Intracranial Regulation

Which type of precautions should the nurse implement for the client diagnosed with septic meningitis? 1. Standard Precautions. 2. Airborne Precautions. 3. Contact Precautions. 4. Droplet Precautions.

4 Droplet Precautions are respiratoryprecautions used for organisms thathave a limited span of transmission.Precautions include staying at least four(4) feet away from the client or wearinga standard isolation mask and gloveswhen coming in close contact with theclient. Clients are in isolation for 24 to48 hours after initiation of antibiotics.)

A client is having a grand mal seizure. Which of the following interventions by the nurse will ensure safety during the seizure. A.Protect the client from injury. B.Place a padded tongue blade between the teeth. C.Lay the client in supine position immediately. D. Give oxygen by facemask immediately.

A It is important to maintain safety by providing protection from injury during a grand mal seizure. Depending on where the seizure occurs, the first action is to provide a safe area and clear the environment of any item that may cause injury. Padded tongue blades are controversial and best practices indicate that they may break and splinter, causing more injury and should not be used. Lying supine is not correct as the client needs to be placed on the side in a recovery position to assist with airway and prevent aspiration of mucous or emesis. Oxygen may be given but may not be the priority over safety. Please note: in this question the word SAFETY is addressed. If the nurse insists that respiratory status IS safety, do not confuse it in the question as worded. In seizures, oxygen may not be the primary problem that the client requires assistance with. SAFETY is vital.

The nurse is caring for an unconscious client and performs passive range of motion to which main reason? A.To ensure that joints remain mobile. B.To ensure that muscle tone is increased. C.To prevent demineralization of bone. D. To maintain muscle mass.

A Passive range of motion maintains joint mobility and reduces the chances of freezing joints. Muscle strength relies on maintaining muscle strength and tone. Weight bearing exercises provide for bone strengthening.

The nurse caring for a client with brain injury administered mannitol (Osmitrol) for intracranial pressure. Which is the most important for the nurse to monitor following administration of mannitol (Osmitrol)? A.Intake and output. B.Pupillary response. C. Changes in pulse pressure D. Respiratory rate.

A The nurse must closely monitor the intake and output following mannitol since the drug promotes diuresis. The osmotic action pulls water from extracellular fluid of the brain. Because of the urinary losses, severe hypokalemia may occur. Some policies warrant replacement of urinary loss for the first two hours following each administration. Close monitoring of blood pressure and intracranial pressure is also necessary. While pupillary response and pulse pressure changes are important in determining changes in intracranial pressure, the question aims at interventions post administration of an osmotic diuretic.

For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of a. risk for injury related to denial of deficits and impulsiveness. b. impaired physical mobility related to right-sided hemiplegia. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability.

A. The patient with right-sided brain damage typically denies any deficits and has 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

A patient is taking Phenytoin for treatment of seizures. Which statement by the patient requires you to re-educate the patient about this medication? A. "Every morning I take this medication with a full glass of milk with my breakfast." B. "I know it is important to have my drug levels checked regularly." C. "I will report a skin rash immediately to my doctor." D. "This medication can lower my body's ability to clot and fight infection."

A. This medication should NOT be taken with milk products or antacids because it affects absorption. All the other options are correct.

Which clinical manifestation would be required to confirm the diagnosis of Parkinson​ disease? A. Tremors at rest and bradykinesia B. Bradykinesia only C. Rigidity only D. Tremor at rest and flaccidity

Answer: A​ Rationale: A diagnosis of Parkinson disease requires the presence of two of the three cardinal​ manifestations: tremor,​ rigidity, and bradykinesia. Tremors at rest and bradykinesia are two of the cardinal signs. Bradykinesia alone would not be diagnostic. Tremors at rest are a cardinal​ sign, but flaccidity is not. Rigidity is a cardinal​ sign, but rigidity alone is not diagnostic.

The healthcare provider of an older adult client with advancing Parkinson disease suggested that the client start an exercise regime. Which exercise should the nurse​ recommend? A. T'ai chi B. Running C. Weight lifting D. Football

Answer:​ A Rationale: For a client with Parkinson​ disease, an exercise regime that promotes balance and walking is the best.​ So, the nurse may recommend​ t'ai chi. Considering the​ client's age,​ football, running, and weight lifting may be too strenuous.

The nurse caring for an unconscious client enters the room and observes the client has one eye closed while the other eye is partially open. Which action will the nurse perform to prevent complications of the eye while the client is unconscious? A. Cleanse the eye every shift of debris and matter. B. Taping the eye closed. C. Do nothing as the client may be waking from coma. D. Apply artificial tears every each shift.

B Taping one or both eyes is appropriate since the blinking reflex may be absent in an unconscious client. If absent, and if the eye cannot close, risk of corneal abrasion occurs because of dryness. Taping will help avoid this injury. While cleansing the eyes is good, it still does not protect from corneal injury. Instilling artificial tears once per shift may not be enough. Having one or both eyes open does not imply that the client is waking from unconsciousness.

A patient with Parkinsons disease is undergoing a swallowing assessment because she has recently developed adventitious lung sounds. The patients nutritional needs should be met by what method? A)Total parenteral nutrition (TPN) B)Provision of a low-residue diet C)Semisolid food with thick liquids D)Minced foods and a fluid restriction

C A semisolid diet with thick liquids is easier for a patient with swallowing difficulties to consume than is a solid diet. Low-residue foods and fluid restriction are unnecessary and counterproductive to the patients nutritional status. The patients status does not warrant TPN.

In planning for discharge planning for a client with bacterial meningitis, the nurse will be sure to include which instruction? A. Keep all family and visitors from visiting your room for protective isolation. B. Make sure you eat high protein diet with plenty of fluids C. Take all of the antibiotics until gone. D. Incorporate regular exercise with active range of motion.

C The client should be instructed to complete all antibiotics until they are completely gone. Failure to complete antibiotics may lead to re-infection and may spread causing endocarditis and other infections in the body, especially if the bacteria were from streptococci. While the client may be in isolation while in the hospital, family may not need to quarantine the client when at home. Some family members receive prophylactic antibiotics, but will be ordered according to the bacterial strain and health care provider (HCP) recommendations. It is important to eat a good diet, but the most important will be taking prescribed antibiotics. While returning to exercise is important, gradual increase should be performed, and the answer selection for exercise was not as important as prescribed antibiotics.

The nurse is caring for a client who has been unconscious and ventilator dependent in the intensive care unit for 6 days. The last three electroencephalograms revealed no brain wave activity, and the health care provider (HCP) pronounces the client with brain death. During assessment, the nurse documents which findings?SATA A.Blink reflex intact. B. Decerebrate posturing is present. C. Nonreactive dilated pupils. D. Gag reflex is absent.

C, D A client on life support and is brain dead will have nonreactive pupillary response and absent gag reflex, along with corneal and blink reflexes. There may still be signs of spinal reflexes such as deep tendon and babinski reflexes. Decerebrate posturing is absent in brain death and reflects absence of brain-stem activity found in brain death. Few cases have seen a type of decerebrate response; however, they are rare and usually reflect spinal origin instead of brain stem origin. Criteria in establishing brain death require absence of all brainstem-mediated reflexes including motor posturing. Spinal cord automations may still emerge.

A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Monitor the blood pressure. b. Send the patient for a computed tomography (CT) scan. c. Check the respiratory rate and effort. d. Assess the Glasgow Coma Scale score.

C. The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed.

The patient is experiencing characteristics of a tonic-clonic seizure. The seizure started at 1402 and it is now 1408, and the patient is still experiencing a seizure. The nurse should? A. Continue to monitor the patient B. Suction the patient C. Initiate the emergency response system D. Restrain the patient to prevent further injury

C. Tonic-clonic seizures should last about 1-3 minutes. If the seizure lasts MORE than 5 minutes, the patient needs medical treatment FAST to stop the seizure....this is known as status epilepticus.

You are alerted to a possible acute subdural hematoma in the patient who A. has a linear skull fracture crossing a major artery. B. has focal symptoms of brain damage with no recollection of a head injury. C. develops decreasing LOC and a headache within 48 hours of a head injury. D. has an immediate loss of consciousness with a brief lucid interval followed by decreasing LOC.

C. An acute subdural hematoma manifests within 24 to 48 hours of the injury. The signs and symptoms are similar to those associated with brain tissue compression by increased intracranial pressure (ICP) and include decreasing LOC and headache.

A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions

D. Remember L is for Language and Logic Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke

A 7-year-old male patient is being evaluated for seizures. While in the child's room talking with the child's parents, you notice that the child appears to be daydreaming. You time this event to be 10 seconds. After 10 seconds, the child appropriately responds and doesn't recall the event. This is known as what type of seizure? A. Focal Impaired Awareness (complex partial) B. Atonic C. Tonic-clonic D. Absence

D. This is an absence seizure and is most common in children. The hallmark of it is staring that appears to be like a daydreaming state. It is very short and the post ictus stage of this type of seizure is immediate.

Which of the following is a contraindication for the administration of tissue plasminogen activator (t-PA)? a) Systolic blood pressure less than or equal to 185 mm Hg b) Ischemic stroke c) Intracranial hemorrhage d) Age 18 years of age or older

Intracranial hemorrhage Intracranial hemorrhage, neoplasm, or aneurysm is a contraindication to t-PA. Clinical diagnosis of ischemic stroke, age 18 years of age or older, and a systolic BP less than or equal to 185 mm Hg are eligibility criteria. (less)

A nurse is assessing an adolescent admitted for a severe ventroperitoneal shunt infection. Which of the following assessment findings would the nurse expect to see?Select one or more: a. Bulging fontanel b. Positive Babinski sign c. Vomiting d. Loss of coordination or balancee. Redness along the shunt tract

c. Vomiting Vomiting is a sign of increased intracranial pressure, which is often present with a shunt infection. WBCs collect in the CSF, and clog the shunt, resulting in shunt malfunction as well as infection.d. Loss of coordination or balanceLoss of coordination or balance is a sign of increased intracranial pressure, which may be present with a shunt infection. WBCs collect in the CSF, and clog the shunt, resulting in shunt malfunction as well as infection.e. Redness along the shunt tractRedness along the shunt tract is often present with a shunt infection as a result of the body's response to the infectious agent.

The client diagnosed with septic meningitis is admitted to the medical floor at noon.Which health-care provider's order would have the highest priority? 1. Administer an intravenous antibiotic. 2. Obtain the client's lunch tray. 3. Provide a quiet, calm, and dark room. 4. Weigh the client in hospital attire.

1 The antibiotic has the highest prioritybecause failure to treat a bacterialinfection can result in shock, systemicsepsis, and death.

The public health nurse is giving a lecture on potential outbreaks of infectious meningitis. Which population is most at risk for an outbreak? 1. Clients recently discharged from the hospital. 2. Residents of a college dormitory. 3. Individuals who visit a third world country. 4. Employees in a high-rise office building.

2 Outbreaks of infectious meningitis aremost likely to occur in dense communitygroups such as college campuses, jails,and military installations.)

The client is diagnosed with meningococcal meningitis. Which preventive measure would the nurse expect the health-care provider to order for the significant others in the home? 1. The Haemophilus influenzae vaccine. 2. Antimicrobial chemoprophylaxis. 3. A 10-day dose pack of corticosteroids. 4. A gamma globulin injection.

2 Chemoprophylaxis includesadministering medication that willprevent infection or eradicate thebacteria and the development ofsymptoms in people who have been inclose proximity to the client.Medications include rifampin(Rifadin), ciprofloxacin (Cipro), andceftriaxone (Rocephin).

The nurse is assessing the client diagnosed with bacterial meningitis. Which clinical manifestations would support the diagnosis of bacterial meningitis? 1. Positive Babinski's sign and peripheral paresthesia. 2. Negative Chvostek's sign and facial tingling. 3. Positive Kernig's sign and nuchal rigidity. 4. Negative Trousseau's sign and nystagmus.

3 A positive Kernig's sign (client unableto extend leg when lying flat) andnuchal rigidity (stiff neck) are signs ofbacterial meningitis, occurring becausethe meninges surrounding the brainand spinal column are irritated.)

The 29-year-old client is admitted to the medical floor diagnosed with meningitis.Which assessment by the nurse has priority? 1. Assess lung sounds. 2. Assess the six cardinal fields of gaze. 3. Assess apical pulse. 4. Assess level of consciousness.

4 Meningitis directly affects the client'sbrain. Therefore, assessing theneurological status would have priorityfor this client.

GCS scores possible:

4- eye opening response 5-verbal response 6-motor response

The patient reports falling when his foot got "stuck" on a crack in the sidewalk, hitting his head when he fell, and "passing out". The paramedics found the patient walking at the scene and talking before transporting the patient to the hospital. In the emergency department, the patient starts to lose consciousness. This is a classic scenario for which complication? A. Epidural hematoma B. Subdural hematoma C. Subarachnoid bleed D. Diffuse axial injury

A Epidural hematoma often results from a linear fracture crossing a major artery in the dura. The classic sign is an initial period of unconsciousness at the scene and a brief lucid interval followed by a decrease in LOC. A subdural hematoma often results from injury to the brain and veins and develops more slowly. The classic sign or symptom of subarachnoid hemorrhage is a patient describing "the worst headache of my life." Diffuse axonal injury is widespread axonal damage occurring after a traumatic brain injury.

You have a patient who has a brain tumor and is at risk for seizures. In the patient's plan of care you incorporate seizure precautions. Select below all the proper steps to take in initiating seizure precautions: A. Oxygen and suction at bedside B. Bed in highest position C. Remove all pillows from the patient's head D. Have restraints on stand-by E. Padded bed rails F. Remove restrictive objects or clothing from patient's body G. IV access

A, E, F, and G. The bed needs to be in the LOWEST position possible, a pillow should be underneath the patient's head to protect it from injury, AVOID using restraints (this can cause musculoskeletal damage).

A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema. An appropriate nursing intervention for the patient is a. avoiding positioning the patient with neck and hip flexion b. maintaining hyperventilation to a PaCO2 of 15 to 20 mm Hg c. clustering nursing activities to provide periods of uninterrupted rest d. routine suctioning to prevent accumulation of respiratory secretions

A. Avoiding positioning the patient with neck and hip flexion. Nursing care activities that increase ICP include hip and neck flexion, suctioning, clustering care activities, and noxious stimuli; they should be avoided or performed as little as possible in the patient with increased ICP. Lowering the PaCO2 below 20 mm Hg can cause ischemia and worsening of ICP; the PaCO2 should be maintained at 30 to 35 mm Hg.

A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the patient communicate is to a. ask questions that the patient can answer with "yes" or "no." b. develop a list of words that the patient can read and practice reciting. c. have the patient practice her facial and tongue exercises with a mirror. d. prevent embarrassing the patient by answering for her if she does not respond.

A. Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.

The nurse is assessing an older adult client. Which finding should cause the nurse to suspect the client has Parkinson disease (PD)? (Select all that​ apply.) A. The client has hand tremors at rest. B. The client does not remember what he ate for breakfast. C. The​ client's blood pressure increases when the client stands up. D. The client has a slurred speech. E. The​ client's facial expression shows no emotion.

Answer: A, B, D, E​ Rationale: PD causes slowed​ movements, including slurred speech. Tremors at rest are very common in PD and easy to identify. Tremors may occur in the​ hands, face,​ neck, lips,​ tongue, and jaw. PD causes a​ frozen, mask-like expression​ (lack of​ affect). The client will not have an expression that is consistent with the emotions the client is feeling. Memory loss occurs in Parkinson disease because of the loss of neurons and other changes in the brain. The client may develop dementia. Postural​ hypotension, not​ hypertension, is a common manifestation in clients with PD. This is caused by damage to the autonomic nervous system.

Which type of therapy is used to manage problems with eating and​ swallowing? A. Physical B. Occupational C. Speech D. Nutritional

Answer: C​ Rationale: Speech therapy is used to manage problems with eating and swallowing. Occupational therapy is used to maintain​ self-care activities, not specifically eating and swallowing. Physical therapy is used to improve coordination of balance and gait. There is no nutritional therapy needed for a client with Parkinson disease.

The nurse observed a client with Parkinson disease frequently wiping their mouth with a handkerchief. After the nurse requested a prescription for an anticholinergic medication from the healthcare​ provider, the client​ asked, "I feel​ better, why do I need another​ medication?" Which response by the nurse is​ correct? A. "It helps dopamine work​ better." B. ​"It will make you feel​ better." C. "The healthcare provider thinks it will help your​ symptoms." D. "It will help reduce tremors and uncontrolled​ drooling."

Answer: D ​Rationale: The client stated that they are feeling better. It is levodopa and not an anticholinergic that will make dopamine work better. Stating that the healthcare provider thinks it will help with the​ client's symptoms will be an incomplete answer. To give a complete​ response, the nurse would state that an anticholinergic reduces tremors and uncontrolled drooling.

A 4 month old infant with bacterial meningitis received new orders...which of the following should the nurse prioritize first? A. Assess fontanelles & high pitched cry B. Give ciprofloxacin IV immediately C. Monitor LOC D. Implement seizure precautions

B When given the option to give antibiotics, we always choose it first. As this will help save the patient's brain. So we can always do our assessments after IV antibiotics are started. Antibiotics are always priority because it will treat and save the baby's life!

The ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture? A) Epistaxis B) Periorbital edema C) Bruising over the mastoid D) Unilateral facial numbness

C An area of ecchymosis (bruising) may be seen over the mastoid (Battles sign) in a basilar skull fracture.

The nurse is caring for a client with increased intracranial pressure (ICP). Which assessment finding would have the most priority? A.Tachycardia B. Hypothermia C. Unequal pupil size D. Decreasing blood pressure

C Pupil size may be affected by increased pressure which affects the third cranial nerve which is one reason for frequent monitoring of pupillary size and response. When ICP increases it affects the hypothalamus and temperature regulation, thus increasing temperature. When ICP increases, it causes pressure on the vagus nerve, thus causing bradycardia not tachycardia. ICP increases cause increase in blood pressure not decreasing blood pressure.

The nurse is caring for a client with increased intracranial pressure. Which respiratory pattern changes will signal increased intracranial pressure? A. Rapid, shallow respirations. B. Nasal flaring. C. Slow, irregular respirations. D. Sudden increase in respiratory secretions.

C Respiratory changes associated with increased intracranial pressure are the result of deterioration of neural control of respirations, which is controlled by the brain stem. Deterioration and pressure produce irregular respiratory patterns. Nasal flaring and rapid shallow respirations are a sign of respiratory distress which may not have root causes because of neurological changes.

A nurse is assessing an adolescent admitted for a severe ventroperitoneal shunt infection. Which of the following assessment findings would the nurse expect to see?Select one or more: a. Bulging fontanel b. Positive Babinski sign c. Vomiting d. Loss of coordination or balance e. Redness along the shunt tract

C,D,E c. VomitingVomiting is a sign of increased intracranial pressure, which is often present with a shunt infection. WBCs collect in the CSF, and clog the shunt, resulting in shunt malfunction as well as infection. d. Loss of coordination or balanceLoss of coordination or balance is a sign of increased intracranial pressure, which may be present with a shunt infection. WBCs collect in the CSF, and clog the shunt, resulting in shunt malfunction as well as infection. e. Redness along the shunt tractRedness along the shunt tract is often present with a shunt infection as a result of the body's response to the infectious agent.

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? A.Ask the client which arm or leg is affected. B.Ask the client if speech was slurred. C.The nurse will ask time of onset of stroke. D.Ask what home medications the client takes.

C. Timing of onset of stroke is important when receiving t-PA. Studies indicate that clients should receive the thrombolytic medication within 3 - 4.5 hours after the onset of a stroke for best outcomes. While asking about speech changes is important, it is more important to establish time frame of stroke onset. Other questions are not important as the emergent need is to determine if the client is a candidate for t-PA administration.

The nurse is caring for a client with Parkinson's disease and prioritizes which intervention in the plan of care? A.Instruct the client to eat foods high in phosphorous which helps mental clarity B. Place client on bedpan every 3 hours to establish voiding C. Elevate client's legs when sitting to avoid edema D. Use armless chair to increase leg strength when getting up

C. A client with Parkinson's disease ambulates with a slow shuffle gait. Slowness and mobility alterations may predispose the client for increased edema so elevating the legs is important. The client should retain as much independence as possible, even with bathroom activities. There is no indication that phosphorous increase will help in mental clarity. Using armless chairs may cause a safety risk since the client will not have arms to hold onto and stabilize self while getting up.

A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.

C. A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin.

Your patient has entered the post ictus stage for seizures. The patient's seizure presented with an aura followed by body stiffening and then recurrent jerking. The patient had incontinence and bleeding in the mouth from injury to the tongue. What is an expected finding in this stage based on the type of seizure this patient experienced? A. Crying and anxiety B. Immediate return to baseline behavior C. Sleepy, headache, and soreness D. Unconsciousness

C. Based on the findings during the seizure the patient experienced a tonic-clonic seizure. In the post ictus stage (after the seizure) the patient is expected to be sleepy (very tired), have soreness, and a headache. The nurse should let the patient sleep.

Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 pounds above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patient's usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television.

C. Hypertension is the single most important modifiable risk factor. 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 as much as hypertension.

A 54-year old man is recovering from a skull fracture with a subacute subdural hematoma. He has return of motor control and orientation but appears apathetic and has reduced awareness of his environment. When planning discharge or the patient, the nurse explains to the patient and the family that a. continuous improvement in the patient's condition should occur until he has returned to pre trauma status b. the patient's complete recovery may take years, and the family should plan for his long term dependent care c. the patient is likely to have long term emotional and mental changes that may require continued professional help d. role changes in family members will be necessary because the patient will be dependent on his family for care and support

C. Residual mental and emotional changes of brain trauma with personality changes are often the most incapacitating problems following head injury and are common in patients who have been comatose longer than 6 hours. Families must be prepared for changes in the patient's behavior to avoid family-patient friction and maintain family functioning, and professional assistance may be required. There is no indication he will be dependent on others for care, but he likely will not return to pre trauma status

A 47-year-old patient will attempt oral feedings for the first time since having a stroke. The nurse should assess the gag reflex and then a. order a varied pureed diet. b. assess the patient's appetite. c. assist the patient into a chair. d. offer the patient a sip of juice.

C. The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless.

After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about a. cerebral aneurysm clipping. b. heparin intravenous infusion. c. oral low-dose aspirin therapy. d. tissue plasminogen activator (tPA).

C. The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.

The nurse notes that a patient with a head injury has a clear nasal drainage. The most appropriate nursing action for this finding is to a. obtain a specimen of the fluid and send for culture and sensitivity. b. take the patient's temperature to determine whether a fever is present. c. check the nasal drainage for glucose with a Dextrostik or Testape. d. have the patient to blow the nose and then check the nares for redness.

Correct Answer: C Rationale: If the drainage is cerebrospinal fluid (CSF) leakage from a dural tear, glucose will be present. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. A dural tear does increase the risk for infections such as meningitis, but the nurse should first determine whether the clear drainage is CSF. Blowing the nose is avoided to prevent CSF leakage.

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? A.Make sure all staff know to speak slowly and in short sentences. B.Make sure all staff speak loudly for the client to hear. C. Make sure all staff write on a clipboard for the client to read communication. D. Make sure all staff assist the client with use of a picture board which is client driven.

D Expressive aphasia clients may understand what is heard or written, but they may not be able to verbally communicate their needs. A picture or communication board helps the client as the client can point to or direct others towards objects on the board for wants and needs. Speaking loudly or slowly is not therapeutic for communication and may diminish the client's dignity. Having staff to be the only ones to write implies one-way communication that is staff-driven and not client-need driven. The focus is client-centered care and the client should be encouraged to express needs and wants through therapeutic means.

When assessing a patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? a. The patient has a positive Kernig's sign. b. The patient complains of having a stiff neck. c. The patient's temperature is 101° F (38.3° C). d. The patient's blood pressure is 86/42 mm Hg.

D Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension.

A 56-year-old 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. The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.

The nurse is providing education to the parents of a 2-year-old boy with hydrocephalus who has just had a ventriculoperitoneal shunt placed. Which information is most important for the parents to be taught? a. "limit the amount of t.v. he watches" b. "watch for changes in his behavior or eating patterns" c. "call the doctor if he gets a headache." d. "always keep his head raised 30 degrees"

b. "watch for changes in his behavior or eating patterns" rationale: Changes in behavior or in eating patterns can suggest a problem with his shunt, such as infection or blockage. Irritability, lack of appetite, increased crying, or inability to settle down may indicate increased intracranial pressure. Any headache needs to be monitored, but if it goes away quickly, such as after eating, it probably isn't a problem. It is not necessary to keep the child's head raised 30 degrees. The child's shunt will not be affected by the amount of television viewed.

A 5-year-old girl sustained a concussion when she fell out of a tree. In preparation for discharge, the nurse is discussing home care with her mother. Which statement made by the mother indicates a correct understanding of the teaching? a. "I should expect my child to have a few episodes of vomiting." b. "If I notice sleep disturbances, I should contact the physician immediately." c. "I should expect my child to have some behavioral changes after the accident." d. "If I notice diplopia, I will have my child rest for 1 hour."

c. "I should expect my child to have some behavioral changes after the accident." The parents are advised of probably post-traumatic symptoms that may be expected, including behavioral changes. If the child has episodes of vomiting, sleep disturbances, or diplopia, they should be immediately reported for evaluation.