Iggy chapter 45 Review questions
The nurse is evaluating the collaborative care of a client with traumatic brain injury (TBI). What is the most important goal for this client? A. Achieving the highest level of functioning B. Increasing cerebral perfusion C. Preventing further injury D. Preventing skin breakdown
A. Achieving the highest level of functioning The most important nurse's goal for the client with TBI is to help him or her achieve the highest level of functioning possible.The nurse assesses cerebral perfusion, such as oxygenation status, but cannot increase cerebral perfusion. Prevention of injury from falls, infection, or further impairment of cerebral perfusion is part of a larger goal for this client. Prevention of skin breakdown is a goal for the care of any client.
Which are risk factors for stroke? SATA A. High blood pressure B. Previous stroke or transient ischemic attack (TIA) C. Smoking D. Use of oral contraceptives E. Female gender
A B C D Common modifiable risk factors for developing a stroke include smoking and the use of oral contraceptives. Other risk factors include high blood pressure and history of a previous TIA.Gender is not a known risk factor for stroke; however, the female client is at risk for delayed recognition of early stroke symptoms.
A client with a traumatic brain injury from a motor vehicle crash is monitored for signs/symptoms of increased intracranial pressure (ICP). Which sign/symptoms does the nurse monitor for? A. Changes in breathing pattern B. Dizziness C. Increasing level of consciousness D. Reactive pupils
A. Changes in breathing pattern The nurse monitors for changes in breathing pattern. This may be indicative of increased intracranial pressure secondary to compression of areas of the brain responsible for respiratory control.Dizziness is a symptom of brain injury, not increased intracranial pressure. Increasing level of consciousness and reactive pupils are desired outcomes for this client.
A client has been admitted with a diagnosis of stroke (brain attack). The nurse suspects that the client has had a right hemisphere stroke because the client exhibits which symptoms? A. Aphasia and cautiousness B. Impulsiveness and smiling C. Inability to discriminate words D. Quick to anger and frustration
B. Impulsiveness and smiling Impulsiveness and smiling are signs and symptoms indicative of a right hemisphere stroke.Aphasia, cautiousness, the inability to discriminate words, quick to anger, and frustration are signs and symptoms indicative of a left hemisphere stroke.
A client in the emergency department (ED) has slurred speech, confusion, and visual problems and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The client also has a history of hypertension and atherosclerosis. What does the nurse suspect that the client is probably experiencing? A. Embolic stroke B. Hemorrhagic stroke C. Thrombotic stroke D. Transient ischemic attack
C. Thrombotic stroke The client's signs and symptoms fit the description of a thrombotic stroke due to its gradual onset.Signs and symptoms of embolic stroke have a sudden onset, unlike this client's symptoms. Hemorrhagic strokes more frequently present with sudden, severe headache. Intermittent episodes of slurred speech, confusion, and visual problems are transient ischemic attacks, which often are warning signs of an impending ischemic stroke.
A client is admitted with a stroke (brain attack). Which tool does the nurse use to facilitate a focused neurologic assessment of the client? A. Glasgow Coma Score (GCS) B. Intracranial pressure monitor C. Mini-Mental State Examination (MMSE; mini-mental status examination) D. National Institutes of Health Stroke Scale (NIHSS)
D. National Institutes of Health Stroke Scale (NIHSS) The nurse uses the NIHSS tool to perform a focused neurologic assessment. Health care providers and nurses at designated stroke centers use a specialized stroke scale such as the NIHSS to assess clients.The Glasgow Coma Score (GCS) provides a non-specific indication of level of consciousness. An intracranial pressure monitor would be requested by the health care specialist if signs and symptoms indicated increased intracranial pressure. The MMSE is used primarily to differentiate among dementia, psychosis, and affective disorders.