Pathophysiology Chapter 16
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? Atherosclerotic lesions in cerebral vessels Diffuse cerebral electrical malfunctions Aneurysm leakage Minor residual deficits
A The traditional definition of TIA as a neurologic deficit resolving within 24 hours was developed before the mechanisms of ischemic cell damage and the penumbra were known and before the newer, more advanced methods of neuroimaging became available. A more accurate definition now is a transient deficit without time limits, best described as a zone of penumbra without central infarction. TIAs are important because they may provide warning of impending stroke. The causes of TIAs are the same as those of ischemic stroke, and include atherosclerotic disease of cerebral vessels and emboli. The most common predisposing factors for cerebral hemorrhage are advancing age and hypertension; other causes include aneurysm rupture. Cerebral electrical malfunctions usually occur with seizure activity
The chart of a client admitted because of seizures notes that the seizure activity began simultaneously in both cerebral hemispheres. The nurse should interpret this to mean that the client experienced: generalized seizure. focal seizure without impairment of consciousness. focal seizure with impairment of consciousness. unknown type of seizure.
A When seizure activity begins simultaneously in both cerebral hemispheres, it is considered a generalized seizure.
After evaluating the client, the physician thinks that his older adult client is exhibiting signs and symptoms of normal pressure hydrocephalus. Which symptom would be seen? Vomiting Headache Papilledema Disturbances in gait
D In adults, slowly developing hydrocephalus may produce deficits such as progressive dementia and gait changes. The other options are symptoms of increased ICP seen in acute onset hydrocephalus.
Which intracranial volume is most capable of compensating for increasing intracranial pressure? Brain cell tissue Intravascular blood Surface sulci fluid Cerebrospinal fluid
D Initial increases in intracranial pressure (ICP) are largely buffered by a translocation of cerebrospinal fluid (CSF) to the spinal subarachnoid space and increased reabsorption of CSF. Of the intracranial volumes, the tissue volume is least capable of undergoing change. Surface sulcus fluid is negligible and not a factor in increased ICP. The compensatory ability of the intravascular blood compartment is also limited by the small amount of blood that is in the cerebral circulation. As the volume-buffering capacity of this compartment becomes exhausted, venous pressure increases and cerebral blood volume and ICP rise.
The nurse is caring for an older adult client with hemiplegia following a stroke. While planning the client's care, the nurse knows the client is at risk for developing which condition? Muscle atrophy Muscular dystrophy Involuntary movements Pseudohypertrophy
A Muscle atrophy can occur with prolonged immobilization following a chronic illness. The client suffering from hemiplegia will have paralysis and immobility. Muscular dystrophy is a genetic disorder characterized by muscle necrosis and increased muscle size. Pseudohypertrophy is associated with muscular dystrophy. Involuntary movements are associated with extrapyramidal tract disorders. Stroke is a pyramidal tract disorder with extrapyramidal tract disorder.
A client has developed global ischemia of the brain. The nurse determines this is: inadequate to meet the metabolic needs of the entire brain. inadequate perfusion of the nondominant side of the brain. inadequate perfusion of the right side of the brain. inadequate perfusion to the dominant side of the brain.
A Global ischemia occurs when blood flow is inadequate to meet the metabolic needs of the entire brain. The result is a spectrum of neurologic disorders reflecting diffuse brain dysfunction.
According to the Glasgow Coma Scale, opening one's eyes to only painful stimuli would receive which score? 2 4 1 3
A Only opening eyes to painful stimulation is scored as a 2. Spontaneously opening eyes is scored as a 4; opening eyes to speech is scored as a 3; no opening is scored as a 1.
The nurse assessing a client with a traumatic brain injury assesses for changes in which neurologic component? Select all that apply. Cognition Level of consciousness Motor function Sensory function Metabolic function
ABCD Brain injuries can cause changes in level of consciousness and alterations in cognition, motor, and sensory function; therefore, the nurse assessing a client with a traumatic brain injury should assess for changes in these areas.
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? Spontaneous eye opening Flaccid motor response Normal flexion Confused conversation
B A score of 3 on the Glasgow Coma Scale indicates the lowest possible score in each of the three scoring categories (eye opening, motor response, and verbal response) and includes flaccid or no motor response, no verbal response and the inability to open the eyes.
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: ECG for arrhythmias Urine output and continence Ability to grasp hands and squeeze on command Respiratory status and oxygen saturation
D Tonic-clonic status epilepticus is a medical emergency and, if not promptly treated, may lead to respiratory failure and death. Treatment consists of appropriate life support measures. Airway/breathing is always the priority in this emergency situation.
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 intracranial fluid volumes and pressures. decrease the client's ability to attempt suicide again. increase oxygen demands and metabolic needs.
A The general goal of treatment with global cerebral ischemia is to decrease metabolic needs and increase oxygenation to the injured cerebral tissue. Artificial ventilation provides appropriate oxygenation; keeping the client paralyzed decreases the body's metabolic needs.
A client has been diagnosed with a cerebral aneurysm and placed under close observation before treatment commences. Which pathophysiologic condition has contributed to this client's diagnosis? Impaired synthesis of clotting factors Deficits in the autonomic control of blood pressure Increased levels of cerebrospinal fluid Weakness in the muscular wall of an artery
A Aneurysms are direct manifestations of a weakness that exists in the muscular wall of an arterial vessel. Hypertension is a significant risk factor, but autonomic contributions are not common. Levels of cerebrospinal fluid (CSF) and hypo- or hypercoagulability are not implicated in the pathogenesis of aneurysms.
The nurse is assessing a client and notes the client is now displaying decerebrate posturing. The position would be documented as: rigidity of the arms with palms of the hands turned away from the body and with stiffly extended legs and plantar flexion of the feet. prone position with arms placed above the head and legs elevated; deep tendon reflexes showing hyperreflexia. flexion of the arms, wrists, and fingers, with abduction of the upper extremities, internal rotation, and plantar flexion of the lower extremities. active range of motion with increased strength in the upper extremities when painful stimulation applied.
A Decerebrate (extensor) posturing results from increased muscle excitability. It is characterized by rigidity of the arms with palms of the hands turned away from the body and with stiffly extended legs and plantar flexion of the feet. Flexion of the arms, wrists, and fingers, with abduction of the upper extremities, internal rotation, and plantar flexion of the lower extremities, would be a response of decorticate posturing. The other options are not specific to a diagnosis.
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
A 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.
The nurse reading a client's lumbar puncture results notifies the physician of findings consistent with meningitis when which sign/symptom is noted? Large number of polymorphonuclear neutrophils Clear cerebrospinal fluid Decreased protein count Increased glucose
A 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.
A high school student sustained a concussion during a football game. The school nurse will educate the family about postconcussion syndrome and ask them to watch for and report which manifestations of its presence? headaches and poor concentration recurrent nosebleeds and hypersomnia unilateral weakness and decreased coordination neck pain and decreased neck range of motion
A Postconcussion syndrome includes mild symptoms, such as headache, irritability, insomnia, and poor concentration and memory. Nosebleeds, hypersomnia, unilateral motor changes, and neck pain are indicative of more severe brain injury and/or soft tissue injury.
The emergency room doctor suspects a client may have bacterial meningitis. The most important diagnostic test to perform would be: Lumbar puncture Blood cultures CT of the head Sputum culture
A The diagnosis of bacterial meningitis is confirmed with abnormal CSF findings. Lumbar puncture findings, which are necessary for accurate diagnosis, include a cloudy and purulent CSF under increased pressure. The other options do not confirm the diagnosis.
A client with a traumatic brain injury has developed extreme cerebral edema. Which clinical manifestations of brain herniation correlate to upward herniation of the midbrain known as uncal herniation? Select all that apply. Deep coma Rhythmic movement of arms and legs Respiratory rate of 8 with intermittent sighs Intracranial bleeding from nose and ears Bilateral small, fixed pupils
A C E Infratentorial herniation results from increased pressure in the infratentorial compartment. Herniation may occur superiorly (upward) through the tentorial incisura or inferiorly (downward) through the foramen magnum. The most prominent signs of upward (uncal) herniation include immediate onset of deep coma; small equal, fixed pupils; and abnormal respirations (slow rate with intermittent sighs or ataxia) and other vital signs. Downward displacement of the midbrain through the tentorial notch (or of the cerebellar tonsils through the foramen magnum) can interfere with medullary functioning and cause cardiac or respiratory arrest. Tissue infarction and intracranial bleeding are causes of cerebral edema, rather than an outcome of herniation. Rhythmic movement of arms and legs could be caused by many things and is not specific to infratentorial herniation.
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? brain death coma delirium vegetative state
B Coma is marked by the client not responding appropriately to stimuli and being in a sleeplike state with eyes closed. The client is not conscious so would not meet the criteria for delirium, which is an acutely confused state. Because this client still exhibits a pain response (the extended arms and legs indicate decerebrate posturing), the client does not meet the criteria for brain death or a vegetative state. Unresponsive pupils do not confirm brain death.
Overstimulation of glutamate receptors is the cause of which type of brain injury? ischemic excitotoxic increased intracranial volume and pressure hypoxic
B 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.
A client's recent computed tomography (CT) scan has revealed the presence of hydrocephalus. Which treatment measure is most likely to resolve this health problem? Aggressive diuresis Placement of a shunt Administration of hypertonic intravenous solution Lumbar puncture
B Hydrocephalus represents a progressive enlargement of the ventricular system due to an abnormal increase in cerebrospinal fluid (CSF) volume. This increase in CSF volume can be resolved by the placement of a shunt to drain the offending fluid volume. Diuresis, hypertonic solution administration, and lumbar puncture are not usual treatment modalities.
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.
B Hypoxia denotes a deprivation of oxygen with maintained blood flow (perfusion), whereas ischemia is a situation of greatly reduced or interrupted blood flow. Hypoxia produces a generalized depressant effect on the brain. Ischemia interferes with delivery of oxygen and glucose as well as the removal of metabolic wastes.
For which common manifestation of acute meningococcal meningitis should the school nurse be assessing students? Diplopia Petechiae Papilledema Focal paralysis
B Meningococcal meningitis causes a petechial rash with palpable purpura in most people. The most common manifestations of acute bacterial meningitis are fever and chills; headache; stiff neck (nuchal rigidity) and back; abdominal and extremity pains; and nausea and vomiting. Other signs include seizures, cranial nerve damage (especially the eighth nerve, with resulting deafness), and focal cerebral signs. General signs and symptoms of brain tumor include headache, papilledema, nausea, vomiting, mental changes, visual disturbances (e.g., diplopia), alterations in sensory and motor function, and seizures. Like meningitis, encephalitis is characterized by fever, headache, and nuchal rigidity, but more often clients also experience neurologic disturbances, such as focal paralysis, lethargy, disorientation, seizures, delirium, and coma.
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
B The nurse should document the perception of a warning of impending seizure activity as a prodrome; it is also referred to as an aura. Clonic and atonic refer to the type of motor activity during a seizure. Ictal refers to the type of neuronal discharge associated with seizure activity
The MRA scan of a client with a suspected stroke reports ruptured berry aneurysm. The nurse plans care for a client with: Encephalitis Subarachnoid hemorrhage Lacunar infarct Thrombotic stroke
B The rupture of a berry aneurysm leads to a subarachnoid hemorrhage.
When the suspected diagnosis is bacterial meningitis, what assessment techniques can assist in determining if meningeal irritation is present? Chvostek sign and Goodell sign Brudzinski sign and Kernig sign Brudzinski sign and Chadwick sign Kernig sign and Chadwick sign
B Two assessment techniques can help determine whether meningeal irritation is present. Kernig sign is resistance to extension of the knee while the person is lying with the hip flexed at a right angle. Brudzinski sign is elicited when flexion of the neck induces flexion of the hip and knee
Which individual has the highest chance of having a primary central nervous system lymphoma? A 68-year-old man who is a smoker and has a family history of cancer An 88-year-old man who has begun displaying signs and symptoms of increased ICP A 24-year-old man with acquired immunodeficiency syndrome (AIDS) and behavioral and cognitive changes A 60-year-old woman who is soon to begin radiation therapy for the treatment of breast cancer
C Explanation: Primary CNS lymphomas are especially common in immunocompromised persons, including those with acquired immunodeficiency syndrome (AIDS) and immunosuppression after transplantation. Behavior and cognitive changes, which are the most common presenting symptoms, occur in about 65% of clients.
A nurse at a long-term care facility provides care for a client who has had recent transient ischemic attacks (TIAs). What significance should the nurse attach to the client's TIAs? TIAs result in an accumulation of small deficits that may eventually equal the effects of a CV. TIAs are relatively benign phenomena that necessitate monitoring, but not treatment. TIAs, by definition, resolve rapidly, but they constitute an increased risk for stroke. The small bleeds that define TIAs can be a warning sign of an impending stroke.
C TIAs can be considered a warning sign for future strokes. They are not hemorrhagic in nature and their effects are not normally cumulative. They may require treatment medically or surgically.
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? Client with the worst headache, nuchal rigidity, and nausea Client with fever, stiff back, and positive Kernig sign
C 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 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 oxygen Administration of TPN Administration of antibiotics Administration of pain medication
C The nurse should prepare to administer antibiotics as ordered by the physician while the diagnostic tests are being completed. Delay in initiation of antimicrobial therapy, most frequently due to medical imaging prior to lumbar puncture or transfer to another medical facility, can result in poor client outcomes.
The nurse observes a new nurse performing the test for Kernig sign on a client. The new nurse performs the test by providing resistance to flexion of the knees while the client is lying with the hip flexed at a right angle. The nurse should explain to the new nurse that: the client should be in a sitting position. the sign elicited was the Brudzinski sign. resistance should be provided with the knee in a flexed position. the sign elicited was the obturator sign.
C The test for Kernig sign for meningeal irritation is performed by providing resistance to flexion of the knees while the client is lying with the hip flexed at a right angle.
The most common cause of an ischemic stroke is which of the following? Intracerebral arterial vasculitis Cardiogenic embolus Thrombosis Vasospasm
C Thrombi are the most common cause of ischemic strokes, usually occurring in atherosclerotic blood vessels.
A family brings a client to the emergency department with increasing lethargy and disorientation. They think the client had a seizure on the drive over to the hospital. The client has been sick with a "cold virus" for the last few days. On admission, the client's temperature is 102°F (38.9°C). Which other clinical manifestations may lead to the diagnosis of encephalitis? Appearance of red-purple discolorations on the skin that do not blanch on applying pressure BP 100/72 mm Hg Petechiae over entire body Impaired neck flexion resulting from muscle spasm
D Like meningitis, encephalitis is characterized by fever, headache, and nuchal rigidity (impaired neck flexion resulting from muscle spasm), but more often clients also experience neurologic disturbances, such as lethargy, disorientation, seizures, focal paralysis, delirium, and coma. Meningococcal meningitis is characterized by a petechial (petite hemorrhagic spots) rash with palpable purpura (red-purple discolorations on the skin that do not blanch on applying pressure) in most people. This BP is within normal range.
The family of a male client documented to be in a vegetative state excitedly reports to the nurse that the client has just opened his eyes for the first time. The best response by the nurse is: "That is a just a reflexive action." "That is a miracle." "Clients in a vegetative state often open and close their eyes." "I will come and assess the client."
D The nurse should assess the client for concurrent awareness as this is the first time that the spontaneous eye opening has occurred. The nurse should be aware that clients in a persistent vegetative state often have spontaneous eye opening without concurrent awareness. This is often confusing for hopeful families.
The nurse is explaining to a client's family how vasogenic brain edema occurs. The most appropriate information for the nurse to provide would be: There is an increase in the production of cerebrospinal fluid volume. There is a decrease in the amount of fluid volume in the brain. Normal physiologic circumstances result in decreased adsorption of CSF. The blood-brain barrier is disrupted, allowing fluid to escape into the extracellular fluid.
D Vasogenic brain edema occurs with conditions that impair the function of the blood-brain barrier and allow the transfer of water and protein from the vascular space into the interstitial space. Increased production of CSF and decreased absorption result in hydrocephalus. It occurs in conditions such as hemorrhage, brain injury, and infectious processes.
