NSG252-EXAM4-Patho Book CH 16 - Disorders of Brain Function (Stroke, TBI, Seizures, etc)
-cerebrospinal fluid
1. The intracranial volume that is most capable of compensating for increasing intracranial pressure is the: -brain cell tissue. -intravascular blood. -surface sulci fluid. -cerebrospinal fluid
confusion
10. The moderate stage of the progressive degenerative Alzheimer-type dementia is manifested by behaviors that include: -confusion. -incontinence. -decreased level of consciousness. -social withdrawal.
Placement of a shunt P. 422 - hydrocephalus treatment includes surgical decompression and shunting.
11. A patient's recent computed tomography (CT) scan has revealed the presence of hydrocephalus. Which of the following treatment measures is most likely to resolve this health problem? -Aggressive diuresis -Placement of a shunt -Administration of hypertonic intravenous solution -Lumbar puncture
Headaches and memory lapses P. 423 - Concussion is a transient dysfunction caused by some mechanical force to the brain.16 Recovery usually takes place within 24 hours, but mild symptoms, such as headache, irritability, insomnia, and poor concentration and memory, may persist for months. This is postconcussion syndrome.
12. A high school senior sustained a concussion during a football game. Which of the following signs and symptoms would indicate the presence of postconcussion syndrome in the days and weeks following his injury? -Headaches and memory lapses -Recurrent nosebleeds and hypersomnia -Unilateral weakness and decreased coordination -Neck pain and decreased neck range of motion
Cells of the penumbra may be saved from hypoxic damage if blood flow is promptly restored.
13. An elderly male patient has been brought to the emergency department after experiencing stroke-like symptoms a few hours ago, and has been subsequently diagnosed with an ischemic stroke. The care team is eager to restore cerebral perfusion despite the likely death of the brain cells directly affected by the stroke. What is the rationale for the care team's emphasis on restoring circulation? -Failure to restore blood flow creates a severe risk for future transient ischemic attacks. -Necrosis will continue unabated throughout the brain unless blood flow is restored. -Cells of the penumbra may be saved from hypoxic damage if blood flow is promptly restored. -Unless blood flow is restored, the patient faces the risk of progressing to hemorrhagic stroke.
Ischemic stroke
14. A patient's emergency magnetic resonance imaging (MRI) has been examined by the physician and tPA has been administered to the patient. What was this patient's most likely diagnosis? -Status epilepticus -Subarachnoid hemorrhage -Ischemic stroke -Encephalitis
Weakness in the muscular wall of an artery
15. A patient has been diagnosed with a cerebral aneurysm and placed under close observation before treatment commences. Which of the following pathophysiologic conditions has contributed to this patient's diagnosis? -Weakness in the muscular wall of an artery -Impaired synthesis of clotting factors -Deficits in the autonomic control of blood pressure -Increased levels of cerebrospinal fluid
Inflammation allows pathogens to cross into the cerebrospinal fluid. P. 433 - In the pathophysiologic process of bacterial meningitis, the bacteria replicate and undergo lysis in the CSF, releasing endotoxins or cell wall fragments. These initiate release of inflammatory mediators, which permits pathogens, neutrophils, and albumin to move across the capillary wall into the CSF.
16. Which of the following pathophysiologic processes occurs in cases of bacterial meningitis? -Infection in the cerebrospinal fluid causes vasoconstriction and cerebral hypoxia. -Trauma introduces skin-borne pathogens to the cerebrospinal fluid. -Infection in the cerebrospinal fluid causes spinal cord compression and neurologic deficits. -Inflammation allows pathogens to cross into the cerebrospinal fluid.
-A 4-year-old child who has become uncoordinated in recent months
17. Which of the following individuals has the highest chance of having a medulloblastoma? -An 88-year-old man who has begun displaying signs and symptoms of increased ICP -A 60-year-old woman who is soon to begin radiation therapy for the treatment of breast cancer -A 4-year-old child who has become uncoordinated in recent months -A 68-year-old man who is a smoker and has a family history of cancer
Complex partial seizure *p. 439 - automatisms and unresponsiveness are common to complex partial seizures
18. A patient with a history of a seizure disorder has been observed suddenly and repetitively patting his knee. After stopping this repetitive action, the patient appears confused and is oriented to person and place but not time. What type of seizure did this patient most likely experience? -Simple partial seizure -Atonic seizure -Myoclonic seizure -Complex partial seizure
vascular dementia.
19. A patient with a long history of cigarette smoking and poorly controlled hypertension has experienced recent psychomotor deficits as a result of hemorrhagic brain damage. The patient's psychomotor deficits are likely the result of: -Alzheimer disease. -frontotemporal dementia (FTD). -vascular dementia. -Wernicke-Korsakoff syndrome
-high mean arterial pressure.
2. A late indicator of increased intracranial pressure is: -tachycardia. -right-sided heart failure. -narrow pulse pressure. -high mean arterial pressure.
I'm really hoping these medications will slow down her mental losses.
20. Which of the following statements by the husband of a patient with Alzheimer disease demonstrates an accurate understanding of his wife's medication regimen? -I'm really hoping these medications will slow down her mental losses. -We're both holding out hope that this medication will cure her Alzheimer's. -I know that this won't cure her, but we learned that it might prevent a bodily decline while she declines mentally. -I learned that if we are vigilant about her medication schedule, she may not experience the physical effects of her disease.
hydrocephalus
3. Extreme cerebral edema may cause the brain to herniate into another compartment. Upward herniation from the infratentorial compartment against the aqueduct of Sylvius causes: -hydrocephalus. -cardiac arrest. -tissue infarction. -intracranial bleeding.
tonic-clonic seizure
A 26 year-old female is resting after a 1-minute episode during which she lost consciousness while her muscles contracted and extremities extended. This was followed by rhythmic contraction and relaxation of her extremities. On regaining consciousness, she found herself to have been incontinent of urine. What has the woman most likely experienced? -A myoclonic seizure -A tonic-clonic seizure -An absence seizure -A complex partial seizure
permanent brain tissue damage. Pg. 428
4. Coup and contrecoup cerebral contusion caused by blunt head trauma against a fixed object results in: -diffuse axonal injuries. -cerebrovascular infarction. -momentary unconsciousness. -permanent brain tissue damage.
petechiae P. 434 - Meningococcal meningitis causes a petechial rash with palpable purpura in most people. The petechiae vary from pinhead to large ecchymoses, or areas of skin gangrene. Other types of meningitis also may produce a petechial rash.
9. Common manifestations of acute meningococcal meningitis, a highly contagious and lethal form of meningitis, include: -diplopia. -petechiae. -papilledema. -focal paralysis.
ipsilateral pupil dilation.
5. An intracranial epidural hematoma causes focal symptoms that can include: -ipsilateral pupil dilation. -ipsilateral hemiparesis. -diffuse venous bleeding. -commuting hydrocephalus
inattention (P. 414) Early signs of reduced consciousness are inattention, mild confusion, disorientation, and blunted responsiveness. The person experiencing delirium becomes inattentive and lethargic or agitated. They may progress to become obtunded and may respond only to vigorous or noxious stimuli.
6. The earliest signs of decreased level of consciousness include: -stupor. -lethargy. -delirium. -inattention.
increased carbon dioxide level. p. 427: Decreased oxygen saturation increases cerebral blood flow, as does an increased carbon dioxide level. Both of these factors result in less oxygen for the cells of the brain. The body attempts to compensate by increasing blood flow to the area.
7. Metabolic factors that increase cerebral blood flow include: -increased oxygen saturation. -increased carbon dioxide level. -decreased serum sodium level. -decreased hydrogen ion concentration.
resolve within one hour of onset.
8. Transient ischemic attacks (TIAs) are characterized by ischemic cerebral neurologic deficits that: -indicate aneurysm leakage. -cause minor residual deficits. -affect diffuse cerebral functions. -resolve within one hour of onset.
Encephalitis P. 434 - Less frequent causes of encephalitis include ingesting toxic substances such as lead. People experience neurologic disturbances such as lethargy, disorientation, seizures, focal paralysis, delirium and coma. Bacterial and viral meningitis are caused by bacterial and viral infections. Meningiomas are a type of brain tumor that are seen in the middle or later years of life.
A child is being seen in the emergency department (ED) after ingesting crayons with lead in them. He is disoriented and having seizures. The provider suspects he has which of the following? -Encephalitis -Viral meningitis -Meningioma -Bacterial meningitis
Absence seizures, which typically occur only in children, often are accompanied by automatisms, and there is often a brief loss of consciousness. The seizure usually lasts only a few seconds and the person is able to immediately resume normal activity. These symptoms do not accompany simple partial seizures. Atonic seizures are characterized by loss of muscle tone. Myoclonic seizures involve brief involuntary muscle contractions induced by stimuli of cerebral origin.
A child with a history of a seizure disorder has been observed suddenly and repetitively patting his knee. The child has a brief loss of contact with the environment and then is ready to resume normal activity. What type of seizure did this client most likely experience? -Absence seizure -Atonic seizure -Myoclonic seizure -Simple partial seizure or focal seizures without impairment of consciousness
gag reflex assessing for problems with chewing and swallowing
A client has experienced a pontine stroke which has resulted in severe hemiparesis. What priority assessment should the nurse perform prior to allowing the client to eat or drink from the food tray? -ability to follow commands looking for hearing loss -cornea blink reflex for ability to see the food tray -blood pressure reading looking for hypertension -gag reflex assessing for problems with chewing and swallowing
Respiratory status and oxygen saturation
A client has started having uncontrolled seizures that are not responding to usual medications. Nurses working with the client must pay special attention to which priority aspects of this client's care? Assessment of: -Respiratory status and oxygen saturation -Urine output and continence -Ability to grasp hands and squeeze on command -ECG for arrhythmias
characterized by an inability to communicate spontaneously with ease or translate thoughts or ideas into meaningful speech or writing.
A client has suffered a stroke that has affected his speech. The physician has identified the client as having expressive aphasia. Later in the day, the family asks the nurse to explain what this means. The most accurate response would be aphasia that is: -characterized by an inability to comprehend the speech of others or to comprehend written material. -characterized by an inability to communicate spontaneously with ease or translate thoughts or ideas into meaningful speech or writing. -manifested as impaired repetition and speech riddled with letter substitutions, despite good comprehension, and fluency. -nearly normal speech except for difficulty with finding singular words.
Brain death
A client has sustained a severe, diffuse brain injury that resulted in seriously compromised brain function. The client is at greatest risk for: -Brain death -Amnesia -Confusion -Paraplegia
Anticoagulation therapy **risk of stroke recurrence is highest in the first week after stroke, and the use of anticoagulation in cardioembolic stroke is imperative.
A client is admitted for cardioembolic stroke. Which therapy to best prevent recurrence of embolic stroke should the nurse monitor for effectiveness? -Anticoagulation therapy -Blood pressure management -Correction of dyslipidemia -Antiarrhythmic therapy
decrease metabolic needs and increase oxygenation.
A client suffering global cerebral ischemia a week after a suicide attempt by hanging is in the intensive care unit receiving treatment. The parent asks the nurse why it is necessary to keep the client paralyzed with medications and on the ventilator. The most appropriate response would be that these therapies: -decrease metabolic needs and increase oxygenation. -decrease the client's ability to attempt suicide again. -decrease intracranial fluid volumes and pressures. -increase oxygen demands and metabolic needs.
decrease metabolic needs and increase oxygenation.
A client suffering global cerebral ischemia a week after a suicide attempt by hanging is in the intensive care unit receiving treatment. The parent asks the nurse why it is necessary to keep the client paralyzed with medications and on the ventilator. The most appropriate response would be that these therapies: -decrease metabolic needs and increase oxygenation. -decrease the client's ability to attempt suicide again. -decrease intracranial fluid volumes and pressures. -increase oxygen demands and metabolic needs.
Complex partial or focal seizure with impairment of consciousness
A client who is diagnosed with seizures describes feeling a strange sensation before losing consciousness. The family members report that the client has been smacking his lips prior to having a seizure. Which type of seizure disorder presents with these symptoms? -Simple partial seizure or prodrome -Atonic seizure -Generalized seizures -Complex partial or focal seizure with impairment of consciousness
FOCAL **Focal seizures with impairment of consciousness sometimes referred to as psychomotor seizures are often accompanied by automatisms or repetitive nonpurposeful activities such as lip smacking, grimacing, patting, or rubbing clothing. Confusion during the postictal period (after a seizure) is common. The other seizures do not display these manifestations.
A client who is diagnosed with seizures describes feeling confused after experiencing a seizure. The family members report that the client has been smacking his lips prior to having a seizure. The client most likely experienced which type of seizure? -Focal -Myoclonic -Clonic -Atonic
Donepezil **The cholinesterase inhibitor donepezil has been effective in slowing cognitive decline in early stages of AD. Memantine is used for moderate to severe AD. Vitamin D and a diet high in protein have not been shown to impact AD, although there is some promising research indicating that anti-inflammatory elements such as Vitamins E and C and ginkgo biloba may have neuroprotective properties.
A client with Alzheimer disease (AD) is forgetful and has started to lose interest in social activities. Which treatment routine would be beneficial for the client? -Donepezil -Memantine -Vitamin D -High protein diet
Focal seizures with impairment of consciousness, sometimes referred to as psychomotor seizures, are often accompanied by automatisms or repetitive nonpurposeful activities such as lip smacking, grimacing, patting, or rubbing clothing. Confusion during the postictal period (after a seizure) is common. Atonic seizures are characterized by loss of muscle tone, and myoclonic seizures involve brief involuntary muscle contractions induced by stimuli of cerebral origin. With tonic-clonic seizures, formerly called grand mal seizures, a person has a vague warning (probably a simple focal seizure) and experiences a sharp tonic contraction of the muscles with extension of the extremities and immediate loss of consciousness.
A client with a history of a seizure disorder has been observed suddenly and repetitively patting his knee. After stopping this repetitive action, the client appears confused—he is oriented to person and place but not time. What type of seizure did this client most likely experience? -Tonic-clonic seizure -Focal seizure with impairment to consciousness -Myoclonic seizure -Atonic seizure
coma
A nurse on a neurology unit is assessing a client with a brain injury. The client is unresponsive to speech, with dilated pupils that do not react to light. The client is breathing regularly with a respiratory rate is 45 breaths/min. In response to a noxious stimulus, the client's arms and legs extend rigidly. What is the client's level of impairment? -vegetative state -coma -delirium -brain death
Retrograde amnesia **The loss of memory following a concussion can be part of the postconcussion syndrome. The term for loss of memory before the accident is retrograde amnesia. Loss of memory following the accident is anterograde amnesia.
A parent brought her 8-year-old child to the emergent care center to be examined following a fall off a playground set, resulting in a head injury. On discharge, the nurse explains to the parent that some symptoms may continue, including the inability to remember what happened before the fall. Which term best describes the diagnosis? -Concussion syndrome -Anterograde amnesia -Postconcussion syndrome -Retrograde amnesia
bruising on the surface of the brain occurred.
A soccer player has been diagnosed with a brain contusion after being injured in a game. The best explanation of the injury by the nurse would be that: -transient neurogenic dysfunction caused by mechanical force to the brain occurred. -hypoxia to the brain occurred. -tearing of brain tissue occurred. -bruising on the surface of the brain occurred.
Encephalitis
A teenager, exposed to West Nile virus a few weeks ago while camping with friends, is admitted with headache, fever, and nuchal rigidity. The teenager is also displaying some lethargy and disorientation. The nurse knows which medical diagnosis listed below may be associated with these clinical manifestations? -Rocky mountain spotted fever -Lyme disease -Encephalitis -Spinal infection
Chronic subdural
An 80-year-old client with a history of heavy alcohol use is being seen by his provider for drowsiness, confusion, and headache. His family states that he fell and hit his head "several weeks ago." Which type of hematoma does the provider suspect? -Epidural -Acute subdural -Chronic subdural -Subacute subdural
Flaccid motor response
An emergency room nurse receives a report that a client's Glasgow Coma Scale (GCS) is 3. The nurse prepares to care for a client with which of the following? -Confused conversation -Normal flexion -Flaccid motor response -Spontaneous eye opening
Atherosclerotic lesions in cerebral vessels
An older adult is brought to the emergency department after experiencing some confusion, slurred speech, and a weak arm. Now the client is back to acting normally. Suspecting a transient ischemic attack (TIA), the health care provider prescribes diagnostic testing looking for which cause of this episode? -Aneurysm leakage -Minor residual deficits -Diffuse cerebral electrical malfunctions -Atherosclerotic lesions in cerebral vessels
Localizes pain
Based on assessment parameters for motor response on the Glasgow Coma Scale, to which client should the nurse assign a score of 5? -Localizes pain -Obeys commands -Decerebrate posture -Normal flexion
Electrocardiogram
Brain death is the term that is used when the loss of function of the entire brain is irreversible. A clinical examination must be done and repeated at least 6 hours later with the same findings for brain death to be declared. What is not assessed in the clinical examination for brain death? -Respiratory effort -Responsiveness -Blink reflex -Electrocardiogram
Blood has accumulated between the man's dura and subarachnoid space.
Following a collision while mountain biking, the diagnostic work up of a 22-year-old male has indicated the presence of an acute subdural hematoma. Which pathophysiologic process most likely underlies his diagnosis? -Vessels have burst between the client's skull and his dura. -Blood has displaced CSF in the ventricles as a consequence of his coup-contrecoup injury. -Blood has accumulated between the man's dura and subarachnoid space. -A traumatic lesion in the frontal or temporal lobe has resulted in increased ICP.
Ipsilateral pupil dilation
Following a head injury, a client is diagnosed with intracranial epidural hematoma. During the initial assessment, the client suddenly becomes unconscious. What additional clinical manifestations correlate with this diagnosis? -Ipsilateral pupil dilation -Ipsilateral hemiparesis -Diffuse venous bleeding from the nose -Increased head circumference with hydrocephalus
Amygdala
For seizure disorders that do not respond to anticonvulsant medications, the option for surgical treatment exists. What is removed in the most common surgery for seizure disorders? -Hippocampus -Temporal neocortex -Amygdala -Entorhinal cortex
Intravenous lorazepam
Generalized convulsive status epilepticus is a medical emergency caused by a tonic-clonic seizure that does not spontaneously end, or recurs in succession without recovery. What is the first-line drug of choice to treat status epilepticus? -Intravenous lorazepam -Intramuscular diazepam -Intravenous cyclobenzaprine -Intramuscular cyproheptadine
Neuronal cell injury and death
Hypoxic injury will result in which effect on the brain? -Depends on the brain's compensatory mechanisms and the extent of the swelling -Neuronal cell injury and death -Can be focal or global with only one part of the brain being underperfused or all of the brain being compromised -Clouding of consciousness, bilaterally small pupils (approximately 2 mm in diameter) with a full range of constriction, and motor responses to pain that are purposeful or semi-purposeful (localizing) and often asymmetric
CT scan
Intracranial aneurysms that rupture cause subarachnoid hemorrhage in the client. How is the diagnosis of intracranial aneurysms and subarachnoid hemorrhage made? -CT scan -MRI -Loss of cranial nerve reflexes -Venography
excitotoxic **Pg 417 - Excitotoxicity is a final common pathway for neuronal cell injury and death. It is associated with excessive activity of excitatory amino acid neurotransmitters (glutamate is the primary excitatory neurotransmitter). Hypoxic injury involves oxygen deprivation. Ischemic injury is caused by a decrease of blood flow. Increased intracranial pressure may result in all three but is not caused by the excitotoxic effects.
Overstimulation of glutamate receptors is the cause of which type of brain injury? -ischemic -hypoxic -excitotoxic -increased intracranial volume and pressure
True - The other types of seizures do not display these manifestations.
T/F: Focal seizures with impairment of consciousness sometimes referred to as psychomotor seizures are often accompanied by automatisms or repetitive nonpurposeful activities such as lip smacking, grimacing, patting, or rubbing clothing.
Epidural hematoma **An epidural hematoma is one that develops between the inner side of the skull and the dura, usually resulting from a tear in an artery, most often the middle meningeal, usually in association with a head injury in which the skull is fractured. A subdural hematoma results from a torn vein; chronic subdural hematoma is common in older persons. Brain atrophy causes the brain to shrink away from the dura and to stretch fragile bridging veins. An intracranial hematoma occurs when a blood vessel ruptures within the brain or between the skull and the brain.
The CT scan report identified that a client with a skull fracture has developed a hematoma that resulted from a torn artery. The report would be interpreted as: -Epidural hematoma -Intracranial hematoma -Subdural hematoma -Chronic subdural hematoma
Prodrome
The nurse is assessing a client who has experienced a seizure. The client describes having a feeling or warning that the seizure would occur. Which term does the nurse use when documenting about this perceived warning? -ictal -prodrome -clonic -atonic
Administration of antibiotics
The nurse is caring for a client admitted to the emergency room with suspected meningitis. The nurse prepares to perform which nursing intervention upon physician orders, while diagnostic testing is being completed? -Administration of antibiotics -Administration of TPN -Administration of oxygen -Administration of pain medication
decorticate posturing
The nurse is caring for a client with head trauma. The client is flexing the arms, wrists, and fingers. There is adduction of the upper extremities with internal rotation and plantar flexion of the lower extremities. How would the nurse describe this in the notes? -decerebrate posturing -decorticate posturing -extensor posturing -diencephalon posturing
An attempt to increase cerebral perfusion
The nurse is conducting a staff inservice on increased intracranial pressure. The nurse determines that the participants are understanding the information when they identify that blood pressure increases in increased intracranial pressure because of which pathophysiologic response? -Increase in pulse rate -An attempt to increase cerebral perfusion -Decreased metabolic demand -Constriction of cerebral arteries
Hypoxia produces a generalized depressive effect on the brain.
The nurse is planning an inservice on hypoxia versus ischemia in brain-injured clients. The nurse should include which of the following? -Hypoxia denotes an interruption in blood flow. -Hypoxia produces a generalized depressive effect on the brain. -Ischemia denotes a deprivation of oxygen with maintained perfusion. -Ischemia does not interfere with delivery of glucose.
Deep vein prophylaxis Falls prevention Swallowing precautions
The nurse is planning care for a client in the acute recovery phase after an ischemic stroke. What interventions will the nurse prioritize when planning care? Select all that apply. -Deep vein prophylaxis -Falls prevention -Swallowing precautions -Reorientation exercises -Stroke prevention education
1. The nurse should assess the client with presenting symptoms of worst headache ever, nuchal rigidity, and nausea because these are presenting signs of aneurysmal subarachnoid hemorrhage from a ruptured cerebral aneurysm. The client with the presenting symptoms of fever, stiff back, and positive Kernig sign is experiencing symptoms of meningitis. Ruptured cerebral aneurysm is a medical emergency with a higher priority than meningitis.
The nurse is working in the emergency room. One client's presenting symptoms include the worst headache ever, nuchal rigidity, and nausea. Another client's presenting symptoms include fever, stiff back, and positive Kernig sign. Which client should the nurse assess first? 1. Client with the worst headache, nuchal rigidity, and nausea 2. Client with fever, stiff back, and positive Kernig sign
Craniotomy and clipping
The nurse knows that which treatment plan listed below is most likely to be prescribed after a computerized tomography (CT) scan of the head reveals a new-onset aneurysmal subarachnoid hemorrhage? -STAT administration of tissue-type plasminogen activator (tPA) -Administration of a diuretic such as mannitol to reduce cerebral edema and ICP -Monitoring in ICU for signs and symptoms of cerebral insult -Craniotomy and clipping of the affected vessel
Decorticate posturing
The nurse observes that the upper extremities of a client with a brain injury are abducted while the lower extremities are internally rotated. The nurse communicates which terminology during hand-off reporting? -Decorticate posturing -Decerebrate posturing -Persistent vegetative state -Increased intracranial pressure
Pressure The injury to the brain that stems from brain tumors is due to the pressure that leads to focal disturbances and increased intracranial pressure.
The nurse planning interventions for a client with a brain tumor bases the intervention on the knowledge that the resultant brain injury is due to: -Ischemia -Excitation -Trauma -Pressure
Large number of polymorphonuclear neutrophils **pg 433 - Lumbar puncture findings, which are necessary for accurate diagnosis, include a cloudy and purulent CSF under increased pressure. The CSF typically contains large numbers of polymorphonuclear neutrophils (up to 90,000/mm3), increased protein content, and reduced sugar content.
The nurse reading a client's lumbar puncture results notifies the physician of findings consistent with meningitis when which sign/symptom is noted? -Decreased protein count -Large number of polymorphonuclear neutrophils -Clear cerebrospinal fluid -Increased glucose
assess the client for additional signs/symptoms of increased intracranial pressure
The spouse of a client admitted to the hospital after a motor vehicle accident reports to the nurse that the client has become very drowsy. The nurse should: -assess the client for additional signs/symptoms of increased intracranial pressure. -contact the physician. -instruct the spouse not to let the client fall asleep until the physician has assessed the client. -prepare the client for EEG testing.
coma
What LOC is marked by the client not responding appropriately to stimuli and being in a sleeplike state with eyes closed. The client is not conscious, but this client still exhibits a pain response (the extended arms and legs indicate decerebrate posturing)? -vegetative state -coma -delirium -brain death
0 to 15 mm Hg
Which intracranial pressure (ICP) would the nurse consider a normal reading? -45 to 60 mm Hg -0 to 15 mm Hg -15 to 30 mm Hg -30 to 45 mm Hg
-Loss of central vision -Repeating of verbal responses
Which symptoms would support the diagnosis of a stroke involving the posterior cerebral artery? Select all that apply. -Loss of central vision -Repeating of verbal responses -Contralateral hemiplegia -Aphasia -Denial of paralyzed side
Tonic-clonic seizure
With ______________ seizures, formerly called grand mal seizures, a person has a vague warning (probably a simple focal seizure) and experiences a sharp tonic contraction of the muscles with extension of the extremities and immediate loss of consciousness. -Tonic-clonic seizure -Focal seizure with impairment to consciousness -Myoclonic seizure -Atonic seizure
Atonic
___________ seizures are characterized by loss of muscle tone, and myoclonic seizures involve brief involuntary muscle contractions induced by stimuli of cerebral origin. -Tonic-clonic seizure -Focal seizure with impairment to consciousness -Myoclonic seizure -Atonic seizure
Focal seizure with impairment to consciousness
________________________, sometimes referred to as psychomotor seizures, are often accompanied by automatisms or repetitive nonpurposeful activities such as lip smacking, grimacing, patting, or rubbing clothing. Confusion during the postictal period (after a seizure) is common. -Tonic-clonic seizure -Focal seizure with impairment to consciousness -Myoclonic seizure -Atonic seizure