital edema and ecchymosis. Because the patient's care is based on the general principles of caring for the patient with a craniotomy, what is the nurse's first action? a. Immediately inform the surgeon b. Apply cold compresses c. Check the pupillary response d. Perform a full neurologic assessment
B
The patient with a traumatic brain injury is receiving mechanical ventilation. Why does the health care provider adjust ventilator settings to maintain a partial pressure of arterial carbon dioxide (Paco₂) at 35 to 28 mm Hg? a. Lower levels of arterial carbon dioxide are essential for gas exchange b. Carbon dioxide is a potent vasodilator that can cause increased ICP c. Carbon dioxide is a waste product that must be eliminated from the body d. Lower levels of arterial carbon dioxide facilitate brain oxygenation
B
The preferred administration time for recombinant tissue plasminogen activator (rtPA [Retavase]) is within how long of stroke symptom onset? a. 30 to 60 minutes b. 3 to 4.5 hours c. 6 to 8 hours d. 24 to 30 hours
B
The provider has prescribed barbiturate coma therapy for a patient with increased ICP. Which complication does the nurse monitor for? a. Decreased LOC b. Reduced gastric motility c. Decreased respiratory rate d. Reduced Glasgow coma scale score
B
What is most likely to be included in the history of a patient with a brain abscess? a. Family history of Huntington disease b. History of HIV/AIDS c. History of osteoarthritis d. Vaccination against influenza
B
Which statement about transient ischemic at- tack (TM) is accurate? a. TIAs do not cause permanent brain damage. b. TIA increases the risk of stroke. c. Symptoms of a TIA usually resolve in 10- 15 minutes. d. After a TIA, a patient is prescribed a beta blocker.
B
Which statement is true about gamma knife therapy for brain tumors? a. It is used for easily reached tumors b. It is noninvasive and has few complications c. It is administered under general anesthesia d. It replaces conventional radiation therapy
B
Which statement is true about motor changes in a patient who has had a stroke? a. Motor deficit is ipsilateral to the hemisphere affected. b. Motor deficit is contralateral to the hemisphere affected. c. Bowel and bladder function remain intact. d. Flaccid paralysis is not an expected finding and should be reported promptly.
B
Which type of hematoma occurs between the skull and the dura? a. Epidural hematoma b. Subdural hematoma c. Intracranial hemorrhage d. Contusion
B
Which interventions does the nurse use for a patient with a left hemisphere stroke? (Select all that apply.) a. Teach the patient to wash both sides of the face. b. Place pictures and familiar objects around the patient. c. Reorient the patient frequently. d. Repeat names of commonly used objects. e. Approach the patient from the unaffected side. f. Establish a structured routine for the patient
Bcdf
Which are key features of a brainstem tumor? (select all that apply) a. Vomiting unrelated to food intake b. Facial pain or weakness c. Nystagmus d. Headache e. Hearing loss f. Hoarseness
Bcef
The client is admitted with a brain abscess. Which diagnostic assessment intervention does the nurse question as nonspecific to the diagnosis? Bone scan Electroencephalogram (EEG) Throat culture Sinus x-rays
Bone scan
A male patient has sustained a stroke and the nurse is planning interventions to help him reestablish urinary continence. What action does the nurse take? a. Obtain an order for a Foley catheter. b. Offer the urinal to the patient every 6 hours. c. Check postvoid residual urine with a bladder ultrasound. d. Restrict fluid to 1500 mL/day.
C
A patient is admitted for a closed head injury from a fall down the stairs. The patient has no history of respiratory disease and no apparent respiratory distress. However, the physician orders oxygen 2 L via nasal cannula. What is the nurse's best action? a. Check the pulse oximetry and apply the oxygen if the saturation level drops below 90% b. Call the physician to discontinue the order because it is unnecessary c. Deliver the oxygen as ordered because hypoxemia may precipitate increased ICP d. Apply the nasal cannula as ordered and gradually wean the patient off the oxygen when the LOC improves
C
A patient is admitted to the critical care unit after a craniotomy to debulk a grade 3 astrocytoma. What is the priority patient problem? a. Risk for infection b. Risk for memory loss c. Risk for increased intracranial pressure d. Potential for organ ischemia
C
A patient is diagnosed with an ischemic stroke. The UAP reports that the patient's Vital signs are blood pressure 150/ 100 mm Hg, pulse 78 beats/ min, respiratory rate of 20/ min, and temperature of 98.7° F. The patient's blood pressure is normally around 120/80. What action does the nurse take first? a. Report the blood pressure immediately to the physician because there is a danger of rebleeding. b. Ask the nursing assistant to repeat the blood pressure measurement in the other extremity with a manual cuff. c. Check the physician's orders to see if the blood pressure is within the acceptable parameters. d. Nothing; an elevated blood pressure is necessary for cerebral perfusion.
C
A patient is scheduled for a craniotomy. What does the nurse tell the patient and family about the procedure? a. The head will not need to be shaved at the surgical site. b. There is a coma state for up to several days after surgery. c. Drainage of a small to moderate amount of cerebrospinal fluid after surgery is normal. d. The family will need to remind the patient of their names and relationships.
C
The nurse is assessing a patient who was struck in the head several times with a bat. There is clear fluid that appears to be leaking from the nose. What action does the nurse take? a. Hand the patient a tissue and ask him to gently blow the nose; observe the nasal discharge for blood clots. b. Immediately report the finding to the physician and document the observation in the nursing notes c. Place a drop of the fluid on a white absorbent background and look for a yellow halo d. Allow the patient to wipe his nose, but no other action is needed; he has most likely been crying
C
The nurse is caring for a patient at risk for an increased ICP related to ischemic stroke. For what purpose does the nurse place the patient's head in a midline neutral position? a. Provide comfort for the patient b. Protect the cervical spine c. Facilitate venous drainage from brain d. Decrease pressure from cerebrospinal fluid
C
The nurse is caring for a patient with a relatively minor head injury after a bump to the head. The nurse has the greatest concern about which symptom? a. Headache b. Nausea and vomiting c. Unequal pupils d. Dizziness
C
The nurse is caring for a patient with right hemisphere damage. The patient demonstrates disorientation to time and place, he has poor depth perception, and demonstrates neglect of the left visual field. Which task is best delegated to the unlicensed assistive personnel (UAP)? a. Move the patient's bed so that his affected side faces the door b. Teach the patient to wash both sides of his face c. Ensure a safe environment by removing clutter. d. Suggest to the family that they bring familiar family pictures
C
The nurse is conducting a presentation to a group of students on the prevention of head injuries. Which statement by a student indicates a need for additional teaching? a. "Drinking, driving, and speeding contribute to the risk for injury" b. "Males are more likely to sustain head injury compared to females." c. "Young people are less likely to get injured because of faster reflexes" d. "Following game rules and not goofing around can prevent injuries"
C
The nurse is taking a history on a teenager who was involved in a motor vehicle accident with friends. The patient has an obvious contusion of the forehead, seems confused, and is laughing loudly and yelling "Ruby! Ruby!" What is the best question for the nurse to ask the patient's friends? a. "Where and why did the accident occur?" b. How can we notify the family for consent for treatment?" c. "Was the patient using drugs or alcohol prior to the accident?" d. "Who is Ruby and why is the patient calling for her?"
C
The nurse is teaching a patient who will receive the disc shaped Gliadel wafer as part of the treatment for a brain tumor. Which statement by the patient indicates understanding of how the wafer works? a. "I'll place the wafer under my tongue and allow it to dissolve" b. "The wafer will be taped to my chest and the drug will be absorbed" c. "The wafer will be placed directly into the cavity during surgery" d. "The wafer is to be dissolved in water and taken with meals"
C
Which determination must be made first in assessing a patient with traumatic brain injury? a. Presence of spinal injury b. Whether the patient is hypotensive c. Presence of a patent airway d. Level of consciousness using the Glasgow coma scale
C
Which statement is true about a patient at risk for increased ICP? a. The appearance of abnormal posturing occurs only when the patient is not positioned for comfort. b. Cushing's reflex, an early sign of increased ICP, consists of severe hypertension, wideing pulse pressure, and bradycardia. c. Dilated or pinpoint pupils that are slow to react to light or nonreactive to light are signs of increased ICP. d. Areas of tenderness over the scalp indicate the presence of contrecoup injuries.
C
The client with a traumatic brain injury from a motor vehicle accident is monitored for signs of increased intracranial pressure (ICP). Which sign does the nurse monitor for? Changes in breathing pattern Dizziness Increasing level of consciousness Reactive pupils
Changes in breathing pattern
The client recovering from a stroke reports double vision that is preventing him from effectively completing activities of daily living. How does the nurse help the client compensate? Approaches the client on the affected side Covers the affected eye Encourages turning the head from side to side Places objects in the client's field of vision
Covers the affected eye
A patient has had an infratentorial craniotomy. Which position does the nurse use for this patient? a. High-Fowler's position, turned to the operative side b. Head of bed at 30 degrees, turned to the nonoperative side c. Flat in bed, turned to the operative side d. Flat in bed, may turn to either side.
D
A patient presents to the emergency department with signs and symptoms of an ischemic stroke. What is the priority factor when considering fibrinolytic therapy? a. Age older than 80 years b. History of stroke c. Recent surgery d. Time since onset of symptoms
D
Blood flow to the brain remains fairly constant as a result of which process? a. Autostasis b. Automobilization c. Hemodynamic stasis d. Autoregulation
D
Following a left hemisphere stroke, the patient has expressive (Broca's) aphasia. Which intervention is best to use when communicating with this patient? a. Repeat the names of objects on a routine basis. b. Face the patient and speak slowly and clearly. c. Obtain a whiteboard with an erasable marker. d. Develop a picture board that has objects and activities.
D
The nurse is assisting a patient who had a large brain tumor removed to get positioned in bed. Which recommended position does the nurse place the patient in? a. Operative side to protect the unaffected side of the brain b. Flat repositioned on either side to decrease tension on the incision c. Elevate the head of bed 30 degrees to promote venous drainage d. Reposition every 2 hours but do not turn the patient onto the operative side
D
The nurse is caring for a patient with an ischemic stroke. Which position is the patient placed in according to current nursing practice? a. Head of the bed is elevated 25 to 30 degrees b. Head of the bed is elevated to 45 degrees c. Supine with hips in flexed position d. The best head of bed position has not been determined
D
The nurse who is providing postoperative care for a patient who had a craniotomy immediately notifies the surgeon of which assessment finding? a. Drainage in the Jackson-Pratt container of 45 mL/8 hours b. Intracranial pressure of 15 mm Hg c. Pco₂ level of 35 mm Hg d. Serum sodium of 117 mEq/L
D
The stroke patient is prescribed docusate (Colace) once a day in the morning. What is the purpose of this drug specific to this patient? a. Laxative to prevent constipation b. Soften the patient's stool c. Increase fluid content of stool d. Prevent increased ICP
D
Which Glasgow coma scale (GCS) data set indicates the most severe injury and loss of consciousness? a. GCS of 13 with loss of consciousness of 15 minutes b. GCS of 9 with loss of consciousness of 30 minutes c. GCS of 12 with loss of consciousness of 3 hours d. GCS of 8 with loss of consciousness of 6.5 hours
D
Which description best defines a basilar skull fracture? a. A simple, clean break in the skull b. A direct opening to brain tissue c. Fragments of bone are in brain tissue d. Cerebrospinal fluid leaks from nose or ears
D
Which organism is commonly involved in opportunistic central nervous system infections for patients with AIDS? a. Streptococcus b. Enterobacter c. Haemophilus influenzae d. Toxoplasmosis
D
Which statement is true about increased ICP in a surgical patient? a. It is a minor postoperative complication b. Diuretics such as furosemide may be given to decrease it. c. Cerebral edema usually subsides within 72 hours d. If not contraindicated, the head of the bed should be placed at 30 degrees
D
The nurse is monitoring the client after supratentorial surgery. Which sign does the nurse report immediately to the provider? Periorbital edema Bilateral ecchymoses of both eyes Moderate amount of serosanguineous drainage on the head dressing Decorticate positioning
Decorticate positioning
Which are risk factors for stroke? Select all that apply. High blood pressure Previous stroke or transient ischemic attack (TIA) Smoking Use of oral contraceptives Female gender
High blood pressure Previous stroke or transient ischemic attack (TIA) Smoking Use of oral contraceptives
The client has had a traumatic brain injury and is comatose. Which technique does the nurse use to prevent increasing intracranial pressure (ICP)? Assessing for Turner's sign Maintaining PCO2 levels at 35 mm Hg Placing the client in the Trendelenburg position Suctioning the client frequently
Maintaining PCO2 levels at 35 mm Hg
The nurse is monitoring the postoperative craniotomy client with intracranial pressure (ICP). Which pharmacologic agent does the nurse expect to be requested to maintain the ICP within a specified range? Dexamethasone (Decadron) Hydrochlorothiazide (HydroDIURIL) Mannitol (Osmitrol) Phenytoin (Dilantin)
Mannitol (Osmitrol)
The client is admitted with a cerebrovascular incident. Which tool does the nurse use to facilitate a focused neurologic assessment of the client? Mini-Mental State Examination (MMSE; mini-mental status exam) Intracranial pressure monitor Reflex hammer National Institutes of Health Stroke Scale (NIHSS)
National Institutes of Health Stroke Scale (NIHSS)
The client is receiving sodium heparin 24 hours after receiving thrombolytic therapy for a stroke. Which emergency drug does the nurse ensure is on the floor? Narcan Protamine sulfate Vitamin K Physostigmine
Protamine sulfate
The nurse is assessing the client with a traumatic brain injury after a skateboarding accident. Which symptom is the nurse most concerned about? Amnesia Head laceration Pupil changes to one side Restlessness
Pupil changes to one side
The client has been admitted with a diagnosis of cerebrovascular incident. The nurse suspects that the client has had a right hemisphere stroke because the client exhibits which symptoms? Aphasia and cautiousness Impulsiveness and smiling Inability to discriminate words Quick anger and frustration
Quick anger and frustration
The client in the emergency department (ED) has slurred speech, confusion, and visual problems, and has been having intermittent episodes of worsening symptoms. The symptoms occur during the day with a gradual onset. The client also has a history of hypertension and atherosclerosis. What does the nurse suspect that the client is probably experiencing? Embolic stroke Hemorrhagic stroke Thrombotic stroke Transient ischemic attack
Thrombotic stroke