NU 250- quiz #3

Which conditions can lead to the development of a brain abscess (select all that apply.)? A: Endocarditis B: Ear infection C: Tooth abscess D: Skull fracture E: Scalp laceration F: Sinus infection

A: Endocarditis B: Ear infection C: Tooth abscess D: Skull fracture F: Sinus infection Infections in close proximity to the brain can migrate into the brain. A skull fracture impairs the protection of the brain, and infection could occur. Endocarditis can release organisms in the bloodstream that mobilize to the brain. A scalp laceration does not lead to a brain abscess.

The patient is admitted with a HA, fever, and general malaise. The HCP has asked that the patient be prepared for a lumbar puncture. What is a priority nursing action to avoid complications? A: Ensure that CT scan is performed prior to the lumbar puncture B: Assess laboratory results for changes in the white cell count. C: Provide acetaminophen for the HA and fever before the procedure D: Administer antibiotics before the procedure to treat the potential meningitis

A: Ensure that CT scan is performed prior to the lumbar puncture

What nursing intervention should be implemented for a patient experiencing increased intracranial pressure (ICP)? A: Monitor fluid and electrolyte status carefully. B: Position the patient in a high Fowler's position. C: Administer vasoconstrictors to maintain cerebral perfusion. D: Maintain physical restraints to prevent episodes of agitation.

A: Monitor fluid and electrolyte status carefully. Fluid and electrolyte disturbances can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically administered in the treatment of ICP.

The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. Which complications will the nurse monitor for (select all that apply.)? A: Seizures B: Vision loss C: Cerebral edema D: Pituitary dysfunction E: Parathyroid dysfunction F: Focal neurologic deficits

A: Seizures B: Vision loss C: Cerebral edema D: Pituitary dysfunction F: Focal neurologic deficits Brain tumors can cause a wide variety of symptoms depending on location such as seizures, vision loss, and focal neurologic deficits. Tumors can put pressure on the pituitary, leading to dysfunction of the gland. As the tumor grows, clinical manifestations of increased intracranial pressure and cerebral edema appear. The parathyroid gland is not regulated by the cerebral cortex or the pituitary gland.

The patient's magnetic resonance imaging revealed the presence of a brain tumor. The nurse anticipates which treatment modality? A: Surgery B: Chemotherapy C: Radiation therapy D: Biologic drug therapy

A: Surgery Surgical removal is the preferred treatment for brain tumors. Chemotherapy and biologic drug therapy are limited by the blood-brain barrier, tumor cell heterogeneity, and tumor cell drug resistance. Radiation therapy may be used as a follow-up measure after surgery.

Stimulation of the parasympathetic nervous system results in (select all that apply) A: constriction of the bronchi B: dilation of the skin blood vessels C: increased secretion of insulin D: increased blood glucose levels E: relaxation of the urinary sphincters

A: constriction of the bronchi B: dilation of the skin blood vessels C: increased secretion of insulin E: relaxation of the urinary sphincters

A patient who is having an acute exacerbation of multiple sclerosis has a prescription for methylprednisolone (Solu-Medrol) 150 mg IV. The label on the vial reads: methylprednisolone 125 mg in 2 mL. How many mL will the nurse administer?

ANS: 2.4 With a concentration of 125 mg/2 mL, the nurse will need to administer 2.4 mL to obtain 150 mg of methylprednisolone.

After change-of-shift report, which patient should the nurse assess first? a. Patient with myasthenia gravis who is reporting increased muscle weakness b. Patient with a bilateral headache described as "like a band around my head" c. Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin) d. Patient with Parkinson's disease who has developed cogwheel rigidity of the arms

ANS: A Because increased muscle weakness may indicate the onset of a myasthenic crisis, the nurse should assess this patient first. The other patients should also be assessed but do not appear to need immediate nursing assessments or actions to prevent life-threatening complications.

A woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate? a. "MS symptoms may be worse after the pregnancy." b. "Women with MS frequently have premature labor." c. "MS is associated with an increased risk for congenital defects." d. "Symptoms of MS are likely to become worse during pregnancy."

ANS: A During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labor is not affected by MS.

The nurse advises a patient with myasthenia gravis (MG) to a. perform physically demanding activities early in the day. b. anticipate the need for weekly plasmapheresis treatments. c. do frequent weight-bearing exercise to prevent muscle atrophy. d. protect the extremities from injury due to poor sensory perception.

ANS: A Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled but is used for myasthenia crisis or for situations in which corticosteroid therapy must be avoided. There is no decrease in sensation with MG, and muscle atrophy does not occur because although there is muscle weakness, they are still used.

A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when evaluating for adverse effects of the medication? a. Inspect the oral mucosa. c. Auscultate the bowel sounds. b. Listen to the lung sounds. d. Check pupil reaction to light.

ANS: A Phenytoin can cause gingival hyperplasia, but does not affect bowel sounds, lung sounds, or pupil reaction to light.

A patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches. Which action will the nurse plan to take first? a. Discuss the need to stop taking the acetaminophen. b. Suggest the use of biofeedback for headache control. c. Describe the use of botulism toxin (Botox) for headaches. d. Teach the patient about magnetic resonance imaging (MRI).

ANS: A The headache description suggests that the patient is experiencing medication overuse headache. The initial action will be withdrawal of the medication. The other actions may be needed if the headaches persist.

A patient reports feeling numbness and tingling of the left arm before experiencing a seizure. The nurse determines that this history is consistent with what type of seizure? a. Focal c. Absence b. Atonic d. Myoclonic

ANS: A The initial symptoms of a focal seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.

The nurse observes a patient ambulating in the hospital hall when the patient's arms and legs suddenly jerk and the patient falls to the floor. The nurse will first a. assess the patient for a possible injury. b. give the scheduled divalproex (Depakote). c. document the timing and description of the seizure. d. notify the patient's health care provider about the seizure.

ANS: A The patient who has had a myoclonic seizure and fall is at risk for head injury and should first be evaluated and treated for this possible complication. Documentation of the seizure, notification of the health care provider, and administration of antiseizure medications are also appropriate actions, but the initial action should be assessment for injury.

A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which nursing interventions will be included in the plan of care (select all that apply)? a. Provide an elevated toilet seat. b. Cut patient's food into small pieces. c. Serve high-protein foods at each meal. d. Place an armchair at the patient's bedside. e. Observe for sudden exacerbation of symptoms.

ANS: A, B, D Because the patient with Parkinson's disease has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High-protein foods will decrease the effectiveness of L-dopa. Parkinson's disease is a steadily progressive disease without acute exacerbations.

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room (select all that apply)? a. Side-rail pads d. Suction tubing b. Tongue blade e. Urinary catheter c. Oxygen mask f. Nasogastric tube

ANS: A, C, D The patient is at risk for further seizures, and O2 and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Use of tongue blades during a seizure is contraindicated. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. A urinary catheter is not required unless there is urinary retention.

A patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Observe for agitation and paranoia. b. Assist with active range of motion (ROM). c. Give muscle relaxants as needed to reduce spasms. d. Use simple words and phrases to explain procedures.

ANS: B ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help maintain strength as long as possible. Psychotic manifestations such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient's ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.

A hospitalized patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first? a. Put a moist hot pack on the patient's neck. b. Start the prescribed PRN O2 at 6 L/min. c. Give the ordered PRN acetaminophen (Tylenol). d. Notify the patient's health care provider immediately.

ANS: B Acute treatment for cluster headache is administration of 100% O2 at 6 to 8 L/min. If the patient obtains relief with the O2, there is no immediate need to notify the health care provider. Cluster headaches last only 60 to 90 minutes, so oral pain medications have minimal effect. Hot packs are helpful for tension headaches but are not as likely to reduce pain associated with a cluster headache.

The home health registered nurse (RN) is planning care for a patient with a seizure disorder related to a recent head injury. Which nursing action can be delegated to a licensed practical/vocational nurse (LPN/LVN)? a. Make referrals to appropriate community agencies. b. Place medications in the home medication organizer. c. Teach the patient and family how to manage seizures. d. Assess for use of medications that may precipitate seizures.

ANS: B LPN/LVN education includes administration of medications. The other activities require RN education and scope of practice.

Which intervention will the nurse include in the plan of care for a patient with primary restless legs syndrome (RLS) who is having difficulty sleeping? a. Teach about the use of antihistamines to improve sleep. b. Suggest that the patient exercise regularly during the day. c. Make a referral to a massage therapist for deep massage of the legs. d. Assure the patient that the problem is transient and likely to resolve.

ANS: B Nondrug interventions such as getting regular exercise are initially suggested to improve sleep quality in patients with RLS. Antihistamines may aggravate RLS. Massage does not alleviate RLS symptoms, and RLS is likely to progress in most patients.

A patient with Parkinson's disease has bradykinesia. Which action will the nurse include in the plan of care? a. Instruct the patient in activities that can be done while lying or sitting. b. Suggest that the patient rock from side to side to initiate leg movement. c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to keep the feet in contact with the floor and slide them forward.

ANS: B Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.

Which action will the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder? a. Encourage a decreased evening intake of fluid. b. Teach the patient how to use the Credé method. c. Suggest the use of adult incontinence briefs for nighttime only. d. Assist the patient to the commode every 2 hours during the day.

ANS: B The Credé method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.

When a 74-yr-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor, the nurse will anticipate teaching the patient about a. oral corticosteroids. b. antiparkinsonian drugs. c. magnetic resonance imaging (MRI). d. electroencephalogram (EEG) testing.

ANS: B The clinical diagnosis of Parkinson's is made when tremor, rigidity, and akinesia, and postural instability are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. MRI and EEG are not useful in diagnosing Parkinson's disease, and corticosteroid therapy is not used to treat it.

A high school teacher who has been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, "I cannot teach any more. It will be too upsetting if I have a seizure at work." Which response by the nurse specifically addresses the patient's concern? a. "You might benefit from some psychologic counseling." b. "Epilepsy usually can be well controlled with medications." c. "You will want to contact the Epilepsy Foundation for assistance." d. "The Department of Vocational Rehabilitation can help with work retraining."

ANS: B The nurse should inform the patient that most patients with seizure disorders are controlled with medication. The other information may be necessary if the seizures persist after treatment with antiseizure medications is implemented.

After a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a. Auscultate the patient's bowel sounds. b. Notify the patient's health care provider. c. Administer the prescribed PRN antiemetic drug. d. Give the scheduled dose of prednisone (Deltasone).

ANS: B The patient's history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.

A hospitalized patient complains of a bilateral headache (4/10 on the pain scale) that radiates from the base of the skull. Which prescribed PRN medications should the nurse administer initially? a. Lorazepam (Ativan) c. Morphine sulfate (MS Contin) b. Acetaminophen (Tylenol) d. Butalbital and aspirin (Fiorinal)

ANS: B The patient's symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, which is sometimes combined with a sedative or muscle relaxant. Lorazepam may be used in conjunction with acetaminophen but would not be appropriate as the initial monotherapy. Morphine sulfate and butalbital and aspirin would be more appropriate for a headache that did not respond to a nonopioid analgesic.

The health care provider is considering the use of sumatriptan (Imitrex) for a 54-yr-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider? a. The patient drinks 1 to 2 cups of coffee daily. b. The patient had a recent acute myocardial infarction. c. The patient has had migraine headaches for 30 years. d. The patient has taken topiramate (Topamax) for 2 months.

ANS: B The triptans cause coronary artery vasoconstriction and should be avoided in patients with coronary artery disease. The other information will be reported to the health care provider, but none of it indicates that sumatriptan would be an inappropriate treatment.

The nurse expects the assessment of a patient who is experiencing a cluster headache to include a. nuchal rigidity. c. projectile vomiting. b. unilateral ptosis. d. throbbing, bilateral facial pain.

ANS: B Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increased intracranial pressure. Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.

When obtaining a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS), the nurse should a. assess for the presence of chest pain. b. inquire about urinary tract problems. c. inspect the skin for rashes or discoloration. d. ask the patient about any increase in libido.

ANS: B Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.

Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis? a. Pupil size c. Respiratory effort b. Grip strength d. Level of consciousness

ANS: C Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? a. Insert an oral airway during the seizure to maintain a patent airway. b. Restrain the patient's arms and legs to prevent injury during the seizure. c. Time and observe and record the details of the seizure and postictal state. d. Avoid touching the patient to prevent further nervous system stimulation.

ANS: C Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.

A 33-yr-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching? a. Recommendation to drink at least 4 L of fluid daily b. Need to avoid driving or operating heavy machinery c. How to draw up and administer injections of the medication d. Use of contraceptive methods other than oral contraceptives

ANS: C Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. There is no need to avoid driving or drink large fluid volumes when taking glatiramer.

Which information about a 60-yr-old patient with multiple sclerosis indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)? a. The patient walks a mile each day for exercise. b. The patient complains of pain with neck flexion. c. The patient has an increased serum creatinine level. d. The patient has the relapsing-remitting form of MS.

ANS: C Dalfampridine should not be given to patients with impaired renal function. The other information will not impact whether the dalfampridine should be administered.

A 40-yr-old patient is diagnosed with early Huntington's disease (HD). When teaching the patient, spouse, and adult children about this disorder, the nurse will provide information about the a. use of levodopa-carbidopa (Sinemet) to help reduce HD symptoms. b. prophylactic antibiotics to decrease the risk for aspiration pneumonia. c. option of genetic testing for the patient's children to determine their own HD risks. d. lifestyle changes of improved nutrition and exercise that delay disease progression.

ANS: C Genetic testing is available to determine whether an asymptomatic individual has the HD gene. The patient and family should be informed of the benefits and problems associated with genetic testing. Sinemet will increase symptoms of HD because HD involves an increase in dopamine. Antibiotic therapy will not reduce the risk for aspiration. There are no effective treatments or lifestyle changes that delay the progression of symptoms in HD.

The nurse determines that teaching about management of migraine headaches has been effective when the patient says which of the following? a. "I can take the (Topamax) as soon as a headache starts." b. "A glass of wine might help me relax and prevent a headache." c. "I will lie down someplace dark and quiet when the headaches begin." d. "I should avoid taking aspirin and sumatriptan (Imitrex) at the same time."

ANS: C It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate (Topamax) is used to prevent migraines and must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal antiinflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches.

Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication? a. Patient has tonic-clonic seizures. b. Patient experiences an aura before seizures. c. Patient has minor elevations in the liver function tests. d. Patient's most recent blood pressure is 156/92 mm Hg.

ANS: C Many older patients (especially with compromised liver function) may not be able to metabolize phenytoin. The health care provider may need to choose another antiseizure medication. Phenytoin is an appropriate medication for patients with tonic-clonic seizures, with or without an aura. Hypertension is not a contraindication for phenytoin therapy.

A 22-yr-old patient seen at the health clinic with a severe migraine headache tells the nurse about having similar headaches recently. Which initial action should the nurse take? a. Teach about the use of triptan drugs. b. Refer the patient for stress counseling. c. Ask the patient to keep a headache diary. d. Suggest the use of muscle-relaxation techniques.

ANS: C The initial nursing action should be further assessment of the precipitating causes of the headaches, quality, and location of pain. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed first.

Which prescribed intervention will the nurse implement first for a patient in the emergency department who is experiencing continuous tonic-clonic seizures? a. Give phenytoin (Dilantin) 100 mg IV. b. Monitor level of consciousness (LOC). c. Administer lorazepam (Ativan) 4 mg IV. d. Obtain computed tomography (CT) scan.

ANS: C To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin will also be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.

Which medication taken by a patient with restless legs syndrome should the nurse discuss with the patient? a. Ibuprofen c. Acetaminophen b. Multivitamin d. Diphenhydramine

ANS: D Antihistamines can aggravate restless legs syndrome. The other medications will not contribute to restless legs syndrome.

A patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which information indicates a need for change in the medication or dosage? a. Shuffling gait c. Cogwheel rigidity of limbs b. Tremor at rest d. Uncontrolled head movement

ANS: D Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.

A 62-yr-old patient who has Parkinson's disease is taking bromocriptine (Parlodel). Which information obtained by the nurse may indicate a need for a decrease in the dosage? a. The patient has a chronic dry cough. b. The patient has four loose stools in a day. c. The patient develops a deep vein thrombosis. d. The patient's blood pressure is 92/52 mm Hg.

ANS: D Hypotension is an adverse effect of bromocriptine, and the nurse should check with the health care provider before giving the medication. Diarrhea, cough, and deep vein thrombosis are not associated with bromocriptine use.

Which nursing diagnosis is of highest priority for a patient with Parkinson's disease who is unable to move the facial muscles? a. Activity intolerance b. Self-care deficit: toileting c. Ineffective self-health management d. Imbalanced nutrition: less than body requirements

ANS: D The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses may also be appropriate for a patient with Parkinson's disease, but the data do not indicate that they are current problems for this patient.

A 19-yr-old woman is hospitalized for a frontal skull fracture from a blunt force head injury. Thin bloody fluid is draining from the patient's nose. What action by the nurse is most appropriate? A: Test the drainage for the presence of glucose. B: Apply a loose gauze pad under the patient's nose. C: Place the patient in a modified Trendelenburg position. D: Ask the patient to gently blow the nose to clear the drainage.

B: Apply a loose gauze pad under the patient's nose. Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage from the nose) may occur with a frontal skull fracture. A loose collection pad may be placed under the nose, and if thin bloody fluid is present, the blood will coalesce and a yellow halo will form if CSF is present. If clear drainage is present, testing for glucose would indicate the presence of CSF. Mixed blood and CSF will test positive for glucose because blood contains glucose. If CSF rhinorrhea occurs, the nurse should inform the physician immediately. The head of the bed may be raised to decrease the CSF pressure so that a tear can seal. The nurse should not place a dressing or tube in the nasal cavity, and the patient should not sneeze or blow the nose.

The nurse is caring for a patient admitted with a subdural hematoma after a motor vehicle accident. What change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)? A: Tachypnea B: Bradycardia C: Hypotension D: Narrowing pulse pressure

B: Bradycardia Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with increased ICP. They consist of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.

The nurse is caring for a patient admitted to the hospital with a head injury who requires frequent neurologic assessment. Which components are assessed using the Glasgow Coma Scale (GCS) (select all that apply.)? A: Judgment B: Eye opening C: Abstract reasoning D: Best verbal response E: Best motor response F: Cranial nerve function

B: Eye opening D: Best verbal response E: Best motor response The three dimensions of the GCS are eye opening, best verbal response, and best motor response. Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.

The nurse is assessing the muscle strength of an older adult patient. The nurse knows the findings cannot be compared with those of a younger adult because A: nutritional status is better in young adults B: muscle bulk and strength decrease in older adults C: muscle strength should be the same for all adults D: most young adults exercise more than older adults

B: muscle bulk and strength decrease in older adults

The nurse prepares to administer temozolomide (Temodar) to a 59-yr-old white male patient with a glioblastoma multiforme (GBM) brain tumor. What should the nurse assess before giving the medication? A: Serum potassium and serum sodium levels B: Urine osmolality and urine specific gravity C: Absolute neutrophil count and platelet count D: Cerebrospinal fluid pressure and cell count

C: Absolute neutrophil count and platelet count Temozolomide causes myelosuppression. The nurse should assess the absolute neutrophil count and the platelet count. The absolute neutrophil count should be greater than 1500/ìL and platelet count greater than 100,000/ìL.

The physician orders intracranial pressure (ICP) readings every hour for a 23-yr-old male patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. It is most important for the nurse to take which action? A: Document the ICP reading in the chart. B: Determine if the patient has a headache. C: Assess the patient's level of consciousness. D: Position the patient with head elevated 60 degrees.

C: Assess the patient's level of consciousness. The patient has an increased ICP (normal ICP ranges from 5 to 15 mm Hg). The most sensitive and reliable indicator of neurologic status is level of consciousness. The Glasgow Coma Scale may be used to determine the degree of impaired consciousness.

A 68-yr-old man with suspected bacterial meningitis just had a lumbar puncture in which cerebrospinal fluid was obtained for culture. Which medication should the nurse administer first? A: Codeine B: Phenytoin (Dilantin) C: Ceftriaxone (Rocephin) D: Acetaminophen (Tylenol)

C: Ceftriaxone (Rocephin) Bacterial meningitis is a medical emergency. When meningitis is suspected, antibiotic therapy (e.g., ceftriaxone) is instituted immediately after the collection of specimens for cultures and even before the diagnosis is confirmed. Dexamethasone may also be prescribed before or with the first dose of antibiotics. The nurse should collaborate with the health care provider to manage the headache (with codeine), fever (with acetaminophen), and seizures (with phenytoin).

A patient has a systemic blood pressure of 120/60 mm Hg and an ICP of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? A: High blood flow to the brain B: Normal intracranial pressure C: Impaired blood flow to the brain D: Adequate autoregulation of blood flow

C: Impaired blood flow to the brain Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = SBP + 2 (DBP)/ 3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP - ICP: 80 mm Hg - 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24 mm Hg, treatment is required.

In planning long-term care for a patient after craniotomy, what must the nurse include in family and caregiver education? A: Seizure disorders may occur in weeks or months. B: The family will be unable to cope with role reversals. C: There are often residual changes in personality and cognition. D: Referrals will be made to eliminate residual deficits from the damage.

C: There are often residual changes in personality and cognition. In long-term care planning, the nurse must include the family and caregiver when teaching about potential residual changes in personality, emotions, and cognition as these changes are most difficult for the patient and family to accept. Seizures may or may not develop. The family and patient may or may not be able to cope with role reversals. Although residual deficits will not be eliminated with referrals, they may be improved.

The patient with a brain tumor is being monitored for increased intracranial pressure (ICP) with a ventriculostomy. What nursing intervention is priority? A: Administer IV mannitol B: Ventilator use to hyperoxygenate the patient C: Use strict aseptic technique with dressing changes. D: Be aware of changes in ICP related to leaking cerebrospinal fluid (CSF).

C: Use strict aseptic technique with dressing changes. The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection. IV mannitol or hypertonic saline will be administered as ordered for increased ICP. Ventilators may be used to maintain oxygenation. CSF leaks may cause inaccurate ICP readings, or CSF may be drained to decrease ICP, but strict aseptic technique to prevent infection is the nurse's priority of care.

A patient sustained a diffuse axonal injury from a traumatic brain injury (TBI). Why are IV fluids being decreased and enteral feedings started? A: Free water should be avoided. B: Sodium restrictions can be managed. C: Dehydration can be better avoided with feedings. D: Malnutrition promotes continued cerebral edema.

D: Malnutrition promotes continued cerebral edema. A patient with diffuse axonal injury is unconscious and, with increased intracranial pressure, is in a hypermetabolic, hypercatabolic state that increases the need for energy to heal. Malnutrition promotes continued cerebral edema, and early feeding may improve outcomes when begun within 3 days after injury. Fluid and electrolytes will be monitored to maintain balance with the enteral feedings. Excess intravenous fluid administration will also increase cerebral edema.

In a patient with a disease that affects the myelin sheath of nerves, such as multiple sclerosis, the glial cells affected are the A: microglia B: astrocytes C: ependymal cells D: oligodendrocytes

D: Oligodendrocytes

The nurse assesses a patient for signs of meningeal irritation. Which finding indicates nuchal rigidity is present? A: Tonic spasms of the legs B: Curling in a fetal position C: Arching of the neck and back D: Resistance to flexion of the neck

D: Resistance to flexion of the neck Nuchal rigidity is a clinical manifestation of meningitis. During assessment, the patient will resist passive flexion of the neck by the health care provider. Tonic spasms of the legs, curling in a fetal position, and arching of the neck and back are not related to meningeal irritation.

A 32-yr-old female patient is diagnosed with diabetes insipidus after transsphenoidal resection of a pituitary adenoma. What should the nurse consider as a sign of improvement? A: Serum sodium of 120 mEq/L B: Urine specific gravity of 1.001 C: Fasting blood glucose of 80 mg/dL D: Serum osmolality of 290 mOsm/kg

D: Serum osmolality of 290 mOsm/kg Laboratory findings in diabetes insipidus include an elevation in serum osmolality and serum sodium and a decrease in urine specific gravity. Normal serum osmolality is 275 to 295 mOsm/kg, normal serum sodium is 135 to 145 mEq/L, and normal specific gravity is 1.003 to 1.030. Elevated blood glucose levels occur with diabetes mellitus.

Drugs or diseases the impair the function of the extrapyramidal system may cause loss of a. sensations of pain and temperature b. regulation of the autonomic nervous system c. integration of somatic and special sensory inputs d. automatic movements associated with skeletal muscle activity

D: automatic movements associated with skeletal muscle memory

The nurse is caring for a patient with peripheral neuropathy who is scheduled for EMG studies tomorrow morning. The nurse should A: ensure the patient has an empty bladder B: instruct the patient about the risk of electric shock C: ensure the patient has no metallic jewelry or metal fragments D: instruct the patient that pain may be experienced during the study

D: instruct the patient that pain may be experienced during the study

A patient is suspected of having a brain tumor. The s/s include: memory deficits, visual disturbances, weakness of right upper and lower extremities and personality changes. The nurse recognizes that the tumor is most likely located in the a. Frontal lobe b. Parietal lobe c. Occipital lobe d. Temporal lobe

a. Frontal lobe

Which modifiable risk factor for stroke would be most important for the nurse to include when planning a community education program? a. Hypertension b. Hyperlipidemia c. Alcohol consumption d. Oral contraceptive use

a. Hypertension Hypertension is the single most important modifiable risk factor, but it is still often undetected and inadequately treated. The public is often more aware of hyperlipidemia and oral contraceptive use as risk factors for stroke. Alcohol is also a modifiable risk factor.

The nurse is caring for a patient with a neurologic disease that affects the pyramidal tract. What clinical manifestation does the nurse assess in this patient? a. Impaired muscle movement b. Decreased deep tendon reflexes c. Decreased level of consciousness d. Impaired sensation of touch, pain, and temperature

a. Impaired muscle movement Among the most important descending tracts are the corticobulbar and corticospinal tracts, collectively termed the pyramidal tract. These tracts carry volitional (voluntary) impulses from the cortex to the cranial and peripheral nerves. Dysfunction of the pyramidal tract is likely to manifest as impaired movement because of hypertonicity. Diseases affecting the pyramidal tract do not result in changes in level of consciousness, impaired reflexes, or decreased sensation.

A CT scan of a 68-yr-old male patient's head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? a. Maintenance of the patient's airway b. Positioning to promote cerebral perfusion c. Control of fluid and electrolyte imbalances d. Administration of tissue plasminogen activator (tPA)

a. Maintenance of the patient's airway Maintenance of a patent airway is the priority in the acute care of a patient with a hemorrhagic stroke. It supersedes the importance of fluid and electrolyte imbalance and positioning. tPA is contraindicated in hemorrhagic stroke.

During admission of a patient with a severe head injury to the emergency department the nurse places the highest priority on assessment for a. Patency of airway b. Presence of neck injury c. Neurologic status with Glasgow coma scale d. Cerebrospinal fluid leakage from the ears or nose

a. Patency of airway

The patient with diabetes mellitus had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient? a. Safety measures b. Patience with communication c. Mobility assistance on the right side d. Place food in the left side of patient's mouth.

a. Safety measures A patient with a right-sided stroke has spatial-perceptual deficits, tends to minimize problems, has a short attention span, is impulsive, and may have impaired judgment. Safety is the biggest concern for this patient. Hemiplegia occurs on the left side of this patient's body. The patient with a left-sided stroke has hemiplegia on the right, is more likely to have communication problems, and needs mobility assistance on the right side with food placed on the left side if the patient needs to be fed after a swallow evaluation has taken place.

The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions (select all that apply.)? a. Ticlopidine b. Clopidogrel c. Enoxaparin d. Dipyridamole e. Enteric-coated aspirin f. Tissue plasminogen activator (tPA)

a. Ticlopidine b. Clopidogrel d. Dipyridamole e. Enteric-coated aspirin Aspirin is the most frequently used antiplatelet agent. Other drugs to prevent clot formation include clopidogrel, dipyridamole, ticlopidine, combined dipyridamole and aspirin, and anticoagulant drugs such as oral warfarin. Tissue plasminogen activator is a fibrinolytic medication used to treat ischemic stroke, not prevent TIAs or strokes.

When assessing a patient with a traumatic brain injury, the nurse notes uncoordinated movement of the extremities. How should the nurse document this assessment? a, Ataxia b. Apraxia c. Anisocoria d. Anosognosia

a. ataxia Ataxia is a lack of coordination of movement, possibly caused by lesions of sensory or motor pathways, cerebellum disorders, or certain medications. Apraxia is the inability to perform learned movements despite having the desire and physical ability to perform them related to a cerebral cortex lesion. Anisocoria is inequality of pupil size from an optic nerve injury. Anosognosia is the inability to recognize a bodily defect or disease related to lesions in the right parietal cortex.

Common psychosocial reactions of the stroke patient to the stroke include (select all that apply) a. depression. b. disassociation. c. intellectualization. d. sleep disturbances. e. denial of severity of stroke.

a. depression. d. sleep disturbances. e. denial of severity of stroke.

A patient's eyes jerk while the patient looks to the left. You will record this finding as a. nystagmus b. CN VI palsy c. oculocephalia d. ophthalmic dyskinesia

a. nystagmus

A female patient has left-sided hemiplegia after an ischemic stroke 4 days earlier. How should the nurse promote skin integrity? a. Position the patient on her weak side the majority of the time. b. Alternate the patient's positioning between supine and side-lying. c. Avoid the use of pillows in order to promote independence in positioning. d. Establish a schedule for the massage of areas where skin breakdown emerges.

b. Alternate the patient's positioning between supine and side-lying. A position change schedule should be established for stroke patients. An example is side-back-side, with a maximum duration of 2 hours for any position. The patient should be positioned on the weak or paralyzed side for only 30 minutes. Pillows may be used to facilitate positioning. Areas of skin breakdown should never be massaged.

The nurse is performing a neurologic assessment for a patient. When assessing the accessory nerve, what action should the nurse take? a. Assess the gag reflex by stroking the posterior pharynx. b. Ask the patient to shrug the shoulders against resistance. c. Ask the patient to push the tongue to either side against resistance. d. Have the patient say "ah" while visualizing elevation of soft palate.

b. Ask the patient to shrug the shoulders against resistance. The spinal accessory nerve is tested by asking the patient to shrug the shoulders against resistance and to turn the head to either side against resistance while observing the sternocleidomastoid muscles and the trapezius muscles. Assessing the gag reflex and saying "ah" are used to assess the glossopharyngeal and vagus nerves. Asking the patient to push the tongue to either side against resistance is used to assess the hypoglossal nerve.

The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke? a. Impulsivity b. Impaired speech c. Left-side neglect d. Short attention span

b. Impaired speech Clinical manifestations of left-sided brain damage include right hemiplegia, impaired speech/language, impaired right/left discrimination, and slow and cautious performance. Impulsivity, left-sided neglect, and short attention span are all manifestations of right-sided brain damage.

Vasogenic cerebral edema increases intracranial pressure by a. shifting fluid in the gray matter b. altering the endothelial lining of cerebral capillaries c. leaking molecules from the intracellular fluid to the capillaries d. alternating the osmotic gradient flow into the intravascular component

b. altering the endothelial lining of cerebral capillaries

A nursing measure that is indicated to reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is a. administering codeine for relief of head and neck pain b. controlling fever with prescribed drugs and cooling techniques c. keeping the room dark and quiet to minimize environmental stimulation d. maintaining the patient on strict bed rest with the head of the bed slightly elevated

b. controlling fever with prescribed drugs and cooling techniques

The nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to a. keep the head of the bed flat b. elevate the head of the bed to 30 degrees c. maintain patient of the left side with the head supported on a pillow d. use a continuous rotation bed to continuously change patient position

b. elevate the head of the bed to 30 degrees

For a patient who is suspected of having a stroke, one of the most important pieces of information that the nurse can obtain is a. time of the patient's last meal. b. time at which stroke symptoms first appeared. c. patient's hypertension history and management. d. family history of stroke and other cardiovascular diseases.

b. time at which stroke symptoms first appeared.

A patient is seen in the emergency department after diving into the pool and hitting the bottom with the blow to face that hyperextended the neck and scraped the skin off the nose. The patient also described "having double vision" when looking down. During the neurologic exam, the nurse finds the patient is unable to abduct either eye. The nurse recognizes this finding is related to a: a basal skull fracture b: a stretch injury to bilateral CN VI c: a stiff neck from the hyperextension injury d: facial swelling from the scrape on the bottom of this pool

b: a stretch injury to bilateral CN VI

During the admitting neurologic examination, the nurse determines the patient has speech difficulties as well as weakness of the right arm and lower face. The nurse would expect a CT scan to show pathology in the distribution of the a. basilar artery. b. left middle cerebral artery. c. right anterior cerebral artery. d. left posterior communicating artery.

b: left middle cerebral artery

When providing care to the patient with an acute stroke, which duty can be delegated to the LPN/LVN? a. Screen patient for tPA eligibility. b. Assess the patient's ability to swallow. c. Administer scheduled anticoagulant medications. d. Place equipment needed for seizure precautions in room.

c. Administer scheduled anticoagulant medications. Assessment and screening are considered part of the registered nurse scope of practice. The LPN/LVN can administer PO or subcutaneous anticoagulant medications. Anticoagulant medications are considered high risk and should be double checked with another LPN/LVN or RN. The UAP can place equipment needed for seizure precautions in the room.

A patient's sudden onset of hemiplegia has necessitated a CT scan of her head. Which action should be the nurse's priority before this diagnostic study? a. Assess the patient's immunization history. b. Screen the patient for any metal parts or a pacemaker. c. Assess the patient for allergies to shellfish, iodine, or dyes. d. Assess the patient's need for tranquilizers or antiseizure medications.

c. Assess the patient for allergies to shellfish, iodine, or dyes. Allergies to shellfish, iodine, or dyes contraindicate the use of contrast media in CT. The patient's immunization history is not a central consideration, and the presence of metal in the body does not preclude the use of CT as a diagnostic tool. The need to assess for allergies supersedes the need for tranquilizers or antiseizure medications in the majority of patients.

The nurse is planning psychosocial support for the family of the patient who suffered a stroke. What factor will have the greatest impact on family coping? a. Specific patient neurologic deficits b. The patient's ability to communicate c. Rehabilitation potential of the patient d. Presence of complications of a stroke

c. Rehabilitation potential of the patient Although a patient's neurologic deficit might initially be severe, the ability of the patient to recover is most likely to positively impact the family's coping. Providing explanations and emotional support beginning in the acute phase through the rehabilitation phase will facilitate coping. Emphasizing successes will offer the most realistic hope for the patient's rehabilitation and helps maintain hope for the patient's future abilities.

Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? a. Overestimation of physical abilities b. Difficulty judging position and distance c. Slow and possibly fearful performance of tasks d. Impulsivity and impatience at performing tasks

c. Slow and possibly fearful performance of tasks Patients with a left-sided stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-sided stroke.

Nursing management of a patient with a brain tumor includes (select all that apply) a. discussing with the patient methods to control inappropriate behavior b. using diversion techniques to keep the patient stimulated and motivated c. assisting and supporting the family in understanding any changes in behavior d. limiting self-care activities until the patient has regained maximum physical functioning e. planning for seizure precautions and teaching the patient and the caregiver about antiseizure drugs

c. assisting and supporting the family in understanding any changes in behavior e. planning for seizure precautions and teaching the patient and the caregiver about antiseizure drugs

Bladder training in a male patient who has urinary incontinence after a stroke includes a. limiting fluid intake. b. keeping a urinal in place at all times. c. assisting the patient to stand to void. d. catheterizing the patient every 4 hours.

c. assisting the patient to stand to void.

The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the a. amount of cardiac output b. oxygen content of the blood c. degree of collateral circulation d. level of carbon dioxide in the blood

c. degree of collateral circulation

The nurse is 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 decreased level of consciousness 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 level of consciousness

c. develops decreased level of consciousness and a headache within 48 hours of a head injury

A patient is exhibiting word finding difficulty and weakness in his right arm. What area of the brain is most likely involved? a. brainstem b. vertebral artery c. left middle cerebral artery d. right middle cerebral artery

c. left middle cerebral artery

The nurse explains to the patient with a stroke who is scheduled for an angiography that this test is used to determine the a. presence of increased ICP b. site and size of the infarction c. patency of the cerebral blood vessels d. presence of blood in the cerebrospinal fluid

c. patency of the cerebral blood vessels

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first? a. patient with a skull fracture whose nose is bleeding b. elderly patient with a stroke who is confused and whose daughter is present c. patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale d. patient who had a craniotomy for a brain tumor who is now 3 days postoperative and has had continued emesis

c. patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale

A patient experiencing TIAs is scheduled for a carotid-endarterectomy. The nurse explains that this procedure is done to a. decreased cerebral edema b. reduce the brain damage that occurs during a stroke in evolution c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow d provide a circulatory bypass around thrombotic plaques obstructing cranial circulation

c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow

During neurologic testing, the patient is able to perceive pain elicited by pinprick. Based on this finding, the nurse may omit testing for a. position sense b. patellar reflexes c. temperature perception d. heel-to-shin movements

c: temperature perception

The nurse is teaching a senior citizen's group about signs and symptoms of a stroke. Which statement by the nurse would provide accurate information? a. "Take the person to the hospital if a headache lasts for more than 24 hours." b. "Stroke symptoms usually start when the person is awake and physically active." c. "A person with a transient ischemic attack has mild symptoms that will go away." d. "Call 911 immediately if a person develops slurred speech or difficulty speaking."

d. "Call 911 immediately if a person develops slurred speech or difficulty speaking." Medical assistance should be obtained immediately for someone with signs and symptoms of a stroke such as sudden numbness; weakness; paralysis of the face, arm, or leg (especially on one side of the body); sudden confusion; trouble speaking or understanding; slurred speech; sudden trouble seeing in one or both eyes; sudden trouble walking; dizziness; loss of balance or coordination; or a sudden, severe headache with no known cause. A person with signs and symptoms of a transient ischemic attack should seek medical attention immediately because it is unknown if the symptoms will resolve or persist and progress to a stroke. Onset of signs and symptoms of a stroke vary depending on the type. Onset of an ischemic thrombotic stroke usually occurs at rest. Onset of an ischemic embolic stroke is not related to rest or activity, and onset of a hemorrhagic stroke usually occurs with activity.

Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is a(n) a. obese 45-year-old Native American b. 35-year-old Asian woman who smokes c. 32-year-old white woman taking oral contraceptives d. 65-year-old African American man who smokes

d. 65-year-old African American man who smokes

The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? a. A 92-yr-old female patient who takes warfarin (Coumadin) for atrial fibrillation b. A 28-yr-old male patient who uses marijuana after chemotherapy to control nausea c. A 42-yr-old female patient who takes oral contraceptives and has migraine headaches d. A 72-yr-old male patient who has hypertension and diabetes mellitus and smokes tobacco

d. A 72-yr-old male patient who has hypertension and diabetes mellitus and smokes tobacco Stroke risk increases after 65 years of age. Strokes are more common in men. Hypertension is the single most important modifiable risk factor for stroke. Diabetes mellitus is a significant stroke risk factor, and smoking nearly doubles the risk of a stroke. Other risk factors include drug abuse (especially cocaine), high-dose oral contraception use, migraine headaches, and untreated heart disease such as atrial fibrillation.

A 74-yr-old man who has right-sided extremity paralysis related to a thrombotic stroke develops constipation. Which action should the nurse take first? a. Assist the patient to the bathroom every 2 hours. b. Provide incontinence briefs to wear during the day. c. Administer a bisacodyl (Dulcolax) rectal suppository every day. d. Arrange for several servings per day of cooked fruits and vegetables.

d. Arrange for several servings per day of cooked fruits and vegetables. Patients after a stroke frequently have constipation. Dietary management includes the following: fluid intake of 2500 to 3000 mL daily, prune juice (120 mL) or stewed prunes daily, cooked fruit three times daily, cooked vegetables three times daily, and whole-grain cereal or bread three to five times daily. Patients with urinary incontinence should be assisted to the bathroom every 2 hours. Suppositories may be ordered for short-term management if the patient does not respond to increased fluid and fiber. Incontinence briefs are indicated as a short-term intervention for urinary incontinence.

The nurse observes a student nurse assigned to initiate oral feedings for a 68-yr-old woman with an ischemic stroke. Which action by the student will require the nurse to intervene? a. Giving the patient 1 oz of water to swallow b. Telling the patient to perform a chin tuck before swallowing c. Assisting the patient to sit in a chair before feeding the patient d. Assessing cranial nerves III, IV, and VI before attempting feeding

d. Assessing cranial nerves III, IV, and VI before attempting feeding The majority of patients after a stroke have dysphagia. The gag reflex and swallowing ability (cranial nerves IX and X) should be assessed before the first oral feeding. Cranial nerves III, IV, and VI are responsible for ocular movements. To assess swallowing ability, the nurse should elevate the head of the bed to an upright position (unless contraindicated) and give the patient a small amount of crushed ice or ice water to swallow. The patient should remain in a high Fowler's position, preferably in a chair with the head flexed forward, for the feeding and for 30 minutes following.

When assessing motor function of a patient admitted with a stroke, the nurse notes mild weakness of the arm. The patient also is unable to hold the arm level. How should the nurse most accurately document this finding? a. Athetosis b. Hypotonia c. Hemiparesis d. Pronator drift

d. Pronator drift Downward drifting of the arm or pronation of the palm is identified as pronator drift. Athetosis is a slow, writhing, involuntary movement of the extremities. Hypotonia is flaccid muscle tone, and hemiparesis is weakness of one side of the body.

The female patient has been brought to the emergency department complaining of the most severe headache of her life. Which type of stroke should the nurse anticipate? a. TIA b. Embolic stroke c. Thrombotic stroke d. Subarachnoid hemorrhage

d. Subarachnoid hemorrhage Headache is common in a patient who has a subarachnoid hemorrhage or an intracerebral hemorrhage. A TIA is a transient loss of neurologic function usually without a headache. A headache may occur with an ischemic embolic stroke, but severe neurologic deficits are the initial symptoms. The ischemic thrombotic stroke manifestations progress in the first 72 hours as infarction and cerebral edema increase.

Which intervention is most appropriate when communicating with a patient with aphasia after a stroke? a. Present several thoughts at once so that the patient can connect the ideas. b. Ask open-ended questions to provide the patient the opportunity to speak. c. Finish the patient's sentences to minimize frustration associated with slow speech. d. Use simple, short sentences accompanied by visual cues to enhance comprehension.

d. Use simple, short sentences accompanied by visual cues to enhance comprehension. When communicating with a patient with aphasia, the nurse should present one thought or idea at a time. Ask questions that can be answered with a "yes," "no," or simple word. Use visual cues and allow time for the individual to comprehend and respond to conversation.

A patient with intracranial pressure monitoring has a pressure of 12 mm Hg. The nurse understands that this pressure reflects a. a severe decrease in cerebral perfusion pressure b. an alteration in the production of cerebrospinal fluid c. the loss of autoregulatory control of intracranial pressure d. a normal balance between brain tissue, blood, and cerebrospinal fluid

d. a normal balance between brain tissue, blood, and cerebrospinal fluid

Information provided by the patient that would help differentiate a hemorrhagic stroke from a thrombotic stroke includes a. sensory disturbance b. a history of hypertension c. presence of motor weakness d. sudden onset of severe headache

d. sudden onset of severe headache