Porth's Patho Ch. 16: Disorders of Brain Function
A client is brought to the emergency department and is diagnosed with an ischemic stroke confirmed by CT scan. The most important treatment for this client would be to:
Administer IV tissue plasminogen activator (tPA)
What medication teaching should be done for a woman of childbearing age with a seizure disorder?
Antiseizure drugs increase the risk for congenital abnormalities.
The nurse is caring for a client with a brain tumor when the client begins to vomit. Which intervention should the nurse do first?
Assess for other 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 and symptoms of increased intracranial pressure
Excessive activity of the excitatory neurotransmitters and their receptor-mediated effects is the cause of which type of brain injury?
Excitotoxic
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
A client who is being seen in the outpatient clinic reports a single episode of unilateral arm and leg weakness and blurred vision that lasted approximately 45 minutes. The client is most likely experiencing:
Transient Ischemic Attack (TIA)
Global and focal brain injuries manifest differently. What is almost always a manifestation of a global brain injury?
altered level of consciousness
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
The parent of an infant who developed hydrocephalus while in utero is very concerned that the child will have significant intellectual dysfunction. The best response to the parent would be:
Because the skull sutures are not fused, there may be no brain damage
For which common manifestation of acute meningococcal meningitis should the school nurse be assessing students?
Petechiae
The most common cause of an ischemic stroke is which of the following?
Thrombosis
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
Which individual has the highest chance of having a primary central nervous system lymphoma?
A 24-year-old man with acquired immunodeficiency syndrome (AIDS) and behavioral and cognitive changes
When the suspected diagnosis is bacterial meningitis, what assessment techniques can assist in determining if meningeal irritation is present?
Brudzinski sign and Kernig sign
The nurse working in an emergency room is caring for a client who is exhibiting signs and symptoms of a stroke. What does the nurse anticipate that the physician's orders will include?
CT scan
The nurse is conducting a community education program on concussions. The nurse evaluates that the participants understand the education when they state that which of these offers the brain protection from external forces?
Cerebrospinal fluid
Which intracranial volume is most capable of compensating for increasing intracranial pressure?
Cerebrospinal fluid
The parents of an infant born with hydrocephalus are concerned about the size of the baby's head. The doctors are telling them that the infant needs the surgical placement of a shunt. The nurse caring for the infant in the neonatal intensive care unit explains that placement of a shunt will:
Decrease the likelihood of further neurological deficits
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
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
The nurse is assessing a client with a traumatic brain injury and assesses for changes in which neurologic component? Select all that apply.
Motor function, cognition, level of consciousness, sensory function
A client suffering a thrombotic stroke is brought into the emergency department by ambulance and the healthcare team is preparing to administer a synthetic tissue plasminogen activator for which purpose?
Thrombolysis
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?
Placement of a shunt
The nurse observes a new nurse performing the test for Kernig's 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:
Resistance should be provided with the knee in a flexed position
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
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
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:
The blood-brain barrier is disrupted, allowing fluid to escape into the extracellular fluid
