Med-Surg Ch 23: Care of Patients With Brain Disorders
A patient diagnosed with a primary brain tumor asks the nurse if this is a common disease. Which response is most appropraite for the nurse to make? A. "Brain tumors are very rare." B. "About 80,000 people a year are diagnosed with a brain tumor." C. "It doesn't really matter. We are just concerned with helping you." D. "Almost all primary brain tumors are malignant."
"About 80,000 people a year are diagnosed with a brain tumor." *About 80,000 new brain tumors are discovered each year in the United States. Many primary brain tumors are benign. Telling the patient his question doesn't really matter is dismissive and nontherapeutic.
The dysarthric patient seated in the dining room of the long-term care facility yells, "Poon! Poon! Poon!" with increasing frustration. What is the nurse's best response? A. "Slow down so that I can understand what you are saying?" B. "Are you asking for a spoon?" C. "Not being able to speak is frustrating." D. "If you tell me what you want, I will get it."
"Are you asking for a spoon?" *Attempting to interpret the dysarthric communication through questions that can be answered simply will reduce frustration.
The patient with trigeminal neuralgia asks the nurse if there is anything she can do to prevent future episodes of the disorder. Which response by the nurse is correct? A. "Surgery is the only form of treatment that will prevent this condition from recurring." B. "It is best if you speak with your physician about this condition." C. "Unfortunately, there is little you can do to prevent future episodes of pain." D. "Drinking very cold or hot liquids is frequently a trigger, so you should avoid both."
"Drinking very cold or hot liquids is frequently a trigger, so you should avoid both." *Drinking cold or very hot liquids, exposure to drafts, light touch or vibration on the face, chewing, brushing the hair, shaving, or washing the face are factors that have been identified as triggers for trigeminal neuralgia. The nurse should provide the patient with this information. Medications and/or surgery are treatments for the disorder, depending on the severity of the case.
Which patient statement indicates a need for further teaching on the prevention of seizures? A. "I need to avoid situations that could potentially trigger a seizure." B. "Alcohol can lower the seizure threshold." C. "I must avoid becoming overly fatigued and should pace activities." D. "I am less likely to have seizures during menstruation."
"I am less likely to have seizures during menstruation." *Menstruation is a time when a seizure is more likely in women. (1) Avoiding seizure triggers is appropriate. (2) Alcohol does lower the seizure threshold. (3) Work and leisure activities should allow for plenty of rest so that the patient does not become unduly fatigued, which can lead to a seizure.
The nurse is providing medication teaching to a patient with epilepsy who is taking phenytoin (Dilantin). Which statement best indicates that the nurse's teaching has been successful? A. "I should decrease my alcohol intake to a single drink per day." B. "I should visit the dentist every 3 to 6 months while taking this medication." C. "I should take an antacid an hour after my Dilantin." D. "This medication may turn my urine orange."
"I should visit the dentist every 3 to 6 months while taking this medication." *Dilantin can cause gingival hyperplasia. The patient should brush teeth and floss regularly and schedule dentist visits every 3 to 6 months. Alcohol interferes with the metabolism of anti-convulsants, increases lethargy, and may trigger seizures. The patient should not consume alcohol at all while taking Dilantin. The patient should not take antacids withing 2 h of taking Dilantin. Dilantin may turn the urine pink
The nurse is caring for an anxious 20 year old college student who just suffered his first seizure in his dorm room. The patient asks the nurse if he is now an epileptic. What is the nurse's best response? A. "No. All other causes of seizure activity must be ruled out before the diagnosis of epilepsy is made." B. "Yes, but you may never have another seizure since it has just now manifested itself." C. No, but you should see a physician to get a prescription for a preventative antispasmodic." D. Yes. All seizures are considered to be epilepsy."
"No. All other causes of seizure activity must be ruled out before the diagnosis of epilepsy is made." *Epilepsy diagnosis is made after all other causes of seizure activity have proven negative. All seizures are considered to be epilepsy.
The nurse is caring for a patient who recently suffered a cerebrovascular accident (CVA). Family members ask the nurse why their father had a seizure. Which response is best for the nurse to make? A. "The seizure was most likely caused by brain cells being deprived of oxygen due to a blood clot in the brain." B. "The stroke generated a toxin that excited the brain cells." C. "The stroke causes an alteration in the cells adjacent to the blot clot." D. "The clot causes an increase in the depolarization of the brain cells due to the clot formation."
"The seizure was most likely caused by brain cells being deprived of oxygen due to a blood clot in the brain." *Thrombi from a CVA can occlude vessels, cutting off oxygen supply to cells of the brain and causing a seizure
The nurse who is caring for a patient following a stroke performs passive range-of-motion exercises on the patient. The patient asks why these exercises are so important. Which response by the nurse is accurate? A. "This helps prevent fatigue from worsening." B. "This helps the patient believe she is making some progress." C. "This helps overcome mood swings and crying spells." D. "This helps to strengthen and retrain muscles."
"This helps to strengthen and retrain muscles." *Physical therapy helps to strengthen muscles and retrains the muscle. It is not specifically designed to help the patient believe she is making progress, or to help overcome mood swings or prevent fatigue.
The nurse is providing teaching to a patient newly diagnosed with focal seizure disorder. Which statement by the nurse is most accurate? A. "Your seizures will typically only affect one side of the body." B. "Simple partial seizures may result in an alteration of consciousness." C. "The simple partial seizure may cause motor impairment to begin in all of your extremities." D. "Simple partial seizures are not treatable."
"Your seizures will typically only affect one side of the body." *Focal seizures only involve one side of the brain and one side of the body. Complex partial seizures may or may not result in an alteration in the level of consciousness. Generalized seizures affect both sides of the body. Simple partial seizures may respond to treatment.
Nursing care of a patient who just had a seizure includes which nursing intervention(s)? (select all that apply) A. Assess for injuries B. Check the glucose level C. Reassure and reorient the patient D. Provide uninterrupted periods of sleep and rest E. Provide a 24-hour sitter
1. Assess for injuries 2. Check the glucose level 3. Reassure and reorient the patient 4. Provide uninterrupted periods of sleep and rest *Assess for injuries and stay with the patient until they regain consciousness. The glucose level is checked. Reassure the patient and orient them. Provide plenty of uninterrupted time so that the patient may rest. (5) It is not necessary to have someone sit with the patient after the seizure once they are conscious.
The nurse is completing a care plan for a stroke patient who is at risk for impaired physical mobility. Which interventions should the nurse include in the care plan? (select all that apply) A. Assist the patient to stand B. Remind the patient to ambulate as much as possible C. Ensure that the call light is within reach D. Coach the patient in active range of motion (ROM) E. Reinforce the use of a walker of cane
1. Assist the patient to stand 2. Ensure that the call light is within reach 3. Coach the patient in active range of motion (ROM) 4. Reinforce the use of a walker of cane *Fall precautions important for this patient include helping the patient to stand, placing the call light within reach, coaching the patient in active ROM, and reinforcing the use of a walker or cane. Reminding the patient to ambulate as much as possible would potentially increase the risk of falls
The nurse is providing teaching to a group of nursing students regarding CVA (stroke). The students demonstrate an understanding of the teaching when listing which factors as being the possible cause of a stroke? (Select all that apply.) A. Atherosclerosis of the arteries in the head and neck B. Meningococcal meningitis C. Cerebral hemorrhage D. Cerebral encephalitis E. Cerebral thrombosis
1. Atherosclerosis of the arteries in the head and neck 2. Cerebral hemorrhage 3. Cerebral thrombosis Possible causes of stroke include cerebral thrombosis and hemorrhage as well as atherosclerosis of the arteries in the head and neck. Encephalitis and meningitis are infections involving the brain and are not typically causes of stroke.
The nurse is caring for a patient admitted with a transient ischemic attack (TIA). A carotid ultrasound reveals a 40% obstruction. The nurse anticipates that the treatment will likely consist of which factor(s)? (Select all that apply) A. Diet modification B. Lifestyle for antiplatelet aggregation C. Aspirin for antiplatelet aggregation D. Daily doses of nitrates E. Endarterectomy
1. Diet modification 2. Lifestyle for antiplatelet aggregation 3. Aspirin for antiplatelet aggregation *Since the patient has a carotid obstruction below 60%, the patient will likely be treated conservatively with measures that include diet and lifestyle modification in conjunction with aspirin therapy. Nitrates and endarterectomy are not initial treatment options for carotid obstruction below 60%
The nurse is caring for an adult patient with a history of seizures. In the event of a seizure, the nurse should document which information? (select all that apply) A. Duration of seizure B. Location of initiation of seizure C. Description of movements D. Family's reaction during the seizure E. Presence of incontinence
1. Duration of seizure 2. Location of initiation of seizure 3. Description of movements 4. Presence of incontinence *The nurse should document seizure duration, location of seizure initiation, description of unilateral or bilateral movement, and presence of incontinence. The family's reaction to the seizure is not included in documentation of a seizure
Intracranial tumors may be treated by several modes of therapy. What types of therapy are you likely to see? (select all that apply) A. Insertion of tiny radioactive particles into the tumor B. High oral doses of iron for 5 days, followed by selenium infusion C. Brain surgery where most or all of the tumor is removed D. Chemotherapy through a reservoir is placed between the scalp ad the skull to get past the blood-brain barrier
1. Insertion of tiny radioactive particles into the tumor 2. Brain surgery where most or all of the tumor is removed 3. Chemotherapy through a reservoir is placed between the scalp ad the skull to get past the blood-brain barrier *Radiation, surgery, and chemotherapy are the three standard modes of therapy for intracranial tumors. (2) Whereas iron and selenium are helpful in patients undergoing cancer treatment, there is no evidence that iron and/or selenium are effective in eradicating brain tumors.
A 21-year-old man complains of a sudden onset of fever, severe headache, and stiffness of the neck. You note a petechial rash over the chest and extremities. which nursing action(s) would be appropriate? (select all that apply) A. Institute Standard Precautions and droplet precautions B. Administer antibiotics as prescribed C. Maintain a quiet and dimly lit patient room D. Encourage active range-of-motion exercises E. Administer narcotic analgesics for headache and neck pain
1. Institute Standard Precautions and droplet precautions 2. Administer antibiotics as prescribed 3. Maintain a quiet and dimly lit patient room *Standard Precautions and droplet precautions should be instituted, as it appears the patient may have bacterial meningitis, which is highly contagious. Antibiotic therapy will be part of the treatment. A quiet and dimly lit room is essential to prevent seizure from the inflammation and to prevent eye pain, as the patient will most likely be photophobic. (4) The patient should be kept as quiet as possible in the acute stage and active range of motion is not part of the treatment at this time. (5) Narcotic analgesics are not prescribed, as they will cloud consciousness and make accurate neurologic assessment difficult.
The nurse is aware that absence seizures are difficult to detect for which reason(s)? (select all that apply) A. Lack of an aura B. Appearance as a brief moment of absentmindedness C. Brief loss of consciousness (LOC) D. Absence of patient memory of the event E. Absence of postictal signs
1. Lack of an aura 2. Appearance as a brief moment of absentmindedness 3. Absence of patient memory of the event 4. Absence of postictal signs *Factors that make absence seizures difficult to detect include the lack of an aura and appearance as a brief moment of absentmindedness with no patient memory of the event or presence of postictal signs. Absence seizures do not result in LOC
To help prevent aspiration while feeding a patient who has a right-sided paralysis, the nurse should implement which intervention(s)? (select all that apply) A. Place the patient in high Fowler position B. Instruct the patient to tilt the head and neck forward C. Instruct the patient to drink liquids through a straw D. Place food in the left side of the mouth E. Avoid mixing foods with different textures
1. Place the patient in high Fowler position 2. Instruct the patient to tilt the head and neck forward 3. Place food in the left side of the mouth 4. Avoid mixing foods with different textures *To help prevent aspiration in this patient, the nurse should position the patient in high Fowler position, instruct the patient to tilt the head and neck forward, place food in the left side of the mouth, and avoid mixing foods with different textures. Drinking through a straw rather than sipping from a cup increases the risk for aspiration
The patient with a right-sided paralysis from a strok becomes frustrated when attempting to self-feed. He throws the spoon at the nurse and begins to cry. What nursing action(s) is/are most appropriate at this time? (select all that apply) A. Retrieve the spoon and sit quietly for a few seconds B. Touch the patient and inquire if he would rather have a high-protein milkshake for his meal C. Remind the patient that such behavior is not acceptable D. Add an intervention to the NCP for increased support with self-feeding E. Complete an incident report
1. Retrieve the spoon and sit quietly for a few seconds 2. Touch the patient and inquire if he would rather have a high-protein milkshake for his meal 3. Remind the patient that such behavior is not acceptable 4. Add an intervention to the NCP for increased support with self-feeding *Completing an incident report is not necessary unless the nurse or someone else was injured
Which condition(s) may cause seizures? (select all that apply) A. Stroke B. Cerebral tumor C. Hyperpyrexia D. Epilepsy E. Metabolic toxicity
1. Stroke 2. Cerebral tumor 3. Hyperpyrexia 4. Epilepsy 5. Metabolic toxicity *All are conditions that may potentially cause seizures
Which are true regarding a stroke? (select all that apply) A. Timing of treatment is important B. A fibrinolytic drug will be given C. Clinical signs and symptoms determine if the stroke ischemic or hemorrhagic D. A CT scan should be done within 2 minutes of arrival at the hospital E. It may occur as a complication of atrial fibrillation
1. Timing of treatment is important 2. A CT scan should be done within 2 minutes of arrival at the hospital 3. It may occur as a complication of atrial fibrillation *Delays in treatment result in brain damage. As part of the stroke protocol, CT scanning is done within 20 minutes of arrival. Atrial fibrillation may cause blood in the atria to pool, becoming a clot, which embolizes to the brain where it blocks the arteries and causes stroke. (2) A fibrinolytic clot-busting drug may be administered once it is determined that a clot is responsible for the loss of blood flow. It is contraindicated in hemorrhagic stroke. (3) The clinical signs and symptoms are very similar, and only imaging studies can determine whether the stroke is ischemic or hemorrhagic.
The LPN/LVN is talking with a patient, who has epilepsy, when he begins having a tonic-clonic seizure. Which assessment(s) should the LPN/LVN make? (Select all that apply.) A. What time the seizure began and how long it lasted? B. What the patient had eaten prior to the seizure? C. Whether body movements are unilateral and symmetrical? D. What the patient was doing prior to the seizure? E. Which direction the patient's eyes turned during the seizure?
1. What time the seizure began and how long it lasted? 2. Whether body movements are unilateral and symmetrical? 3. What the patient was doing prior to the seizure? 4. Which direction the patient's eyes turned during the seizure? *There are several observations that should be observed and documented when a patient experiences a seizure so that a proper diagnosis can be made and treatment plan can be developed. The nurse should document what the patient was doing prior to the seizure, how long it lasted, and description of body and eye movements. It is not necessary to document what the patient last ate.
Your patient describes that she experiences visual disturbances as shimmering arc-shaped lights in her field of vision and blocks in her vision similar to a blind spot. This is followed by a one-sided headache. She is experiencing: (Select all that apply.) A. an aura-type disturbance prior to onset of a migraine headache. B. optic neuritis. C. retinal detachment. D. visual disturbances called a scotoma.
1. an aura-type disturbance prior to onset of a migraine headache. 2. optic neuritis. 3. retinal detachment. 4. visual disturbances called a scotoma.
During a generalized seizure, you could expect the patient to experience: (Select all that apply.) A. loss of muscle tone. B. tonic-clonic movements. C. automatisms. D. absence for a few seconds. E. possible urinary incontinence. F. unilateral movements of limbs.
1. loss of muscle tone. 2. tonic-clonic movements. 3. absence for a few seconds. 4. possible urinary incontinence.
The nurse is educating a patient about his cluster headaches. The nurse includes information that cluster headaches may be accompanied by which signs or symptoms? (Select all that apply) A. reddened conjunctiva B. Nasal congestion C. Ptosis D. Lethargy E. Sensitivity to touch
1. reddened conjunctiva 2. Nasal congestion 3. Ptosis 4. Sensitivity to touch *Manifestations of cluster headaches may include severe unilateral orbital, supraorbital, or temporal pain along with one of the following: redness of the conjunctiva of the eye, tering, nasal congestion, dripping nose, facial swelling, pupil constriction, ptosis (drooping) of the eyelids, and sensitivity to touch. Cluster headaches might cause restlessness (patients often pace), not lethargy
The teaching plan for the patient with epilepsy should include: (Select all that apply.) A. refrain from drinking alcohol. B. wear a Medic-Alert bracelet or necklace. C. do not go anywhere by yourself. D. don't become overly tired. E. eat bananas to replace potassium loss. F. swim only with a partner.
1. refrain from drinking alcohol. 2. wear a Medic-Alert bracelet or necklace. 3. do not go anywhere by yourself. 4. don't become overly tired. 5. eat bananas to replace potassium loss. 6. swim only with a partner.
The nurse reinforces the information given by the physician that endarterectomy as an intervention for stroke prevention is reserved for people who have corotid obstruction of greater than what percentage? A. 30% B. 40% C. 50% D. 60%
60%
The nurse is caring for a patient with brain tumor related hydrocephalus who is scheduled to undergo placement of a ventriculoperitoneal (V-P) shunt. Which information is most important for the nurse to include when explaining the purpose of the procedure? A. A V-P shunt redirects the cerebrospinal fluid (CSF) from the ventricls to the peritoneum B. A V-P shunt stimulates ventricles to reabsorb ecess CSF C. A V-P shunt channels excess CSF to the left atrium D. A V-P shunt provides a port from which excess CSF can be aspirated
A V-P shunt redirects the cerebrospinal fluid (CSF) from the ventricls to the peritoneum *Obstruction of CSF flow may require placing a shunt to reduce CSF pressure and prevent increased intracranial pressure (ICP). A shunt is a tube placed in a ventricle and attached to a small manual pump that moves excess CSF fluid from the ventricles to the peritonial cavity or into the atrium of the heart, so that it may be absorbed
Which symptom is a key sign of a brain tumor? A. Morning nausea B. Difficulty reading C. A headache that awakens patient D. Increasing blood pressure
A headache that awakens patient *A headache that awakens the patient is an early sign of a brain tumor. Morning nausea, difficulty reading, and increasing BP are nonspecific findings that can be attributed to multifactorial causes
A patient was recently diagnosed as having Bell palsy. Which nursing intervention is most important for the nurse to include in the patient's care plan? A. Administer pain medication as needed B. Administer artificial tears and acyclovir C. Implement aspiration precautions D. Offer the patient a small fan to cool the face
Administer artificial tears and acyclovir *Treatment consists of closing and patching the eye if it loses the blink reflex. Artificial tear eye drops are also used to prevent dyness of the cornea. Corticosteroids are given if they can be started right after the beginning of symptoms. They are ineffective if delayed more than 7 days. Acyclovir may be prescribed as well, since herpes virus may be a causitive organism. Bell palsy is usually a painless condition. Bell palsy does not pose a particular risk for aspirations. Cool air may trigger or exacerbate Bell palsy
You are providing care to a 60-year-old patient with trigeminal neuralgia, and you identify that pain is the priority problem. You anticipate A. Assessing the level of pain based on facial expressions B. Administering an anticonvulsant class of medication C. Placing warm cloths on the face D. Preparing the patient for surgery
Administering an anticonvulsant class of medication *One of the anticonvulsant medications is usually prescribed for the pain of this neurologic disorder and must be administered. (1) The patient will move facial muscles as little as possible during an episode of pain, as movement makes the pain worse. Facial expression is not a good way to assess pain. The patient should verbally or in writing express the degree of pain using a pain scale. (3) Touching the face is to be avoided; warm cloths to the face are contraindicated. (4) Surgery is indicated only if pain cannot be controlled with medication.
A patient has had a left-sided cerebrovascular accident (CVA). Which condition does the nurse expect the patient to have as a result of the CVA? A. Aphasia B. Ataxia C. Dyslexia D. Quadriplegia
Aphasia *Speech centers are located in the left hemisphere; processing is often affected by a left CVA. Although ataxia, dyslexia, or quadriplegia may also occur, the most specific to a left CVA is aphasia.
The nurse is providing patient teaching to a 23-year-old female who has recently been diagnosed with epilepsy. The nurse should educate the patient that seizures are most likely to occur at which time in the patient's menstrual cycle? A. 1 week after menstruation B. 1 week before menstruation C. At the time of ovulation D. At the time of menstruation
At the time of menstruation *It is important that the patient is aware that studies have found that women with epilepsy are more prone to seizures at the time of menstruation. The time of ovulation, 1 week after menstruation, and 1 week before menstruation did not affect seizure activity.
A man and his wife are sitting in their pajamas in the living room when the man cries out. He attempts to rise from his chair, but he falls when he discovers that the left side of his body becomes paralyzed. The left side of his mouth and his left eye are drooping. What should his wife do? A. Help him stand and walk to the car. She can drive him to the hospital because it is only 3 miles away. He will receive care more immediately than if the wife calls an ambulance B. Sit with him for an hour to see if his condition resolves. If it worsens, she should transport him to the hospital C. Call 911 immediately. The emergency team will be able to assess him, give supportive care, and transport him D. Assess his pulse and breathing. If he is in no immediate cardiac distress, she can help him change into street clothes before driving him to the hospital
Call 911 immediately. The emergency team will be able to assess him, give supportive care, and transport him *The husband is exhibiting signs of a stroke, and time is of the essence. The emergency team can begin care as soon as they arrive and during transport. In addition, the husband will be attended to immediately in the hospital if he is received from an ambulance. (1, 2, 4) Do not perform activities that will delay treatment. As well, the wife should not drive him to the hospital since delays in care may be experienced.
A patient is admitted to the urgent care center for complaints of an abrubt onset of severe headache. Clinical history indicates that symptoms started during sleep and recurred several times during the day. These symptoms suggest A. Brain tumor B. Migraine C. Cluster headaches D. Tension headaches
Cluster headaches *Awakening with a headache and then experiencing several headache episodes during the day indicate probable cluster headaches. (1) Brain tumor may awaken the patient during the night and may cause an unrelenting headache. (2) Migraine usually lasts several hours and does not occur on awakening. Migraine is not recurrent during the same day. (4) Tension headaches tend to occur during the day and are either persistent or resolve and do not recur on the same day.
The nurse is caring for a stroke patient who is experiencing homonymous hemianopsia. The patient asks if he is going to have any limititations when discharged from the hospital. The nurse anticipates the patient will be restricted from what activity? A. Ambulating independently B. Cooking on a stove C. Reading a book D. Driving a vehicle
Driving a vehicle *Homonymous hemianopsia is blindness in part of the visual field of both eyes. Driving a vehicle may be very dangerous for this patient. With proper occupational therapy, the patient should be able to ambulate independently, cook, and read
The nurse obtaining an admission history for a patient recovering from a CVA finds a medication history including aspirin (Ecotrin). What should alert the nurse to a possible adverse effect of this drug? A. Abdominal distention N. Hyperactivity C. Nausea D. Epistaxis
Epistaxis *Aspirin is an antiplatelet agent; its major adverse effect is that it can cause bleeding. Nosebleeds would be an indication this is occurring. Abdominal distention is generally caused by a full bladder or colon; however, further evaluation is necessary, since a distended abdomen can also result from bleeding. More information would be necessary (e.g., is the abdomen firm or hard?).
The nurse is assessing a patient on intravenous (IV) phenytoin (Dilantin). Which assessment finding is most concerning to the nurse? A. Blood pressure (BP) 138/92 B. Frequent hiccups C. Irregular apical pulse D. Nausea and vomiting
Irregular apical pulse *IV phenytoin can cause cardiac arrhythmias and hypotension, especially if given faster than 50 mg/min
The nurse instructs a person taking phenytoin (Dilantin) that periodic blood tests will be necessary. The nurse explains that the laboratory checks will monitor for which potential medication-induced change? A. Potassium depletion B. Liver damage C. Increasing creatinine D. Increasing sedimentation rates
Liver damage *Periodic blood tests are recommended for people taking phenytoin to monitor for liver damage
The nurse is caring for a patient with bacterial meningitis. What interventions should the nurse include in the plan of care? A. Maintain a quiet environment with minimal stimulation B. Provide all care using sterile technique C. Limit intake of oral fluids D. Provide magazine and other activites to reduce daytime naps
Maintain a quiet environment with minimal stimulation *The environment is kept quiet with minimal stimulation to reduce the possibility of seizure. The care is done with general precautions. Fluid intake is encouraged, as are daytime naps to preserve energy
Following a craniotomy for the removal of a brain tumor, the patient exhibits nuchal rigidity, rash on the chest, headache, and a positive Brudzinski sign. What do these assessment findings indicate to the nurse? A. Intracranial bleeding B. Encephalitis C. Increasing intracranial pressure D. Meningitis
Meningitis
Which nursing intervention best encourages self-feeding in a patient with right-sided paralysis after a CVA? A. Place finger foods on the left side of the plate B. Support the right hand in holding an adaptive cup C. Seat the patient in the dining room with other residents D. Place large helpings of food in the center of the plate
Place finger foods on the left side of the plate *Finger foods ont he nonparalyzed side encourage self-feeding. Privacy is more supportive to early efforts than being in a common dining room. Smaller helpings on the same side of the nonparalyzed limb are conducive to self-feeding
The patient reports intense intermittent headaches over the last 6 months that are proveeded by specific symptoms. What symptom is the patient most likely experiencing? A. Nausea and vomiting B. Focal Seizures C. Scotoma D. Fainting
Scotoma *The headaches are most likely migraines. Scotoma (spots before the eyes) is the typical prodromal symptom of a migraine headache
A patient has been diagnosed with a cerebral neoplasm. What are the symptoms of a cerebral neoplasm? A. Grand mal seizure activity and facial paralysis B. Severe headache that wakes patient and visual problems C. Loss of muscle strength and paresthesia D. Long-term memory loss and paralysis
Severe headache that wakes patient and visual problems *The symptoms of a cerebral neoplasm depend on location and may appear gradual. Headache awakening the patient is a key sign. Vomiting, visual problems, and other signs of increased intracranial pressure may occur. Approximately 20% to 50% of adults with brain tumors develop seizure activity. Personality changes, disturbances in judgment and memory, loss of muscular strength and coordination, or difficulty speaking clearly are all symptoms of a cerebral neoplasm. Long-term memory loss, paralysis, paresthesia, grand mal seizure activity, and facial paralysis are not symptoms of a cerebral neoplasm.
The nurse is assisting a patient with agnosia after a CVA. Which intervention is most appropriate? A. Showing the patient a spoon while calling it by name and describing its purpose B. Moving the patient's hand with a toothbrush in repetitive motion to brush teeth C. Describing the placement of food on the plate D. Providing an adaptive fork to enhance self-feeding
Showing the patient a spoon while calling it by name and describing its purpose *Identifying objects and their intended use is helpful to people agnosia who can no longer recognize items. The other options are helpful to people with apraxia, hernianopsia, and altered coordination, respectively
A patient who has epilepsy is to take phenytoin (Dilantin). What is an important teaching point that the LPN/LVN should include regarding this medication? A. The patient should have periodic drug levels drawn. B. The patient should take the medication with juice containing vitamin C. C. The patient should take an extra dose of the medication before exercising. D. The patient should regulate the dosage according to need.
The patient should have periodic drug levels drawn. *The dosage of antiseizure medication is based on a therapeutic blood level of the drug; therefore, it is necessary for the patient to understand the importance of having periodic phenytoin (Dilantin) levels drawn. The dosage is not regulated by need. It is not necessary to take the medication with juice containing vitamin C. The patient should take the medication as scheduled and not take extra doses before exercising.
A patient is admitted to a rehabilitation facility following a brain injury that has resulted in dysphagia. While observing the patient and his wife, the nurse determines further instruction is necessary if which activity is performed? A. The patient tilts his head back when trying to swallow solid foods. B. The patient's wife places a teaspoon of food in the patient's mouth at a time. C. The patient sits in his chair for 45 minutes after each meal. D. The patient sips from a cup rather than using a straw.
The patient tilts his head back when trying to swallow solid foods. *The patient should tilt his head slightly forward when swallowing in order to prevent aspiration of food and fluids. Sipping from a cup, sitting upright for 45 minutes after each meal, and putting only a teaspoon of food in the patient's mouth at a time will help prevent choking and aspiration in the patient with dysphagia.
You determine that the appropriate problem statement for a patient with status epilepticus is Potential for injury due to seizure activity, An appropriate expected outcome would be A. Everyone will stay calm during the episodes B. The caregiver will stay with the patient during the episodes C. The patient will be free from any injuries associated with the seizures D. Standing orders will be obtained to medicate acute sezire episodes
The patient will be free from any injuries associated with the seizures *Interventions should prevent injuries to the head or extremities from seizure activity. Sometimes it is impossible to prevent biting of the tongue. Turning the patient to the side and suctioning the oral cavity helps prevent aspiration. (1) Staying calm or (2) staying with the patient does not prevent injury. (4) Standing orders for medication do not preclude injury to the patient during the seizure but may shorten the seizure episode and stop it.
The nurse is writing the care plan for a cerbrovascular accident (CVA) paitient who has partial left-sided paralysis and is experiencing ataxia. Which intervention is most beneficial for this patient? A. Encourage the patient to ambulate as much as possible when she feels the energy to do so B. Ensure the patient receives pureed foods and thickened liquids C. Place the patient's call light on the right side of the patient and remind her to call for assistance before getting up D. Encourage the patient to use a communication board
The patient with ataxia has experienced a loss of balance or poor coordination; therefore, placing the call light on this patient's right side and reminding her to call for helpe will best address her high risk of falling. Pureed foods and thickened liquids are necessary for the patient with dysphagia, and a communication board would assist a patient with dysarthria or aphasia
Hydrocephalus is a complication after an intercerebral bleed because: A. blood in the cerebral ventricular system interferes with the resorption of CSF. B. excessive amounts of CSF are produced after an intercerebral bleed. C. excessive hormone production increases the production of CSF. D. the ventricles become blocked by blood clots.
blood in the cerebral ventricular system interferes with the resorption of CSF.
Besides small emboli or small blood vessel rupture, a TIA may be caused by ____________________.
large artery atherosclerosis.
An effective treatment to stop a migraine headache for many people is to: A. place an ice bag on the throbbing area of the head. B. lie down in an odor-free, darkened room with the eyes closed. C. sit very still in an upright position with the eyes closed. D. apply heat packs to the forehead and neck.
lie down in an odor-free, darkened room with the eyes closed.
A patient has had a cerebrocascular accident. You assess the patient's readiness for transfer to another level of care. The patient continues to have agnosia and apraxia. These clinical findings indicate that the patient would A. require assistance with undertaking activities of daily living B. Demonstrate independence in perform ordinary tasks C. Prompt self to complete sequential tasks D. not understand verbal communication
require assistance with undertaking activities of daily living *Agnosia is the inability to recognize an object by sight, touch, or hearing; apraxia is the inability to carry out sequential movements on command. The two together would make it difficult to carry out activities of daily living. (2) Independence in performing ordinary tasks would not be possible. (3) Prompting of self would not occur, and sequential tasks could not be performed. (4) The patient does not have aphasia and could probably understand most verbal commands.
A post-CVA patient is experiencing motor difficulties on the right side of the body. You know that: A. the accident occurred on the left side of the brain. B. the accident occurred on the right side of the brain as the patient experiences the deficit of the same side as the insult. C. it was caused by a subarachnoid hemorrhage. D. because the motor symptoms are on the right side, there will be no bowel or bladder dysfunction.
the accident occurred on the left side of the brain.
One of the best things for building the self-esteem of the neurologically impaired person is: A. to establish small, accomplishable goals. B. time to adapt to body changes. C. a way to be a productive member of society. D. contact with friends and family.
to establish small, accomplishable goals.
During a seizure, it is important for the nurse to observe A. the type of aura the patient experiences B. where movement occurs and how it progresses C. the quality and rate of respirations during the seizure D. the position of the patient's arms and legs during the seizure
where movement occurs and how it progresses
