Final

A mother brings her 6-year-old to the ED after the child fell off a bike. The physician diagnoses a concussion. The mother asks the nurse what a concussion is. What should the nurse's response be?

" A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain".

The nurse is providing health education to a client who has a C6 spinal cord injury. The client ask why autonomic dysreflexia is considered an emergency. What would be the nurse's best answer?

"The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel."

The nurse has been asked to teach a patient how to self-administer nitroglycerin. The nurse should instruct the patient to do which of the following? Select all of the teaching points that apply.

* Let the tablet dissolve in the mouth and keep the tongue still. The tablet can be crushed between the teeth but not swallowed. * Take the tablet in anticipation of any activity that can produce pain. * Call emergency services if after taking three tablets (one every 5 minutes), pain persists.

The nurse is caring for a client newly diagnosed with CAD. While developing a teaching plan for the client to address modifiable risk factors for CAD, the nurse will include which factor(s)? Select all that apply.

*Elevated blood pressure *Obesity

The nurse is assessing a client with acute coronary syndrome (ACS). The nurse includes a careful history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are suggestive of ACS? Select all that apply.

*Unusual Fatigue *Dyspnea *Syncope

The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply.

*Young age *Male gender *Alcohol or drug use

A client with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring?

Applying thigh-high elastic stockings

Which of the following if left untreated, can lead to an ischemic stroke?

Atrial fibrillation

A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client?

Bradycardia and hypertension

Which type of brain injury is characterized by a loss of consciousness with stupor and confusion?

Contusion

A client presents to the clinic complaining of intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the client that angina is most often attributable to what cause?

Coronary arteriosclerosis.

A client is admitted for treatment of Prinzmetal's angina. When developing this client's care plan, the nurse should keep in mind that this type of angina is a result of what trigger?

Coronary artery spasm.

The public health nurse is participating in a health fair and interviews a client with a history of hypertension, who is currently smoking one pack of cigarettes per day. The client denies any of the most common manifestations of CAD. The nurse should expect the focuses of CAD treatment to be:

Diet therapy and smoking cessation.

A client diagnosed with a stroke is having difficulty forming words during communication. This would be appropriately documented as

Dysarthria

A client comes to the emergency department reporting chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see?

Elevated ST segment

A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring to this client is aware that an absolute contraindication for thrombolytic therapy is what?

Evidence of hemorrhagic stroke.

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

Form words that are understandable or comprehend spoken words.

The laboratory values for a client diagnosed with coronary artery disease (CAD) have just come back from the lab. The client's low density lipoprotein (LDL) level is 112 mg/dL. This nurse recognizes that this value is

High

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. This advice is based on research data that shows the most important risk factor for stroke is?

Hypertension.

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency . What is the origin of the client's symptoms?

Impaired cerebral circulation.

The nurse is caring for a client who has undergone a perctaneous transluminal coronary angioplasty (PTCA). What is the major indicator of success for this procedure?

Increase in the size of the artery's lumen.

A client is admitted to the neurologic ICU witth C4 spinal cord injury. When writing the plan of care for this client, which of the following nursing diagnosis would the nurse prioritize in the immediate care of this client?

Ineffective breathing patterns related to weakness of the intercostal muscles.

The nurse is caring for an adult client who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina.

Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD)

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which actin by the student nurse requires further intervention?

Keeping the client in one position to decrease bleeding.

A client has been admitted to the ICU after being recently diagnosed with an aneurysm and the client's admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the client's plan of care?

Maintain the client on complete bed rest.

A client is brought to the ED by her family after falling off the roof. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention?

Making openings in the skull.

An adult client is admitted to the ED with chest pain. The client states that he had unrelieved chest pain for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions?

Morphine sulfate, oxygen, and bed rest.

A patient with a C7 spinal cord fracture informs the nurse "My head is killing me!" The nurse assesses a blood pressure of 210/140 mm Hg, Heart rate of 48 and observes diaphoresis on the face. What is the first action by the nurse?

Place the patient in a sitting position.

Which stimulus is known to trigger an episode of autonomic dysreflexia in the client who has suffered a spinal cord injury?

Placing a blanket over the client

A client with cardiovascular disease is being treated with amlodipine, which is intended to cause what therapeutic effect?

Reducing the heart's workload by decreasing heart rate and myocardial contraction.

A 13-year-old was brought to the ED after being hit in the head by a baseball and is subsequently diagnosed with a concussion. What assessment finding would rule out discharging the client?

The client's speech is slightly slurred.

A client with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the client about what potential adverse effects?

Throbbing headache or dizziness.

The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke?

Weakness on one side of the body and difficulty with speech.

A nurse practitioner provides health teaching to a patient who has difficulty managing hypertension. This patient is at an increased risk for which type of stroke?

intracerebral hemorrhage

A client with a spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this client? Select all that apply.

*Orthostatic hypotension *Autonomic dysreflexia *DVT

As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for a benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply.

*Recent intracranial pathology *Current anti coagulation therapy *Symptoms onset grater than 3 hours prior to admission.

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

Elevating the head of the bed to 30 degrees.

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem?

Lioresal (Baclofen)

The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the phyician?

The client's vital signs are temperature, 100.9 F, Heart rate 88 beats/minute, respiratory rate, 18 breaths/minute, and blood pressure, 130/80 mm Hg.

The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four clients who might be at risk for a stroke. Which client is likely at the highest risk for a hemorrhagic stroke?

White male, age 60, with history of uncontrolled hypertension.

The ED nurse is caring for a client who has been brought by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture?

Bruising over the mastoid.

A client with a C5 spinal cord injury has tetraplegia. After being moved out of the ICU, the clients reports a severe throbbing headache. What should the nurse do first?

Check the client's indwelling urinary catheter for kinks to ensure patency.

A nurse is educating a client with coronary artery disease about nitroglycerin administration. The nurse tells the client that nitroglycerin has what actions? Select all that apply.

*Reduced myocardial oxygen consumption. *Dilates blood vessels *Decreases ischemia *Relieves pain

Elevated ICP is most commonly associated with head injury. Which of the following are clinical signs of ICP that a nurse should evaluate? Select all that apply.

*Respiratory irregularities *Slow bounding pulse *Widened pulse pressure

A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first?

Ask the client if he has trouble breathing.

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best?

Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes.

The statements presented here match the nursing interventions with nursing diagnoses. Which statements are true for a client with a stroke? Select all that apply.

*Impaired swallowing: Provide a pureed diet. *Disturbed sensory perception: Stand on the client's unaffected side. *Impaired verbal communication: Repeat words and instructions.

An ED nurse is assessing a 71-year-old female client for a suspected MI. When planning the assessment, the nurse should be cognizant of what signs and symptoms of MI that are particularly common in female clients? Select all that apply.

*Nausea *Indigestion