Exam 2: Cognition/Sensation & Mobility
The nurse is caring for a client with a right below-the-knee amputation. There is a large amount of bright red blood on the client's residual limb dressing. Which intervention should the nurse implement first? A Notify the client's surgeon immediately. B Assess the client's blood pressure and pulse. C Reinforce the dressing with additional dressing D Check the client's last hemoglobin and hematocrit level.
B
When caing for a patient who is using Buck's traction after a hip fracture, which action can the nurse delegate to unlicensed assistive personnel UAP? A) Monitor the skin under the traction boot for redness B) Ensure that the weight for the traction is off the floor C) Check for intact sensation and movement in the affected leg D) Offer reassurance that hip and leg pain are nomal after hip fracture
B
When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? A Apply an eye patch to the right eye B Place objects needed on the patient's left side C Place objects needed on the patient's right side D Teach the patient that the left visual deficit will resolve
B
Which information in a 60-year-old womans health history will alert the nurse to the need for a more focused assessment of the musculoskeletal system? A The patient experienced a sprained ankle at age 13. B The patients mother became much shorter with aging. C The patients father died of complications of miliary tuberculosis. D The patient reports taking ibuprofen (Advil) for occasional headaches.
B
Which statement by a patient who has had an above-the-knee amputation indicates that the nurses discharge teaching has been effective? A I should elevate my residual limb on a pillow 2 or 3 times a day. B I should lay on my abdomen for 30 minutes 3 or 4 times a day. C I should change the limb sock when it becomes soiled or stretched out. D I should use lotion on the stump to prevent drying and cracking of the skin.
B
for the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? a) speaking loudly and slowly b) using a pciture board for the client to point to pictures c) writing directions so the pt can read them d) speaking in short sentences
B
what is a priority nursing assessment in the first 24 hr after admission of the client with a thrombotic stroke? a) cholesterol level b) pupil size and pupillary response c) Bowel sounds d) ECG
B
A nurse is teaching a client who had a stroke about ways to adapt to a visual disability while ambulating. Which does the nurse identify as the primary safety precaution to use? A Wear a patch over one eye B Place personal items on the sighted side C Lie in bed with the unaffected side toward the door D Turn the head from side to side when walking
D
BP should be kept 180 for 24 hr for which type of stroke and why?
ischemic, to preserve remaining tissues
expressive aphasia
knows what they want to say but have trouble saying it
antihypertensive medication
labetalolol
The nurse will collaborate with the interdisciplinary team on communication assist with a client with expressive aphasia. The team decided on which intervention to help with communication?
make sure the client knows how to use a picture board
A nurse is caring for a client with a C5 spinal injury. Which action is most important for a client with injury to the C5 spinal cord?
monitor respiratory status
for hemorhagic stroke, burst blood vessle, vasospasm
nimodipine
A client is admitted following a thrombotic stroke. What priority assessment is most important for the nurse to perform in the first 24 hours?
pupil size and pupillary response
educate families about behavioral problems for pt with which side of stroke?
right side stroke
which kind of ischemic stroke is silent with no sudden onset symtoms
thrombotic
. After a spinal cord injuy, male fetility is affected causing poor spem quality and ejaculatoy dysfunction. T F
true
#1 s/s for hemorrhagic stroke
worse headache of their life
A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for A Surgical endarterectomy. B Transluminal angioplasty. C Intravenous heparin administration. D Tissue plasminogen activator (tPA) infusion.
D
A patient is admitted to the emergency department with possible left lower leg fractures. The initial action by the nurse should be to A elevate the left leg. B splint the lower leg. C obtain information about the tetanus immunization status. D check the popliteal, dorsalis pedis, and posterior tibial pulses.
D
A patient is receiving gentamicin (Garamycin) 80 mg IV twice daily for acute osteomyelitis. Which action should the nurse take before administering the gentamicin? A Ask the patient about any nausea. B Obtain the patients oral temperature. C Change the prescribed wet-to-dry dressing. D Review the patients blood urea nitrogen (BUN) and creatinine levels.
D
A patient with lower leg fracture has an external fixation device in place and is scheduled for discharge. Which information will the nurse include in the discharge teaching? A You will need to assess and clean the pin insertion sites daily. B The external fixator can be removed during the bath or shower. C You will need to remain on bed rest until bone healing is complete. D Prophylactic antibiotics are used until the external fixator is removed.
A
An assessment finding that alerts the nurse to the presence of osteoporosis in a middle-aged patient is A measurable loss of height. B the presence of bowed legs. C an aversion to dairy products. D statements about frequent falls
A
A 48-year-old patient with a fracture of the left femur has Buck's traction in place while waiting for surgey. To assess for pressure areas on the patient's back and sacral area and to provide skin care, the nurse should A) Have the patient lift the buttocks by bending and pushing with the ight leg. B) Loosen the traction and help the patient tun onto the unaffected side. C) Place a pillow between the patient's legs and tun gently to each side. D) Tun the patient patially to each side with the assistance of another nurse.
A
A patient is admitted to the emergency depatment with a possible cevical spinal cord injuy following an automobile crash. Duing the admission of the patient, the nurse places the highest pioity on A) maintaining a patent aiway B) assessing the patient for head and other injuies C) maintaining immobilization of the cevical spine D) assessing the patient's motor and sensoy function
A
A patient is hospitalized for initiation of regional antibiotic irrigation for acute osteomyelitis of the right femur. Which intervention will be included in the plan of care? A Immobilization of the right leg B Frequent weight-bearing exercise C Avoiding administration of nonsteroidal anti-inflammatory drugs (NSAIDs) D Support of the right leg in a flexed position
A
A patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures complains of constant severe pain in the leg, which is unrelieved by the prescribed morphine. Pulses are faintly palpable and the foot is cool. Which action should the nurse take next? A Notify the health care provider. B Assess the incision for redness. C Reposition the left leg on pillows. D Check the patients blood pressure.
A
Which modifiable risk factor for stroke would be most important for the nurse to include when planning a community education program? A Hypertension B Hyperlipidemia C Alcohol consumption D Oral contraceptive use
A
a newly admitted pt diagnosed with R sided brain stroke has a nursing diagnosis of disturbed visual sensory perceptin related to homonymous hemianopsia. Early in the care of the pt, what should the nurse do? a) place objects on the R side within the pt filed of vision b) approach the pt from the L side to encourge the pt to turn the head c) place objects on the pt L side to assess the pt o=ability to compensate d) patch the affected eye to encourage the pt to turn the head to scan the environment
A
a pt had a synovial fluid analysis what finding will be a concern for the nurse? a) couldy fluids b) scant thin fluid c) pale yellow fluid d) straw colored fluid
A
The nurse is teaching the family of a client with difficulty swallowing about decreasing the risk of aspiration while eating. Which of the following strategies should the nurse include in the teaching plan. (Select all that apply) A. Maintaining an upright position while eating B. Restricting the diet to liquids until swallowing improves C. Introducing foods on the unaffected side of the mouth D. Keeping distractions to a minimum E. Cutting food into large pieces of finger food
A, C, D
When communicating with a client who has aphasia, which of the following are helpful? Select all that apply. A Present one thought at a time B Avoid writing messages C Speak with normal volume D Make use of gestures E Encourage pointing to the needed object
A, C, D, E
A patient presents to the ED with a possible hip fracture. What clinical manifestations should the nurse be aware of? Select all that apply) A) Extenal rotation B) Intenal rotation C) Shotening of the affected leg D) Lengthening of the affected leg E) Muscle spasms F) Severe pain
A, C, E, F
A patient is being discharged after 2 weeks of IV antibiotic therapy for acute osteomyelitis in the left leg. Which information will be included in the discharge teaching? A How to apply warm packs safely to the leg to reduce pain B How to monitor and care for the long-term IV catheter site C The need for daily aerobic exercise to help maintain muscle strength D The reason for taking oral antibiotics for 7 to 10 days after discharge
B
A patient with a ight lower leg fracture will be discharged home with an extenal fixation device in place. Which infomation will the nurse teach? A "The extenal fixator can be removed for your bath or shower." B "You will need to check and clean the pin insetion sites daily." C "You will need to remain on bed rest until bone healing is complete." D "Prophylactic antibiotics are used until the extenal fixator is removed."
B
On the first postoperative day, a patient with a below-the-knee amputation complains of pain in the amputated limb. Which action is best for the nurse to take? A Explain the reasons for the phantom limb pain. B Administer prescribed analgesics to relieve the pain. C Loosen the compression bandage to decrease incisional pressure. D Remind the patient that this phantom pain will diminish over time.
B
One month after a spinal cord injuy, which finding is most impotant for you to monitor? A) Bladder scan indicates 100 mL. B) The left calf is 5 cm larger than the ight calf. C) The heel has a reddened, nonblanchable area. D) Reflux bowel emptying.
B
The client admitted with a diagnosis of a fractured hip who is in Buck's traction is complaining of severe pain. Which intervention should the nurse implement? A Adjust the patient-controlled analgesia (PCA) machine for a lower dose. B Ensure the weights of the Buck's traction are off the floor and hang freely. C Raise the head of the bed to 45 degrees and the foot to 15 degrees. D Turn the client on the affected leg using pillows to support the other leg.
B
The female client diagnosed with osteoporosis tells the nurse she is going to perform swim aerobics for 30 minutes every day. Which response is most appropriate by the nurse? 31 A Praise the client for committing to do this activity B Explain to the client walking 30 minutes a day is a better activity. C Encourage the client to swim every other day instead of daily D Discuss with the client how sedentary activities help prevent osteoporosis.
B
The nurse instructs the client with a right BKA to lie on the stomach for at least 30 minutes a day. The client asks the nurse, "Why do I need to lie on my stomach?" Which statement is the most appropriate statement by the nurse? A "This position will help your lungs expand better." B "Lying on your stomach will help prevent contractures." C "Many times this will help decrease pain in the limb." D "The position will take pressure off your backside."
B
A patient has a stroke affecting the ight hemisphere of the brain. Based on knowledge of the effects of ight brain damage, the nurse establishes a nursing diagnosis of: A) impaired physical mobility related to ight hemiplegia. B) risk for injuy related to denial of deficits and impulsiveness. C) impaired verbal communication related to speech-language deficits. D) ineffective coping related to depression and distress about disability.
B Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.
After being hospitalized for 3 days with a ight femur fracture, a 32-year-old patient suddenly develops shotness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? A) Stay with the patient and offer reassurance B) Administer the prescibed PRN oxygen at 4 L/min C) Check the patient's legs for swelling or tendeness. D) Notify the health care provider about the symptoms.
B The patient's clinical manifestations and history are consistent with a pulmonary embolus, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic need for oxygen is a higher priority. The health care provider should be notified after the oxygen is started and pulse oximetry and assessment for fat embolus or venous thromboembolism (VTE) are obtained.
Several weeks after a stroke, a patient has uinay incontinence resulting from an impaired awareness of bladder fullness. For an effective bladder training program, which nursing intevention will be best to include in the plan of care? A) Limit fluid intake to 1200 mL daily to reduce uine volume. B) Assist the patient onto the bedside commode evey 2 hours. C) Pefom intermittent catheterization after each voiding to check for residual uine. D) Use an extenal condom catheter to protect the skin and prevent embarassment.
B a. Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200 mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown.
A patient is being discharged after 2 weeks of IV antibiotic therapy for acute osteomyelitis in the left leg. Which infomation will be included in the discharge teaching? A ) How to apply wam packs safely to the leg to reduce pain B) How to monitor and care for the long-tem IV catheter site C) The need for daily aerobic exercise to help maintain muscle strength D) The reason for taking oral antibiotics for 7 to 10 days after discharge
B a. The patient will be on IV antibiotics for several months, and the patient will need to recognize signs of infection at the IV site and how to care for the catheter during daily activities such as bathing. IV antibiotics rather than oral antibiotics are used for acute osteomyelitis. Patients are instructed to avoid exercise and heat application because these will increase swelling and the risk for spreading infection.
The nurse is teaching a client about taking prophylactic warfarin sodium (Coumadin). Which statement indicates that the client understands how to take the drug? Select all that apply. A) "The drug's action peaks in 2 hours" B) "Maximum dosage is not achieved until 3 to 4 days after starting the medication" C) "Effects of the drug continue for 4 to 5 days after discontinuing the medication" D) "Protamine sulfate is the antidote for warfarin" E "I should have my blood levels tested periodically"
B, C, E
A patient is admitted to the emergency department (ED) with SCI at the level of T2. which finding is of most concern to the nurse?
BP 90/60
A patient with kyphosis is scheduled for dual-energy x-ray absorptiometry (DEXA) testing. The nurse will plan to A give an oral sedative. B start an intravenous line. C teach the patient about DEXA. D screen the patient for shellfish allergies.
C
Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin? A The patient has dysphasia. B The patient has atrial fibrillation. C The patient states, "My symptoms started with a terrible headache." D The patient has a history of brief episodes of right-sided hemiplegia.
C
Duing assessment of a patient with a spinal cord injuy, the nurse detemines that the patient has a poor cough with diaphragmatic breathing. Based on this finding, the nurses' first action should be to: a) nitiate frequent tuning and repositioning b) use tracheal suctioning to remove secretions C) assess lung sounds and respiratoy rate and depth D) prepare the patient for endotracheal intubation and mechanical ventilation
C
Following a motor vehicle accident, a patient arrives in the emergency department with massive right lower leg swelling. Which action will the nurse take first? A Elevate the leg on pillows. B Apply a compression bandage. C Check leg pulses and sensation. D Place ice packs on the lower leg.
C
The day after a having a left below-the-knee amputation, a patient complains of pain in the left foot. Which action is best for the nurse to take? a) explain the reasoining for the phantom limb pain B) loosen the compression bandage to decrease incisional pressure c) administer prescribed analgesics to relieve pain d) inform the pt that this phantom pain will diminish over time
C
When counseling an older patient about ways to prevent fractures, which information will the nurse include? A Tack down scatter rugs in the home. B Most falls happen outside the home. C Buy shoes that provide good support and are comfortable to wear. D Range-of-motion exercises should be taught by a physical therapist.
C
When the nurse is assessing a new patient in the clinic, which information about the patients medications will be of most concern? A The patient takes a daily multivitamin and calcium supplement. B The patient has migraine headaches that are treated with nonsteroidal anti-inflammatory drugs (NSAIDs). C The patient has severe asthma and requires frequent therapy with oral steroids. D The patient takes hormone replacement therapy (HRT) to prevent hot flashes.
C
Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? A Overestimation of physical abilities B Difficulty judging position and distance C Slow and possibly fearful performance of tasks D Impulsivity and impatience at performing tasks
C
Which statement by the patient indicates a good understanding of the nurse's teaching about a new shot-am plaster cast? A) "I can get the cast wet as long as I dy it ight away with a hair dyer." B) "I should avoid moving my fingers and elbow until the cast is removed." C) "I will apply an ice pack to the cast over the fracture site off and on for 24 hours." D) "I can use a cotton-tipped applicator to ub lotion on any dy areas under the cast."
C
during the first 24 hr after a thrombolytic tx from an ischemic stroke, the primary goal is to control the clients A) pulse b) RR c) BP d) temp
C
the nurse is conducting an assessment of a new pt to the floor. what assessment findings alerts the nurse to presence of osteoporosis? a) hx of previous fall b) presence of bowed legs c) a measurable loss of height d) an upright posture
C
The second day after admission with a fractured pelvis, a 64-year-old patient suddenly develops confusion. Which action should the nurse take first? a) take BP b) assess pt orientation c) check o2 sat d) observe for facial asymmetry
C The patient's history and clinical manifestations suggest a fat embolus. The most important assessment is oxygenation. The other actions are also appropriate but will be done after the nurse assesses gas exchange.
In which order will the nurse pefom the following actions when caing for a patient with possible cevical spinal cord trauma who is admitted to the emergency depatment? a. Administer O2 using a non-rebreathing mask. b. Monitor cardiac rhythm and blood pressure. c. Immobilize the patient's head, neck, and spine. d. Transfer the patient to radiology for spinal CT.
C, A, B, D The first action should be to prevent further injury by stabilizing the patient's spinal cord. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, continuous monitoring of heart rhythm and BP is indicated. CT scan to determine the extent and level of injury is needed once initial assessment and stabilization is accomplished.
In which order will the nurse take these actions when caring for a patient with left leg fractures after a motor vehicle accident? A. Obtain x-rays. B. Check pedal pulses. C. Assess lung sounds. D. Take blood pressure. E. Apply splint to the leg. F. Administer tetanus prophylaxis.
C, D, B, E, A, F
A 58-year-old woman who has a family history of osteoporosis is diagnosed with osteopenia following densitometry testing. In teaching the woman about her osteoporosis, the nurse explains that A estrogen replacement therapy must be started to prevent rapid progression to osteoporosis. B continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. C with a family history of osteoporosis, there is no way to prevent or slow gradual bone resorption. D calcium loss from bones can be slowed by increasing calcium intake and weight-bearing exercise.
D
A 74-yr-old man who has right-sided extremity paralysis related to a thrombotic stroke develops constipation. Which action should the nurse take first? A Assist the patient to the bathroom every 2 hours. B Provide incontinence briefs to wear during the day. C Administer a bisacodyl (Dulcolax) rectal suppository every day. D Arrange for several servings per day of cooked fruits and vegetables.
D
A nurse is caing for a client who has a C4 spinal cord injuy. which of the following should the nurse recognize the client as being at the greatest isk for? a) neurogenic shock b) paralytic ileus c) stress ulcer d) respiratory compromise
D
A nurse is providing education to a patient with a recent diagnosis of a transient ischemic attack (TIA). Which of the statements by the patient indicates that the patient understands the information? A "Because TIAs don't cause permanent damage, I don't need to worry about having another one" B "TIAs are usually caused by large bleeds in the brain that resolve on their own" C "TIAs are usually caused by small bleeds in the brain that resolve on their own" D "It's important to seek medical attention immediately if I experience these symptoms again because it means I could be having a stroke"
D
A patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient's husband is visiting, he feeds and dresses the wife. Which nursing diagnosis is most appropriate for the patient? A Interrupted family processes related to effects of illness of a family member B Situational low self-esteem related to increasing dependence on spouse for care C Impaired nutrition: less than body requirements related to hemiplegia and aphasia D Disabled family coping related to inadequate understanding by patient's spouse
D
A patient with a comminuted fracture of the right femur has Bucks traction in place while waiting for surgery. To assess for pressure areas on the patients back and sacral area and to provide skin care, the nurse should A loosen the traction and have the patient turn onto the unaffected side. B place a pillow between the patients legs and turn gently to each side. C turn the patient partially to each side with the assistance of another nurse. D have the patient lift the buttocks by bending and pushing with the left leg.
D
A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When admitting the patient, which clinical manifestation will the nurse expect to find? A Impulsive behavior B Right Sided Neglect C Hyperactive left-sided reflexes D Difficulty in understanding commands
D
A person's right thumb was accidentally severed with an axe. The amputated right thumb was recovered. Which action by the nurse preserves the thumb so it could possibly be reattached in surgery? A Place the right thumb directly on some ice. B Put the right thumb in a glass of warm water C Wrap the thumb in a clean piece of material. D Secure the thumb in a plastic bag and place on ice.
D
The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? A A 92-yr-old female patient who takes warfarin (Coumadin) for atrial fibrillation B A 28-yr-old male patient who uses marijuana after chemotherapy to control nausea C A 42-yr-old female patient who takes oral contraceptives and has migraine headaches D A 72-yr-old male patient who has hypertension and diabetes mellitus and smokes tobacco
D
The nurse is teaching a senior citizen's group about signs and symptoms of a stroke. Which statement by the nurse would provide accurate information? A "Take the person to the hospital if a headache lasts for more than 24 hours." B "Stroke symptoms usually start when the person is awake and physically active." C "A person with a transient ischemic attack has mild symptoms that will go away." D "Call 911 immediately if a person develops slurred speech or difficulty speaking."
D
When assessing a 64-year-old woman, the nurse notes that the patient has lost 1 inch in height since the previous visit 2 years ago. The nurse will plan to teach the patient about A discography studies. B myelographic testing. C magnetic resonance imaging (MRI). D dual-energy x-ray absorptiometry (DEXA).
D
Which intervention is most appropriate when communicating with a patient with aphasia after a stroke? A Present several thoughts at once so that the patient can connect the ideas. B Ask open-ended questions to provide the patient the opportunity to speak. C Finish the patient's sentences to minimize frustration associated with slow speech. D Use simple, short sentences accompanied by visual cues to enhance comprehension.
D
Which menu choice by a patient with osteoporosis indicates that the nurses teaching about appropriate diet has been effective? A Pancakes with syrup and bacon B Whole wheat toast and fruit jelly C Two-egg omelet and a half grapefruit D Oatmeal with skim milk and fruit yogurt
D
a female pt who is 49 has lost a noticebable amount of height withing the last year. the nurse suspects the pt has osteoporosis, what shoul the nurse educate the pt about? a) discography studies b) myelographic testing c) MRI d) dual energy x-ray absorptiometry
D
which menu choice by a pt with osteoporosis indicates that the nurses teaching about appropriate diet has been effective? a) pancakes with syrup and bacon b) whole whear toast and fruit jelly c) 2-egg omelet and half grapefruit d) almond oatmeal with skim milk and fruit yogurt
D
a pt is to receive fosamax for her osteoporosis. before giving this med the nurse will? a) ask the pt about any muscle cramps b) have the pt empty the bladder b4 giving the med c) give the pt breakfast before giving the med d) assist the pt to sit upright on the side of the bed
D To avoid esophageal erosions, the patient taking bisphosphonates should be upright for at least 30 minutes after taking the medication. Fosamax should be taken on an empty stomach, not after taking other medications or eating. Leg cramps and hot flashes are not side effects of bisphosphonates.
What statement from the 64 year old diabetic patient who has had an above-the-knee amputation indicates that the nurse's discharge teaching has been effective? A "I should elevate my residual limb on a pillow 2 or 3 times a day." B) "I should change the limb sock when it becomes soiled or each week." C) "I should use lotion on the stump to prevent skin dying and cracking." D) "I should lay flat on my abdomen for 30 minutes 3 or 4 times a day."
D The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limb sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage flexion contracture.
The nurse obtains all of the following infomation about a 65-year-old patient in the clinic. When developing a plan to decrease stroke isk, which isk factor is most impotant for the nurse to address? A) The patient has a daily glass of wine to relax. B) The patient is 25 pounds above the ideal weight. C) The patient works at a desk and relaxes by watching television. D) The patients blood pressure BP is usually about 180/90 mm Hg.
D a. Hypertension is the single most important modifiable risk factor and this patients hypertension is at the stage 2 level. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not so much as hypertension.
A patient with sudden-onset ight-sided weakness has a CT scan and is diagnosed with an intracerebral hemorhage. Which infomation about the patient is most impotant to communicate to the health care provider? a) the patients speech is difficult to understand b) the pt BP is 144/90 c) pt takes a diuretic because hx of HTN d) pt has a fib and takes warfarin (Coumadin)
D a. The use of warfarin will have contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patients care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.
The patient with a spinal cord injuy is complaining of a headache. Which of the following vital signs is the most impotant for the nurse to monitor? A) BP B) RR c) pulse D) O2 sat
a HTN, throbbing headache, diaphoresis above the level of injury, bradycardia, piloerection, flushing of the skin above the level of injury, blurred vision, nasal congestion, anxiety and nausea are all significant findings indicating that the patient is experiencing autonomic dysreflexia.
reduce inflammation/pain medication
Toradol, ketorlac
The emergency department nurse receives a client with an ischemic stroke, and prepares to administer tissue plasminogen activator (t-PA). What question should the nurse ask first before administering the t-PA?
ask onset time of stroke
hemorrhagic stroke
bleeding in the brain from rupture blood vessel
ischemic stroke
blockage of blood flow (blood clot)
priority finding for a patient recovering from a stroke
dysphagia
FAST meaning
facial drooping, arm drfit, slurred speech, timely (brain is life)
calcium, vitamin D and biphosphonate drugs increase bone density and increase the likelihood of fractures True False
false
a pt who has just had surgery to repair a hip fracture can take a tub bath 2 weeks after the surgery True False
false The patient can take a tub bath 4-6 weeks after surgery depending on the doctors orders. That hip should not be submerged in water until a minimum of 4 weeks of healing has occurred.
which medication is used to treat/prevent osetoporosis
fosamax
pain control, calm environment, limit visitors, monitor IV fluids for overload are all interventions for what kind of stroke?
hemorhaggic
which type of stroke would a nurse need to administer stool softener and why?
hemorrhagic stroke to minimize ICP and stress
which type of stroke should a client have seizure precautions and strict bedrest and why?
hemorrhagic, due to bleeding in the brain and to reduce ICP
direct vasodialator, rapidly reduces BP
hydralazine
biggest risk factor for hemorrhagic stroke?
hypertension
receptive aphasia
inability to understand what you are saying
What causes an initial incomplete SCI to result in complete cord damage?
infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites
