Quiz 2 405
When preparing to discharge a client home, the nurse has met with the family and warned them that the client may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? A. Unmet physiologic needs B. Frustration around changes in function and communication C. Temporary changes in metabolism D. Changes in brain activity during sleep and wakefulness
B Emotional problems associated with stroke are often related to the new challenges around ADLs and communication. These challenges are more likely than metabolic changes, unmet physiologic needs, or changes in brain activity, each of which should be ruled out.
A 4-year-old boy has a febrile seizure during a well-child visit. What action would be a priority? A. Loosening the child's clothing to ensure a patent airway B. Using a tongue blade to pry open the child's jaw C. Hyperextending the child's head while placing him on his side D. Protecting the child from harm during the seizure
D During a seizure, the child should not be held down in a specific position. Protecting the child's head and body during the seizure is the priority. Ensuring a patent airway is an important intervention but is not accomplished by loosening the child's clothing or hyperextending his head. The child should be placed on his side and nothing should be inserted into his mouth to forcibly open the jaw.
A nursing student is writing a care plan for a newly admitted client who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the client's plan of care? A. Hyperthermia B. Adult failure to thrive C. Post-trauma syndrome D. Disturbed sensory perception
D The client who has experienced a stroke is at a high risk for disturbed sensory perception. Stroke is associated with multiple other nursing diagnoses, but hyperthermia, adult failure to thrive, and post-trauma syndrome are not among these.
A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client? A. Passive range-of-motion exercises to prevent contractures B. Supine positioning C. Early initiation of physical therapy D. Absolute bed rest in a quiet, non stimulating environment
D. The client is placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity, pain, and anxiety elevate BP, which increases the risk for bleeding. Visitors are restricted. The nurse administers all personal care. The client is fed and bathed to prevent any exertion that might raise BP. Clients with increased ICP are normally positioned with the HOB elevated.
A rehabilitation nurse caring for a client who has had a stroke is approached by the client's family and asked why the client has to do so much for self-care while obviously struggling to do so. What would be the nurse's best answer? A. "Rehabilitation means helping clients do exactly what they did before their stroke." B."We are trying to help the client be as useful as possible." C. "We aren't here to care for the client the way the hospital staff did; we are here to help the client get better and return home." D. "The focus on care in a rehabilitation facility is to help the client to resume as much self-care as possible."
D. In both acute care and rehabilitation facilities, the focus is on teaching the client to resume as much self-care as possible. The goal of rehabilitation is not to be "useful," nor is it to return clients to their pre-stroke level of functioning, which may be unrealistic.
A client with a left hemispheric stroke is having difficulty with their normal speech patterns. The nurse is not sure whether the client has expressive aphasia or apraxia. Which statement would most likely be reflective of apraxia? A. The client starts by saying "good morning" but finishes with saying "good day" to the nurse. B. The client sits up and turns to one side to see the object and states what is needed. C. The client points and gestures to an object needed on the overhead table. D. The nurse gives direction to get out of bed but the client does not understand.
A Apraxia is an inability to perform a previously learned action as may be seen when a client makes verbal substitutions for desired syllables or words. The client changed "good morning" to "good day," which is suggestive of this condition. Aphasia which can be expressive aphasia (inability to express oneself) or receptive aphasia (inability to understand language) is more likely represented with the client being unable to understand directions to get out of bed and by pointing and gesturing to an object needed rather than speaking. The client turning to one side so he/she can see the object may be more indicative of blindness to one side (homonymous hemianopsia).
A client is admitted to the neurologic ICU with a spinal cord injury. When assessing the client the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? A. Spinal shock B. Hypertensive emergency C. Epidural hemorrhage D. Hypovolemia
A In spinal shock, the reflexes are absent, BP and heart rate fall, and respiratory failure can occur. Hypovolemia, hemorrhage, and hypertension do not cause this sudden change in neurologic function.
The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action? A. Prepare for interventions to increase the client's BP. B. Prepare an ice bath to lower core body temperature. C. Prepare to transfuse packed red blood cells. D. Place the client in the Trendelenburg position.
A Manifestations of neurogenic shock include decreased BP and heart rate. Cardiac markers would be expected to rise in cardiogenic shock. Transfusion, repositioning, and ice baths are not indicated interventions.
A nurse is taking care of a client with swallowing difficulties after a stroke. What are some interventions the nurse can accomplish to prevent the client from aspirating while eating? Select all that apply. A. Assist the client out of bed and into the chair for meals. B. Instruct the client to tuck his/her chin towards their chest when swallowing. C. Recommend the insertion of a percutaneous endoscopic gastrostomy (PEG) tube. D. Encourage the client to increase his/her intake of water and juice. E. Request a swallowing assessment by a speech therapist before the client's discharge
A, B If swallowing function is partially impaired, it may return over time, or the client may be educated in alternative swallowing techniques, advised to take smaller boluses of food, and educated about types of foods that are easier to swallow. The client may be started on a thick liquid or pureed diet, because these foods are easier to swallow than thin liquids. Having the client sit upright, preferably out of bed in a chair, and instructing them to tuck the chin toward the chest as they swallow will help prevent aspiration. Recommending the insertion of a percutaneous endoscopic gastrostomy (PEG) tube would not prevent the client from aspirating while eating. A PEG tube could be placed if the client was unable to tolerate or resume an oral intake. A swallowing assessment should be done before allowing any oral intake and preferably within 4 to 24 hours after a stroke. A nurse can also accomplish a swallowing study using a validated and reliable assessment tool.
A 15-year-old adolescent is brought to the emergency department by his parents. The adolescent is febrile with chills that started suddenly. He states, "I had a sinus infection and sore throat a couple of days ago." The nurse suspects bacterial meningitis based on which findings? Select all that apply. A. Vomiting B. Complaints of stiff neck C. Negative Brudzinski sign D. Photophobia E. Absent headache
A,B,D Vomiting, complaints of stiff neck, photophobia
When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal? A. Elevation of the head of the bed B. Position changes every 15 minutes while awake C. Extension of the neck D. Head turned slightly to the right side
A. Elevation of the head of the bed promotes venous drainage and lowers ICP; the nurse should avoid flexing or extending the neck or turning the head side to side. The head should be in a neutral midline position. Excessively frequent position changes are unnecessary.
What should be included in the client's care plan when establishing an exercise program for a client affected by a stroke? A. Exercise the affected extremities passively four or five times a day. B. Have the client perform active range-of-motion (ROM) exercises once a day. C. Schedule passive range of motion every other day. D. Keep activity limited, as the client may be overstimulated.
A. The affected extremities are exercised passively and put through a full ROM four or five times a day to maintain joint mobility, regain motor control, prevent development of a contracture in the paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. Active ROM exercises should ideally be performed more than once per day.
A client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How might the nurse help the client manage the potential sensory and perceptional difficulties? A. Place the client's extremities where the client can see them. B. Keep the lighting in the client's room low. C. Place the client's clock on the affected side. D. Approach the client on the side where vision is impaired.
A. The client with homonymous hemianopsia (loss of half of the visual field) turns away from the affected side of the body and tends to neglect that side and the space on that side; this is called amorphosynthesis. In such instances, the client cannot see food on half of the tray, and only half of the room is visible. It is important for the nurse to remind the client constantly of the other side of the body, to maintain alignment of the extremities, and if possible, to place the extremities where the client can see them. Clients with a decreased field of vision should be approached on the side where visual perception is intact. All visual stimuli (clock, calendar, and television) should be placed on this side. The client can be taught to turn the head in the direction of the defective visual field to compensate for this loss. Increasing the natural or artificial lighting in the room and providing eyeglasses are important in increasing vision. There is no reason to keep the lights dim.
The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? A. Provide a board of commonly used needs and phrases. B. Speak in a loud and deliberate voice to the client. C. Help the client complete his or her sentences as needed. D. Have the client speak to loved ones on the phone daily.
A. The inability to talk on the telephone or answer a question or exclusion from conversation causes anger, frustration, fear of the future, and hopelessness. A common pitfall is for the nurse or other health care team member to complete the thoughts or sentences of the client. This should be avoided because it may cause the client to feel more frustrated at not being allowed to speak and may deter efforts to practice putting thoughts together and completing a sentence. The client may also benefit from a communication board, which has pictures of commonly requested needs and phrases. The board may be translated into several languages.
A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication? a. Acute pain b. Bleeding c. Seizures d. Septicemia
B Bleeding is the most common side effect of t-PA administration, and the client is closely monitored for any bleeding. Septicemia, pain, and seizures are much less likely to result from thrombolytic therapy.
The physician has ordered rectal diazepam for a 2-year-old boy with status epilepticus. Which instruction is essential for the nurse to teach the parents? A. Gradually reduce the dosage as seizures stop. B. Monitor their child's level of sedation. C. Monitor for an allergic reaction to the medication. D. Watch for fever indicating infection.
B Diazepam is useful for home management of prolonged seizures and requires that the parents be educated on its proper administration. Monitoring the child's level of sedation is key when giving diazepam because it slows the central nervous system. Parents need to monitor the overall health of the child, including temperature when needed, but that has nothing to do with the diazepam. When the use of an anticonvulsant is stopped, gradual reduction of the dosage is necessary to prevent seizures or status epilepticus. This is not done without a physician's order. Monitoring for allergic reactions is necessary when any medications have been prescribed, but is not specific to diazepam.
A client with a recent stroke history is admitted to a rehabilitation unit and placed on high fall risk precautions. The client is impulsive, easily distracted, frequently forgets his/her cane when walking, and the location of his/her room. What stroke conditions do these signs best indicate? A. Hemorrhagic stroke B. Right hemispheric stroke C. Ischemic stroke D. Left hemispheric stroke
B In right hemispheric stroke, signs include a client that is easily distracted and has impulsive behavior and poor judgment. The client can be unaware of deficits like motor weakness, as demonstrated by the client forgetting the cane. Clients can also have spatial or perceptual deficits. This means they can get lost in familiar and unfamiliar places. This client was unable to find his/her room. The client who has a right hemisphere stroke demonstrates weakness on the left side of the body. The client with left hemispheric stroke has signs such as paralysis or weakness in the right side of the body, right-sided visual deficits, and slow cautious behaviors. Ischemic and hemorrhagic strokes describe what caused the stroke rather than what side of the brain was affected. Signs and symptoms differ for each type of stroke. Ischemic strokes can include numbness to one side of the face. Headache, decreased level of consciousness, and seizures typically are signs of a hemorrhagic stroke.
The nurse inspects the eyes of a child and observes that the sclera is showing over the top of the iris. The nurse documents this finding as: A. Decorticate posturing B. Sunsetting C. Doll's eye D. Nystagmus
B Sunsetting is when the sclera of the eyes is showing over the top of the iris. Decorticate posturing includes adduction of the arms, flexion at the elbows with the arms held over the chest, and flexion of the wrists with both hands fisted and the lower extremities adducted and extended. Nystagmus is manifested by involuntary rapid rhythmic eye movements. Doll's eye is a maneuver that tests for symmetric eye movement to the opposite side when the head is turned in the other direction
The nurse knows that children have larger heads in relation to the body and a higher center of gravity. When developing a teaching plan for parents, the nurse includes information about an increased risk for which problem? A. Posterior plagiocephaly B. Head trauma C. Caput succedaneum D. Febrile seizures
B The larger head size in relation to the body, coupled with a higher center of gravity, causes children to hit their head more readily when involved in motor vehicle accidents, bicycle accidents, and falls. Febrile seizures are not related to anatomy or physiology. Caput succedaneum is an edematous area on the scalp caused by pressure of the uterus or vagina during head-first delivery. Posterior plagiocephaly is caused by early closure of the lamboid suture.
A client diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the client and family needs to begin as soon as the client is settled on the unit and will continue until the client is discharged. What will family education need to include? A. How to differentiate between hemorrhagic and ischemic stroke B. How to correctly modify the home environment C. Risk factors for ischemic stroke D. Techniques for adjusting the client's medication dosages at home
B For a client with a hemorrhagic stroke, teaching addresses the use of assistive devices or modification of the home environment to help the client live with the disability. This is more important to the client's needs than knowing about risk factors for ischemic stroke. It is not necessary for the family to differentiate between different types of strokes. Medication regimens should never be altered without consultation.
A hospitalized child is scheduled for magnetic resonance imaging (MRI) with contrast. What nursing intervention(s) will the nurse complete to ensure safety during the examination? Select all that apply. A. Connect the child to a heart monitor B. Assess the IV site for patency C. Assess for a latex allergy D. Review any prescriptions for sedation E. Place child in clothing with no metal
B,D,E When preparing a child for an MRI procedure, it is important the child and parent are aware of the test procedure. No metal can be used in the MRI scanner room so all clothing, jewelry, etc. need to be removed before testing. IV contrast may be used so the IV needs to be patent and in good working order. If the child is to be sedated the nurse should review the sedation prescription and identify any discrepancies before the child goes for the examination. If the child is to be sedated a heart monitor will be used, but it is not necessary for the nurse on the unit to connect the child. A special monitor compatible with the MRI scanner will be used. If sedated the child may also receive oxygen just as a prevention because the exam take a long time in a confined space. Having a latex allergy is not a contraindication for receiving gadolinium, the MRI contrast used during testing.
A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? A. Administer an analgesic. B. Call the health care provider immediately. C. Sit with the client for a few minutes. D. Inform the nurse manager.
B. A headache may be an indication that the aneurysm is leaking. The nurse should notify the health care provider immediately. The health care provider will decide whether administration of an analgesic is indicated. Informing the nurse manager is not necessary. Sitting with the client is appropriate, once the health care provider has been notified of the change in the client's condition.
A nurse is talking with the parents of a child who has had a febrile seizure. The nurse would integrate an understanding of what information into the discussion? A. The child's risk for epilepsy is now increased. B. Febrile seizures are benign in nature. C. Structural damage occurs with febrile seizure. D. The child's risk for cognitive problems is greatly increased.
B. Parents need reassurance that febrile seizures, although frightening, are benign in nature. Children who experience one or more febrile seizures are at no greater risk of developing epilepsy than the general population. No evidence exists that febrile seizures cause structural damage or cognitive declines.
The nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? A. Take ibuprofen for a serious headache. B. Take antihypertensive medication as prescribed. C. Drowsiness is normal for the first week after discharge. D. Mild, intermittent seizures can be expected.
B. The client and family are provided with information that will enable them to cooperate with the care and restrictions required during the acute phase of hemorrhagic stroke and to prepare the client to return home. Client and family teaching includes information about the causes of hemorrhagic stroke and its possible consequences. Symptoms of hydrocephalus include gradual onset of drowsiness and behavioral changes. Hypertension is the most serious risk factor, suggesting that appropriate antihypertensive treatment is essential for a client being discharged. Seizure activity is not normal; reports of a serious headache should be reported to the health care provider before any medication is taken. Drowsiness is not normal or expected.
A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for which purpose? A. To decrease cerebral edema B. To remove atherosclerotic plaques blocking cerebral flow C. To prevent seizure activity that is common following a TIA D. To determine the cause of the TIA
B. The main surgical procedure for select clients with TIAs is carotid endarterectomy, the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in clients with occlusive disease of the extracranial arteries. An endarterectomy does not decrease cerebral edema, prevent seizure activity, or determine the cause of a TIA.
A 16-year-old boy reports to the school nurse with headaches and a stiff neck. Which sign or symptom would alert the nurse that the child may have bacterial meningitis? A. Frequent urination B. Sunset eyes C. Sunlight is "too bright" D. Fixed and dilated pupils
C Photophobia, or intolerance of light, is another symptom of bacterial meningitis. Fixed and dilated pupils are a symptom of head trauma and warrant prompt intervention. Frequent urination is a symptom of a type I Arnold-Chiari malformation. Sunset eyes indicate increased intracranial pressure typical of hydrocephalus.
The nurse is performing a neurological assessment on a child. The previous examination noted the child to be alert but answering questions inappropriately. In this exam, the child only responds to vigorous stimuli. Which action should the nurse take first? A. Document the findings on the hourly assessment tool. B. Have another nurse verify the results. C. Notify the health care provider. D. Reassess in 1 hour.
C The level of consciousness is the earliest indicator of improvement or deterioration of the neurological status. Consciousness includes alertness, the ability to respond to stimuli, and cognition. If the child is alert but responding to questions inappropriately, then the child is said to be in a confused state. When the child only responds to vigorous stimuli, then the child is in a state of stupor. The change indicates a worsening state of consciousness. The health care provider should be notified of the change. The nurse can have a second nurse assess the child, but this does not get the child much needed help or intervention. The nurse would certainly document the findings, but only after calling the health care provider. The nurse should be alert to the changes and not wait to reassess.
The nurse is caring for a client who is known to be at risk for cardiogenic embolic strokes. What arrhythmia does this client most likely have? A. Bundle branch block B. Supraventricular tachycardia C. Atrial fibrillation D. Ventricular tachycardia
C. Cardiogenic embolic strokes are associated with cardiac arrhythmias, which is usually atrial fibrillation. Absence of a regular contraction of the fibrillating atria leads to an increase of atrial pressure and dilation, which together with hemoconcentration, endothelial dysfunction, and a prothrombotic state are prerequisites for thrombus formation. In other words, the irregularity of the heartbeat caused by atrial fibrillation makes the heart more likely to form clots. Studies have shown that strokes that are caused by atrial fibrillation have an increased poor outcome in terms of severity and resulting disability. The other listed arrhythmias are less commonly associated with this type of stroke.
A 4-year-old boy has a history of seizures and has been started on a ketogenic diet. Which food selection would be most appropriate for his lunch? A. Spaghetti with meatballs, garlic bread, and a cola drink B. A grilled cheese sandwich, potato chips, and a milkshake C. A hamburger on a bun, French fries, and milk D. Fried eggs, bacon, and iced tea
D The ketogenic diet involves a high intake of fats, adequate protein intake, and a very low intake of carbohydrates, resulting in a state of ketosis. The child is kept in a mild state of dehydration. Eggs and bacon are high in fat; the tea does not contain any carbohydrates. Therefore, this is the best choice. The hamburger is fat and protein, the bun is a carbohydrate, and the French fries and the milk both contain fat and protein, but both contain a lot of carbohydrates. The pasta and the sauce for the spaghetti are carbohydrates, the meatballs are protein, and the garlic bread is a carbohydrate, as is the cola drink. The grilled cheese sandwich has the fat and protein from the cheese, but the bread and chips are primarily carbohydrates, and the milkshake has fat, protein, and carbohydrates. Only the selection in A contains a ketogenic meal.
