Test 4

A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying a cool washcloth to the head b. Assisting the client to a position of comfort c. Keeping voices soft and soothing d. Maintaining low lighting in the room e. Providing antipyretics for fever

ANS: A, B, C, D The client with meningitis often has high fever, pain, and some degree of confusion. Cool washcloths to the forehead are comforting and help with pain. Allowing the client to assume a position of comfort also helps manage pain. Keeping voices low and lights dimmed also helps convey caring in a nonthreatening manner. The nurse provides antipyretics for fever.

A nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.) a. Client who exhibits extreme emotional lability b. Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38 c. Client with mild forgetfulness and a slight limp d. Client who has a past hospitalization for a suicide attempt e. Client who is unable to walk or eat 3 weeks post-stroke

ANS: A, B, D, E Clients most at risk for post-stroke depression are those with a previous history of depression, severe stroke (NIH Stroke Scale score of 38 is severe), and post-stroke physical or cognitive impairment. The client with mild forgetfulness and a slight limp would be a low priority for this referral.

A nursing student studying the neurologic system learns which information? (Select all that apply.) a. An aneurysm is a ballooning in a weakened part of an arterial wall. b. An arteriovenous malformation is the usual cause of strokes. c. Intracerebral hemorrhage is bleeding directly into the brain. d. Reduced perfusion from vasospasm often makes stroke worse. e. Subarachnoid hemorrhage is caused by high blood pressure.

ANS: A, C, D An aneurysm is a ballooning of the weakened part of an arterial wall. Intracerebral hemorrhage is bleeding directly into the brain. Vasospasm often makes the damage from the initial stroke worse because it causes decreased perfusion. An arteriovenous malformation (AVM) is unusual. Subarachnoid hemorrhage is usually caused by a ruptured aneurysm or AVM.

A family member of a patient who experienced a stroke is anxious and says to the nurse, "Something is the matter with Grandpa. All he does is cry!" Which response by the nurse is best at this time?

"He is emotionally labile and may have this behavior for some time." "It sounds like he is depressed, so I will inform the provider." If the frontal lobe has been injured by a stroke, the patient may experience emotional lability in which the patient laughs then cries, most often for no apparent reason. It is an uncontrollable response and should be explained to the family. Hemianopsia leads to neglect of one side of the body. Crying is not a symptom of brain stem deterioration, which would include respiratory problems, and it is not an exclusive symptom of depression.

A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population? (Select all that apply.) a. Admission can overwhelm the coping mechanisms for older clients. b. Alcohol is typically involved in most traumatic brain injuries for this age group. c. These clients are more susceptible to systemic and wound infections. d. Other medical conditions can complicate treatment for these clients. e. Very few traumatic brain injuries occur in this age group.

ANS: A, C, D Older clients often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and noisy. Because of decreased protective mechanisms, they are more susceptible to both local and systemic infections. Other medical conditions can complicate their treatment and recovery. Alcohol is typically not related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes. The 65- to 76-year-old age group has the second highest rate of brain injuries compared to other age groups.

The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.) a. Alcohol intake b. Diabetes c. High-fat diet d. Obesity e. Smoking

ANS: A, C, D, E Alcohol intake, a high-fat diet, obesity, and smoking are all modifiable risk factors for stroke. Diabetes is not modifiable but is a risk factor that can be controlled with medical intervention.

A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.) a. A client with a moderate trauma may need hospitalization. b. A Glasgow Coma Scale score of 10 indicates a mild brain injury. c. Only open head injuries can cause a severe TBI. d. A client with a Glasgow Coma Scale score of 3 has severe TBI. e. The terms "mild TBI" and "concussion" have similar meanings.

ANS: A, D, E "Mild TBI" is a term used synonymously with the term "concussion." A moderate TBI has a Glasgow Coma Scale (GCS) score of 9 to 12, and these clients may need to be hospitalized. Both open and closed head injuries can cause a severe TBI, which is characterized by a GCS score of 3 to 8.

A patient with severe muscle spasticity has been prescribed tizanidine. The nurse instructs the patient about which adverse effect of tizanidine?

(a centrally acting skeletal muscle relaxant) and drowsiness and sedation are common adverse effects

A client who is diagnosed with stroke is very drowsy but can respond when awakened. Using the National Institutes of Health Stroke​ Scale, which level of consciousness should the nurse​ document? 1 2 0 3

1 A score of 1 means that the client is not alert but is arousable by minor stimulation to​ obey, answer, or respond. A score of 0 means that the client is alert and keenly responsive. A score of 2 means that the client is not​ alert, requires repeated stimulation to​ attend, or is obtunded and requires strong or painful stimuli to make movements. A score of 3 means that the client responds only with motor or autonomic effects or is totally​ unresponsive, flaccid, and areflexic.

A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include? (Select all that apply.) a. Discharging the client on a statin medication b. Providing the client with comprehensive therapies c. Meeting goals for nutrition within 1 week d. Providing and charting stroke education e. Preventing venous thromboembolism

ANS: A, D, E Core Measures established by The Joint Commission include discharging stroke clients on statins, providing and recording stroke education, and taking measures to prevent venous thromboembolism. The client must be assessed for therapies but may go elsewhere for them. Nutrition goals are not part of the Core Measures.

A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurses primary assessment focus? A)Cardiac and respiratory status B)Seizure activity C)Pain D)Fluid and electrolyte balance

A Feedback: Acute care begins with managing ABCs. Patients may have difficulty keeping an open and clear airway secondary to decreased LOC. Neurologic assessment with close monitoring for signs of increased neurologic deficit and seizure activity occurs next. Fluid and electrolyte balance must be controlled carefully with the goal of adequate hydration to promote perfusion and decrease further brain activity.

A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patients family in adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurses response to the family?A)The patient should mobilize as soon as she is physically able. B)To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. C)The patient should remain on bed rest until she expresses a desire to mobilize. D)Lack of mobility will greatly increase the patients risk of stroke recurrence.

A Feedback: As soon as possible, the patient is assisted out of bed and an active rehabilitation program is started. Delaying mobility causes complications, but not necessarily stroke recurrence. Mobility should not be withheld until the patient initiates.

When preparing to discharge a patient home, the nurse has met with the family and warned them that the patient may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? A)Frustration around changes in function and communication B)Unmet physiologic needs C)Changes in brain activity during sleep and wakefulness D)Temporary changes in metabolism

A Feedback: 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.

The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke? A)Facial droop B)Dysrhythmias C)Periorbital edema D)Projectile vomiting

A Feedback: Facial drooping or asymmetry is a classic abnormal finding on a physical assessment that may be associated with a stroke. Facial edema is not suggestive of a stroke and patients less commonly experience dysrhythmias or vomiting.

After a major ischemic stroke, a possible complication is cerebral edema. Nursing care during the immediate recovery period from an ischemic stroke should include which of the following? A)Positioning to avoid hypoxia B)Maximizing PaCO2 C)Administering hypertonic IV solution D)Initiating early mobilization

A Feedback: Interventions during this period include measures to reduce ICP, such as administering an osmotic diuretic (e.g., mannitol), maintaining the partial pressure of carbon dioxide (PaCO2) within the range of 30 to 35 mm Hg, and positioning to avoid hypoxia. Hypertonic IV solutions are not used unless sodium depletion is evident. Mobilization would take place after the immediate threat of increased ICP has past.

A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurses care of this patient? A)The patient should be approached on the side where visual perception is intact. B)Attention to the affected side should be minimized in order to decrease anxiety. C)The patient should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. D)The patient should be approached on the opposite side of where the visual perception is intact to promote recovery.

A Feedback: Patients with decreased field of vision should first be approached on the side where visual perception is intact. All visual stimuli should be placed on this side. The patient can and should be taught to turn the head in the direction of the defective visual field to compensate for this loss. The nurse should constantly remind the patient of the other side of the body and should later stand at a position that encourages the patient to move or turn to visualize who and what is in the room.

The patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the patients atmosphere more conducive to communication? A)Provide a board of commonly used needs and phrases. B)Have the patient speak to loved ones on the phone daily. C)Help the patient complete his or her sentences. D)Speak in a loud and deliberate voice to the patient.

A Feedback: 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 patient. This should be avoided because it may cause the patient to feel more frustrated at not being allowed to speak and may deter efforts to practice putting thoughts together and completing a sentence. The patient may also benefit from a communication board, which has pictures of commonly requested needs and phrases. The board may be translated into several languages.

Following diagnostic testing, a patient has been admitted to the ICU and placed on cerebral aneurysm precautions. What nursing action should be included in patients plan of care? A)Supervise the patients activities of daily living closely. B)Initiate early ambulation to prevent complications of immobility. C)Provide a high-calorie, low-protein diet. D)Perform all of the patients hygiene and feeding.

A Feedback: The patient 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. As such, independent ADLs and ambulation are contraindicated. There is no need for a high-calorie or low-protein diet.

A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what?A)Evidence of hemorrhagic stroke B)Blood pressure of 180/110 mm Hg C)Evidence of stroke evolution D)Previous thrombolytic therapy within the past 12 months

A Feedback: Thrombolytic therapy would exacerbate a hemorrhagic stroke with potentially fatal consequences. Stroke evolution, high BP, or previous thrombolytic therapy does not contraindicate its safe and effective use.

Which description of an acute embolic stroke given by the nurse is most​ accurate? The local cerebral tissue becomes engorged with blood from a ruptured cerebral vessel. A blood clot lodges in a cerebral vessel and blocks blood flow. Infarcted areas in the brain slough​ off, leaving cavities in the brain tissue. Cerebral vascular pressure exceeds the elasticity of the vessel​ wall, resulting in hemorrhages.

A blood clot lodges in a cerebral vessel and blocks blood flow. In embolic​ stroke, a blood clot or other matter traveling through cerebral blood vessels becomes lodged in a narrow vessel blocking blood flow. The area of the brain supplied by the blocked vessel becomes ischemic. The clot may originate from a thrombus formed in the left side of the heart during atrial​ fibrillation, bacterial​ endocarditis, recent myocardial infarction​ (MI), atherosclerotic plaque from the carotid​ artery, rheumatic heart​ disease, or ventricular aneurysm. Infarcted areas of the brain become ischemic but do not slough off. Hemorrhagic stroke is when local cerebral tissue becomes engorged with blood from a ruptured cerebral vessel. An embolic stroke is not the result of cerebral vascular pressure increases.

During a patients recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help patients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply. A)National Institutes of Health Stroke Scale (NIHSS) score B)Race C)LOC at time of admission D)Gender E)Age

A, C, E Feedback: It is helpful for clinicians to be knowledgeable about the relative importance of predictors of stroke outcome (age, NIHSS score, and LOC at time of admission) to provide stroke survivors and their families with realistic goals. Race and gender are not predictors of stroke outcome.

After teaching a client with a spinal cord injury, the nurse assesses the client's understanding. Which client statement indicates a correct understanding of how to prevent respiratory problems at home? a. "I'll use my incentive spirometer every 2 hours while I'm awake." b. "I'll drink thinned fluids to prevent choking." c. "I'll take cough medicine to prevent excessive coughing." d. "I'll position myself on my right side so I don't aspirate."

A. "I'll use my incentive spirometer every 2 hours while I'm awake." Often, the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand the lungs more fully and prevents atelectasis. Clients should drink fluids that they can tolerate; usually thick fluids are easier to tolerate. The client should be encouraged to cough and clear secretions. Clients should be placed in high-Fowler's position to prevent aspiration.

A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which instruction should the nurse include in this education? a. "Participate in an exercise program to strengthen muscles." b. "Purchase a mattress that allows you to adjust the firmness." c. "Wear flat instead of high-heeled shoes to work each day." d. "Keep your weight within 20% of your ideal body weight."

A. "Participate in an exercise program to strengthen muscles." Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not prevent low back pain.

A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first? a. Client with a Glasgow Coma Scale score that was 10 and is now is 8 b. Client with a Glasgow Coma Scale score that was 9 and is now is 12 c. Client with a moderate brain injury who is amnesic for the event d. Client who is requesting pain medication for a headache

ANS: A A 2-point decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement in the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the declining Glasgow Coma Scale score.

A client had an embolic stroke and is having an echocardiogram. When the client asks why the provider ordered "a test on my heart," how should the nurse respond? a. "Most of these types of blood clots come from the heart." b. "Some of the blood clots may have gone to your heart too." c. "We need to see if your heart is strong enough for therapy." d. "Your heart may have been damaged in the stroke too."

ANS: A An embolic stroke is caused when blood clots travel from one area of the body to the brain. The most common source of the clots is the heart. The other statements are inaccurate.

After a stroke, a client has ataxia. What intervention is most appropriate to include on the client's plan of care? a. Ambulate only with a gait belt. b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform post-void residuals.

ANS: A Ataxia is a gait disturbance. For the client's safety, he or she should have assistance and use a gait belt when ambulating. Ataxia is not related to swallowing, aspiration, or voiding.

A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best? a. "Increased pressure from the abscess can cause seizures." b. "Preventing febrile seizures with an abscess is important." c. "Seizures always occur in clients with brain abscesses." d. "This drug is used to sedate the client with an abscess."

ANS: A Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse. Phenytoin is not used to prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This drug is not used for sedation.

A client with a stroke has damage to Broca's area. What intervention to promote communication is best for this client? a. Assess whether or not the client can write. b. Communicate using "yes-or-no" questions. c. Reinforce speech therapy exercises. d. Remind the client not to use neologisms.

ANS: A Damage to Broca's area often leads to expressive aphasia, wherein the client can understand what is said but cannot express thoughts verbally. In some instances the client can write. The nurse should assess to see if that ability is intact. "Yes-or-no" questions are not good for this type of client because he or she will often answer automatically but incorrectly. Reinforcing speech therapy exercises is good for all clients with communication difficulties. Neologisms are made-up "words" often used by clients with sensory aphasia.

A nurse is providing community screening for risk factors associated with stroke. Which client would the nurse identify as being at highest risk for a stroke? a. A 27-year-old heavy cocaine user b. A 30-year-old who drinks a beer a day c. A 40-year-old who uses seasonal antihistamines d. A 65-year-old who is active and on no medications

ANS: A Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this client uses them seasonally and there is no information that they are abused or used heavily. The 65-year-old has only age as a risk factor.

A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The client's spouse is very frustrated, stating that the client's personality has changed and the situation is intolerable. What action by the nurse is best? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse this is expected and he or she will have to learn to cope.

ANS: A Personality and behavior often change permanently after head injury. The nurse should explain this to the spouse. Asking the client about his or her behavior isn't useful because the client probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to learn to cope belittles the spouse's concerns and feelings.

A client has an intraventricular catheter. What action by the nurse takes priority? a. Document intracranial pressure readings. b. Perform hand hygiene before client care. c. Measure intracranial pressure per hospital policy. d. Teach the client and family about the device

ANS: B All of the actions are appropriate for this client. However, performing hand hygiene takes priority because it prevents infection, which is a possibly devastating complication.

A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI). The nurse notes the presence of an aneurysm clip in the client's record. What action by the nurse is best? a. Ask the client how long ago the clip was placed. b. Have the client sign an informed consent form. c. Inform the provider about the aneurysm clip. d. Reschedule the client for computed tomography.

ANS: A Some older clips are metal, which would preclude the use of MRI. The nurse should determine how old the clip is and relay that information to the MRI staff. They can determine if the client is a suitable candidate for this examination. The client does not need to sign informed consent. The provider will most likely not know if the client can have an MRI with this clip. The nurse does not independently change the type of diagnostic testing the client receives.

A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting. The client's mental status is deteriorating. What action by the nurse is most appropriate? a. Attempt to find the family to sign a consent. b. Inform the provider that the procedure cannot occur. c. Nothing; no consent is needed in an emergency. d. Sign the consent form for the client.

ANS: A The nurse should attempt to find the family to give consent. If no family is present or can be found, under the principle of emergency consent, a life-saving procedure can be performed without formal consent. The nurse should not just sign the consent form.

A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority? a. Call the provider or Rapid Response Team. b. Increase the rate of the IV fluid administration. c. Notify respiratory therapy for a breathing treatment. d. Prepare to give IV pain medication.

ANS: A These manifestations indicate Cushing's syndrome, a potentially life-threatening increase in intracranial pressure (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not need a breathing treatment or pain medication.

A client who had a severe traumatic brain injury is being discharged home, where the spouse will be a full-time caregiver. What statement by the spouse would lead the nurse to provide further education on home care? a. "I know I can take care of all these needs by myself." b. "I need to seek counseling because I am very angry." c. "Hopefully things will improve gradually over time." d. "With respite care and support, I think I can do this."

ANS: A This caregiver has unrealistic expectations about being able to do everything without help. Acknowledging anger and seeking counseling show a realistic outlook and plans for accomplishing goals. Hoping for improvement over time is also realistic, especially with the inclusion of the word "hopefully." Realizing the importance of respite care and support also is a realistic outlook.

A nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and determines the client's score to be 36. How should the nurse plan care for this client? a. The client will need near-total care. b. The client will need cuing only. c. The client will need safety precautions. d. The client will be discharged home

ANS: A This client has severe neurologic deficits and will need near-total care. Safety precautions are important but do not give a full picture of the client's dependence. The client will need more than cuing to complete tasks. A home discharge may be possible, but this does not help the nurse plan care for a very dependent client.

A client has a subarachnoid bolt. What action by the nurse is most important? a. Balancing and recalibrating the device b. Documenting intracranial pressure readings c. Handling the fiberoptic cable with care to avoid breakage d. Monitoring the client's phlebostatic axis

ANS: A This device needs frequent balancing and recalibration in order to read correctly. Documenting readings is important, but it is more important to ensure the device's accuracy. The fiberoptic transducer-tipped catheter has a cable that must be handled carefully to avoid breaking it, but ensuring the device's accuracy is most important. The phlebostatic axis is not related to neurologic monitoring.

A nurse is seeing many clients in the neurosurgical clinic. With which clients should the nurse plan to do more teaching? (Select all that apply.) a. Client with an aneurysm coil placed 2 months ago who is taking ibuprofen (Motrin) for sinus headaches b. Client with an aneurysm clip who states that his family is happy there is no chance of recurrence c. Client who had a coil procedure who says that there will be no problem following up for 1 year d. Client who underwent a flow diversion procedure 3 months ago who is taking docusate sodium (Colace) for constipation e. Client who underwent surgical aneurysm ligation 3 months ago who is planning to take a Caribbean cruise

ANS: A, B After a coil procedure, up to 20% of clients experience re-bleeding in the first year. The client with this coil should not be taking drugs that interfere with clotting. An aneurysm clip can move up to 5 years after placement, so this client and family need to be watchful for changing neurologic status. The other statements show good understanding.

A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury. What actions should the nurse include in the client's care? (Select all that apply.) a. Assess tube placement per agency policy. b. Keep the head of the bed elevated at least 30 degrees. c. Listen to lung sounds at least every 4 hours. d. Run continuous feedings on a feeding pump. e. Use blue dye to determine proper placement.

ANS: A, B, C, D All of these options are important for client safety when continuous enteral feedings are in use. Blue dye is not used because it can cause lung injury if aspirated.

An older adult client with Parkinson disease uses a​ walker, speaks in a slurred manner with poor​ articulation, but tries to speak louder to accommodate for this impairment. The client​ states, "I catch my daughter looking at me angrily​ sometimes, but she​ doesn't say​ anything." Which nursing diagnosis is the priority​? A. Communication: Verbal, Impaired B. Caregiver Role Strain C. ​Falls, Risk for D. Nutrition, Imbalanced: Less than Body Requirements

Answer: B ​Rationale: The client is making accommodations for preventing falls by using a walker. Being the primary​ caregiver, the​ client's daughter assists the client in feeding so imbalanced nutrition is not a risk. The client is also practicing speech by speaking louder. It is the​ caregiver's role strain that is the major risk for this client.​

Which symptom for a client with Parkinson disease​ (PD) is due to the lack of automatic muscle​ movement? A. Diminished voice volume B. Reduced ability to swallow C. Alterations in sleep pattern D. Diminished physical mobility

Answer: C ​Rationale: Alterations in sleep pattern may occur due to lack of automatic muscle movement in a client with Parkinson disease. Reducing strenuous activities near​ bedtime, limiting intake of​ caffeine, and providing a glass of milk before bedtime are all examples of interventions that directly address issues with sleep pattern. Reduced ability to​ swallow, diminished voice​ volume, and diminished physical mobility are all related to dysfunction of voluntary muscle movement.

A client has a history of transient ischemic attacks​ (TIAs). Which medication does the nurse expect to find in the​ client's list of​ prescriptions? Beta blocker Antiplatelet Anticoagulant Stool softener

Antiplatelet An antiplatelet may be prescribed for clients who have TIAs or who have had previous strokes. Its purpose is to prevent clot formation with the resulting vessel occlusion. An oral anticoagulant medication may be prescribed shortly after a stroke to prevent blood clot formation and to enhance cerebral blood flow by keeping the blood thin. A beta blocker is useful for lowering blood pressure but is limited in preventing stroke. Docusate sodium​ (Colace) is a stool softener that may be prescribed after a stroke to prevent straining at​ stool, which increases intracranial pressure​ (ICP).

A patient has been admitted to the hospital with symptoms of an embolic stroke. What etiologic factor in the patient's history places the patient at particular risk for this type of stroke?

Atrial fibrillation The source of most embolic strokes is typically the heart. Emboli occur in patients with a history of atrial fibrillation, ischemic heart disease, or myocardial infarction. Diabetes, aortic aneurysm, and irritable bowel disease are not primary risk factors.

When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of which the nurse should be aware? A)Generalized pain B)Alteration in level of consciousness (LOC) C)Tonicclonic seizures D)Shortness of breath

B Feedback: Alteration in LOC is the earliest sign of deterioration in a patient after a hemorrhagic stroke, such as mild drowsiness, slight slurring of speech, and sluggish papillary reaction. Sudden headache may occur, but generalized pain is less common. Seizures and shortness of breath are not identified as early signs of hemorrhagic stroke.

The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke? A)Providing frequent small meals rather than three larger meals B)Teaching the patient to perform deep breathing and coughing exercises C)Keeping a urinary catheter in situ for the full duration of recovery D)Limiting intake of insoluble fiber

B Feedback: Because pneumonia is a potential complication of stroke, deep breathing and coughing exercises should be encouraged unless contraindicated. No particular need exists to provide frequent meals and normally fiber intake should not be restricted. Urinary catheters should be discontinued as soon as possible.

A preceptor is discussing stroke with a new nurse on the unit. The preceptor would tell the new nurse which cardiac dysrhythmia is associated with cardiogenic embolic strokes? A)Ventricular tachycardia B)Atrial fibrillation C)Supraventricular tachycardia D)Bundle branch block

B Feedback: Cardiogenic embolic strokes are associated with cardiac dysrhythmias, usually atrial fibrillation. The other listed dysrhythmias are less commonly associated with this type of stroke.

A patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patients admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the patients plan of care? A)Elevate the head of the bed to 45 degrees. B)Maintain the patient on complete bed rest. C)Administer enemas when the patient is constipated. D)Avoid use of thigh-high elastic compression stockings.

B Feedback: Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in ICP, and prevent further bleeding. The patient 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, except for family, are restricted. The head of the bed is elevated 15 to 30 degrees to promote venous drainage and decrease ICP. Some neurologists, however, prefer that the patient remains flat to increase cerebral perfusion. No enemas are permitted, but stool softeners and mild laxatives are prescribed. Thigh-high elastic compression stockings or sequential compression boots may be ordered to decrease the patients risk for deep vein thrombosis (DVT).

A patient has recently begun mobilizing during the recovery from an ischemic stroke. To protect the patients safety during mobilization, the nurse should perform what action? A)Support the patients full body weight with a waist belt during ambulation. B)Have a colleague follow the patient closely with a wheelchair. C)Avoid mobilizing the patient in the early morning or late evening. D)Ensure that the patients family members do not participate in mobilization.

B Feedback: During mobilization, a chair or wheelchair should be readily available in case the patient suddenly becomes fatigued or feels dizzy. The family should be encouraged to participate, as appropriate, and the nurse should not have to support the patients full body weight. Morning and evening activity are not necessarily problematic.

A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patients plan of care, what goal should be prioritized? A)Prevent complications of immobility. B)Maintain and improve cerebral tissue perfusion. C)Relieve anxiety and pain. D)Relieve sensory deprivation.

B Feedback: Each of the listed goals is appropriate in the care of a patient recovering from a stroke. However, promoting cerebral perfusion is a priority physiologic need, on which the patients survival depends.

When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient position is most consistent with this goal? A)Head turned slightly to the right side B)Elevation of the head of the bed C)Position changes every 15 minutes while awake D)Extension of the neck

B Feedback: 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.

A rehabilitation nurse caring for a patient who has had a stroke is approached by the patients family and asked why the patient has to do so much for herself when she is obviously struggling. What would be the nurses best answer? A)We are trying to help her be as useful as she possibly can. B)The focus on care in a rehabilitation facility is to help the patient to resume as much self-care as possible. C)We arent here to care for her the way the hospital staff did; we are here to help her get better so she can go home. D)Rehabilitation means helping patients do exactly what they did before their stroke.

B Feedback: In both acute care and rehabilitation facilities, the focus is on teaching the patient to resume as much self-care as possible. The goal of rehabilitation is not to be useful, nor is it to return patients to their prestroke level of functioning, which may be unrealistic.

A family member brings the patient to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurses best answer? A)Have your heart checked regularly .B)Stop smoking as soon as possible. C)Get medication to bring down your sodium levels. D)Eat a nutritious diet.

B Feedback: Smoking is a modifiable and highly significant risk factor for stroke. The significance of smoking, and the potential benefits of quitting, exceed the roles of sodium, diet, and regular medical assessments.

The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at the highest risk for a hemorrhagic stroke? A)White female, age 60, with history of excessive alcohol intake B)White male, age 60, with history of uncontrolled hypertension C)Black male, age 60, with history of diabetes D)Black male, age 50, with history of smoking

B Feedback: Uncontrolled hypertension is the primary cause of a hemorrhagic stroke. Control of hypertension, especially in individuals over 55 years of age, clearly reduces the risk for hemorrhagic stroke. Additional risk factors are increased age, male gender, and excessive alcohol intake. Another high-risk group includes African Americans, where the incidence of first stroke is almost twice that as in Caucasians.

As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply. A)INR above 1.0 B)Recent intracranial pathology C)Sudden symptom onset D)Current anticoagulation therapy E)Symptom onset greater than 3 hours prior to admission

B, D, E Feedback: Some of the absolute contraindications for thrombolytic therapy include symptom onset greater than 3 hours before admission, a patient who is anticoagulated (with an INR above 1.7), or a patient who has recently had any type of intracranial pathology (e.g., previous stroke, head injury, trauma).

A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this client's discharge teaching? a. "Take warm baths to promote muscle relaxation." b. "Avoid crowds and people with colds." c. "Relying on a walker will weaken your gait." d. "Take prescribed medications when symptoms occur."

B. "Avoid crowds and people with colds." The client should be taught to avoid people with any type of upper respiratory illness because these medications are immunosuppressive. Warm baths will exacerbate the client's symptoms. Assistive devices may be required for safe ambulation. Medication should be taken at all times and should not be stopped.

A nurse assesses the health history of a client who is prescribed ziconotide (Prialt) for chronic back pain. Which assessment question should the nurse ask? a. "Are you taking a nonsteroidal anti-inflammatory drug?" b. "Do you have a mental health disorder?" c. "Are you able to swallow medications?" d. "Do you smoke cigarettes or any illegal drugs?"

B. "Do you have a mental health disorder?" Clients who have a mental health or behavioral health problem should not take ziconotide. The other questions do not identify a contraindication for this medication.

An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer? a. Intrathecal baclofen (Lioresal) b. Methylprednisolone (Medrol) c. Atropine sulfate d. Epinephrine (Adrenalin)

B. Methylprednisolone (Medrol) Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy usually show improvement in motor and sensory function. The other medications are inappropriate for this client.

The nurse caring for a client with a history of transient ischemic attacks​ (TIAs) is reviewing medications ordered to prevent a stroke. Which medication therapy requires​ follow-up? Thiazide diuretic Anticoagulant Antiplatelet Beta blocker

Beta Blocker Even though beta blockers are useful in lowering blood​ pressure, they are very limited in preventing stroke. Anticoagulants and antiplatelets are used to reduce the risk of stroke in clients with TIAs. Hypertension is the leading cause of stroke. Research indicates that thiazide diuretics and certain other antihypertensives are useful in reducing stroke risk.

The nurse is teaching a client about the cause of a transient ischemic attack​ (TIA). Which should the nurse​ include? Brief period of a neurologic deficit Vascular blockage Sudden intracranial bleed Formation of a clot in a blood vessel

Brief period of a neurologic deficit A TIA is a type of ischemic stroke resulting from a localized neurologic deficit lasting 24 hours or less. Vascular blockage is the cause of an embolic stroke. Intracranial bleeds cause hemorrhagic strokes. A thrombotic stroke is the result of the formation of a clot in a blood vessel.

A community health nurse is giving an educational presentation about stroke and heart disease at the local senior citizens center. What nonmodifiable risk factor for stroke should the nurse cite?A)Female gender B)Asian American race C)Advanced age D)Smoking

C Feedback: Advanced age, male gender, and race are well-known nonmodifiable risk factors for stroke. High-risk groups include people older than 55 years of age; the incidence of stroke more than doubles in each successive decade. Men have a higher rate of stroke than that of women. Another high-risk group is African Americans; the incidence of first stroke in African Americans is almost twice that as in Caucasian Americans; Asian American race is not a risk factor. Smoking is a modifiable risk.

A patient 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 patients cardiac and neurologic status, the nurse monitors the patient for signs of what complication? A)Acute pain B)Septicemia C)Bleeding D)Seizures

C Feedback: Bleeding is the most common side effect of t-PA administration, and the patient is closely monitored for any bleeding. Septicemia, pain, and seizures are much less likely to result from thrombolytic therapy.

The nurse is discharging home a patient who suffered a stroke. He has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common patient response to a change in body image? A)Denial B)Fear C)Depression D)Disassociation

C Feedback: Depression is a common and serious problem in the patient who has had a stroke. It can result from a profound disruption in his or her life and changes in total function, leaving the patient with a loss of independence. The nurse needs to encourage the patient to verbalize feelings to assess the effect of the stroke on self-esteem. Denial, fear, and disassociation are not the most common patient response to a change in body image, although each can occur in some patients.

A patient diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the patient and family needs to begin as soon as the patient is settled on the unit and will continue until the patient is discharged. What will family education need to include? A)How to differentiate between hemorrhagic and ischemic stroke B)Risk factors for ischemic stroke C)How to correctly modify the home environment D)Techniques for adjusting the patients medication dosages at home

C Feedback: For a patient with a hemorrhagic stroke, teaching addresses the use of assistive devices or modification of the home environment to help the patient live with the disability. This is more important to the patients 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.

The nurse is caring for a patient diagnosed with an ischemic stroke and knows that effective positioning of the patient is important. Which of the following should be integrated into the patients plan of care? A)The patients hip joint should be maintained in a flexed position. B)The patient should be in a supine position unless ambulating. C)The patient should be placed in a prone position for 15 to 30 minutes several times a day. D)The patient should be placed in a Trendelenberg position two to three times daily to promote cerebral perfusion.

C Feedback: If possible, the patient is placed in a prone position for 15 to 30 minutes several times a day. A small pillow or a support is placed under the pelvis, extending from the level of the umbilicus to the upper third of the thigh. This helps to promote hyperextension of the hip joints, which is essential for normal gait, and helps prevent knee and hip flexion contractures. The hip joints should not be maintained in flexion and the Trendelenberg position is not indicated.

The nurse is reviewing the medication administration record of a female patient who possesses numerous risk factors for stroke. Which of the womans medications carries the greatest potential for reducing her risk of stroke? A)Naproxen 250 PO b.i.d. B)Calcium carbonate 1,000 mg PO b.i.d. C)Aspirin 81 mg PO o.d. D)Lorazepam 1 mg SL b.i.d. PRN

C Feedback: Research findings suggest that low-dose aspirin may lower the risk of stroke in women who are at risk. Naproxen, lorazepam, and calcium supplements do not have this effect.

The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps:1. Change in pH2. Blood flow decreases3. A switch to anaerobic respiration4. Membrane pumps fail5. Cells cease to function6. Lactic acid is generatedPut these steps in order in which they occur .A)6,3,5,2,4,1 B)3,5,2,4,1,6 C)2,3,6,1,4,5 D)1,6,2,5,3,4

C Feedback: The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL per 100 g of blood per minute. At this point, neurons are no longer able to maintain aerobic respiration. The mitochondria must then switch to anaerobic respiration, which generates large amounts of lactic acid, causing a change in the pH. This switch to the less efficient anaerobic respiration also renders the neuron incapable of producing sufficient quantities of adenosine triphosphate (ATP) to fuel the depolarization processes. The membrane pumps that maintain electrolyte balances begin to fail, and the cells cease to function.

The nurse is preparing health education for a patient who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? A)Mild, intermittent seizures can be expected. B)Take ibuprofen for complaints of a serious headache. C)Take antihypertensive medication as ordered .D)Drowsiness is normal for the first week after discharge.

C Feedback: The patient 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 patient to return home. Patient 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 patient being discharged. Seizure activity is not normal; complaints of a serious headache should be reported to the physician before any medication is taken. Drowsiness is not normal or expected.

A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, "I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better." How should the nurse respond? a. "If you don't want to participate in the rehabilitation program, I'll let the provider know." b. "Rehabilitation programs have helped many clients with your injury. You should give it a chance." c. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." d. "When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first."

C. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet this client's needs.

A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect should the nurse monitor? a. Peripheral edema b. Black tarry stools c. Bradycardia d. Nausea and vomiting

C. Bradycardia Fingolimod (Gilenya) is an antineoplastic agent that can cause bradycardia, especially within the first 6 hours after administration. Peripheral edema, black and tarry stools, and nausea and vomiting are not adverse effects of fingolimod.

A nurse cares for several clients on a neurologic unit. Which prescription for a client should direct the nurse to ensure that an informed consent has been obtained before the test or procedure? a. Sensation measurement via the pinprick method b. Computed tomography of the cranial vault c. Lumbar puncture for cerebrospinal fluid sampling d. Venipuncture for autoantibody analysis

C. Lumbar puncture for cerebrospinal fluid sampling A lumbar puncture is an invasive procedure with many potentially serious complications. The other assessments or tests are considered noninvasive and do not require an informed consent.

A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find? a. Hyperresponsive reflexes b. Excessive somnolence c. Nystagmus d. Heat intolerance

C. Nystagmus Early signs and symptoms of MS include changes in motor skills, vision, and sensation. Hyperresponsive reflexes, excessive somnolence, and heat intolerance are later manifestations of MS.

A nurse cares for a client with a spinal cord injury. With which interdisciplinary team member should the nurse consult to assist the client with activities of daily living? a. Social worker b. Physical therapist c. Occupational therapist d. Case manager

C. Occupational therapist The occupational therapist instructs the client in the correct use of all adaptive equipment. In collaboration with the therapist, the nurse instructs family members or the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin care. The other team members are consulted to assist the client with unrelated issues.

Damage to which cranial nerve (CN) would lead to facial paralysis in the patient?

CN Vll Damage to CN VII would be responsible for facial paralysis. Damage to CN IX interferes with the gag reflex. Damage to CN XII leads to impaired tongue movement. CN IX and X damage can cause an inability to swallow.

After performing swallowing studies for a client recovering from a​ stroke, the speech therapist recommends a pureed diet and​ honey-thick liquids. Which is a priority for the​ nurse? Calling the healthcare provider about the results Ordering a pureed diet Documenting the results of the swallowing studies Carefully monitoring for coughing after giving the client a thickened beverage

Carefully monitoring for coughing after giving the client a thickened beverage Maintaining client safety is a priority when feeding for the first time. While all the answer options are​ appropriate, the priority is to assess the client for coughing when eating or drinking a thickened liquid.

A client who had a stroke secondary to cerebral stenosis discussed surgical options with the surgeon. Which option should the nurse anticipate will be​ performed? Cautious observation only Extracranial-intracranial bypass Carotid angioplasty with stenting Carotid endarterectomy

Carotid angioplasty with stenting Carotid angioplasty with stenting is used to surgically treat cerebral stenosis. Carotid endarterectomy is used to remove plaque from a carotid artery. An extracranial-intracranial bypass may be required if an occluded or stenotic vessel is not directly accessible. The client has already had a stroke from the​ stenosis, and there is no indication that comorbidities could prevent the surgery.

The nurse is caring for a patient admitted 1 week ago with an acute spinal cord injury. Which of the following assessment findings would alert the nurse to the presence of autonomic dysreflexia? A) Tachycardia B) Hypotension C) Hot, dry skin D) Throbbing headache

Correct Answer(s): D Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system reflected by hypertension, bradycardia, throbbing headache, and diaphoresis.

A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? A)Sit with the patient for a few minutes .B)Administer an analgesic. C)Inform the nurse-manager .D)Call the physician immediately

D Feedback: A headache may be an indication that the aneurysm is leaking. The nurse should notify the physician immediately. The physician will decide whether administration of an analgesic is indicated. Informing the nurse-manager is not necessary. Sitting with the patient is appropriate, once the physician has been notified of the change in the patients condition.

A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the patient is becoming progressively more drowsy over the course of the day. What is the nurses best response to this assessment finding? A)Report this finding to the physician as an indication of decreased metabolism. B)Provide more stimulation to the patient and monitor the patient closely. C)Recognize this as the expected clinical course of a hemorrhagic stroke. D)Report this to the physician as a possible sign of clinical deterioration.

D Feedback: Alteration in LOC often is the earliest sign of deterioration in a patient with a hemorrhagic stroke. Drowsiness and slight slurring of speech may be early signs that the LOC is deteriorating. This finding is unlikely to be the result of metabolic changes and it is not expected. Stimulating a patient with an acute stroke is usually contraindicated.

The public health nurse is planning a health promotion campaign that reflects current epidemiologic trends. The nurse should know that hemorrhagic stroke currently accounts for what percentage of total strokes in the United States? A)43% B)33% C)23% D)13%

D Feedback: Strokes can be divided into two major categories: ischemic (87%), in which vascular occlusion and significant hypoperfusion occur, and hemorrhagic (13%), in which there is extravasation of blood into the brain or subarachnoid space.

What should be included in the patients care plan when establishing an exercise program for a patient affected by a stroke? A)Schedule passive range of motion every other day. B)Keep activity limited, as the patient may be over stimulated. C)Have the patient perform active range-of-motion (ROM) exercises once a day. D)Exercise the affected extremities passively four or five times a day.

D Feedback: 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 patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this patient? A)Range-of-motion exercises to prevent contractures B)Encouraging independence with ADLs to promote recovery C)Early initiation of physical therapy D)Absolute bed rest in a quiet, nonstimulating environment

D Feedback: The patient 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 patient is fed and bathed to prevent any exertion that might raise BP.

After a subarachnoid hemorrhage, the patients laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurses most appropriate action? A)Administer a bolus of normal saline as ordered. B)Prepare the patient for thrombolytic therapy as ordered. C)Facilitate testing for hypothalamic dysfunction. D)Prepare to administer 3% NaCl by IV as ordered.

D Feedback: The patient may be experiencing syndrome of inappropriate antidiuretic hormone (SIADH) or cerebral salt-wasting syndrome. The treatment most often is the use of IV hypertonic 3% saline. A normal saline bolus would exacerbate the problem and there is no indication for tests of hypothalamic function or thrombolytic therapy.

A nursing student is writing a care plan for a newly admitted patient who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the patients plan of care? A)Adult failure to thrive B)Post-trauma syndrome C)Hyperthermia D)Disturbed sensory perception

D Feedback: The patient 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 female patient is diagnosed with a right-sided stroke. The patient is now experiencing hemianopsia. How might the nurse help the patient manage her potential sensory and perceptional difficulties? A)Keep the lighting in the patients room low. B)Place the patients clock on the affected side. C)Approach the patient on the side where vision is impaired. D)Place the patients extremities where she can see them.

D Feedback: The patient 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 patient 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 patient constantly of the other side of the body, to maintain alignment of the extremities, and if possible, to place the extremities where the patient can see them. Patients 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 patient 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.

A patient recovering from a stroke has severe shoulder pain from subluxation of the shoulder and is being cared for on the unit. To prevent further injury and pain, the nurse caring for this patient is aware of what principle of care? A)The patient should be fitted with a cast because use of a sling should be avoided due to adduction of the affected shoulder. B)Elevation of the arm and hand can lead to further complications associated with edema. C)Passively exercising the affected extremity is avoided in order to minimize pain. D)The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.

D Feedback: To prevent shoulder pain, the nurse should never lift a patient by the flaccid shoulder or pull on the affected arm or shoulder. The patient is taught how to move and exercise the affected arm/shoulder through proper movement and positioning. The patient is instructed to interlace the fingers, place the palms together, and push the clasped hands slowly forward to bring the scapulae forward; he or she then raises both hands above the head. This is repeated throughout the day. The use of a properly worn sling when the patient is out of bed prevents the paralyzed upper extremity from dangling without support. Range-of-motion exercises are still vitally important in preventing a frozen shoulder and ultimately atrophy of subcutaneous tissues, which can cause more pain. Elevation of the arm and hand is also important in preventing dependent edema of the hand.

A nurse assesses a client with a neurologic disorder. Which assessment finding should the nurse identify as a late manifestation of amyotrophic lateral sclerosis (ALS)? a. Dysarthria b. Dysphagia c. Muscle weakness d. Impairment of respiratory muscles

D. Impairment of respiratory muscles In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops. Eventually, the respiratory muscles are involved, which leads to respiratory compromise. Dysarthria, dysphagia, and muscle weakness are early clinical manifestations of ALS.

A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which prescribed medication should the nurse prepare to administer? a. Baclofen (Lioresal) b. Interferon beta-1b (Betaseron) c. Dantrolene sodium (Dantrium) d. Methylprednisolone (Medrol)

D. Methylprednisolone (Medrol) Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other drugs are not used to treat acute exacerbations of MS. Interferon beta-1b is used to treat and control MS, decrease specific symptoms, and slow the progression of the disease. Baclofen and dantrolene sodium are prescribed to lessen muscle spasticity associated with MS.

A nurse prepares a client for prescribed magnetic resonance imaging (MRI). Which action should the nurse implement prior to the test? a. Implement nothing by mouth (NPO) status for 8 hours. b. Withhold all daily medications until after the examination. c. Administer morphine sulfate to prevent claustrophobia during the test. d. Place the client in a gown that has cloth ties instead of metal snaps.

D. Place the client in a gown that has cloth ties instead of metal snaps. Metal objects are a hazard because of the magnetic field used in the MRI procedure. Morphine sulfate is not administered to prevent claustrophobia; lorazepam (Ativan) or diazepam (Valium) may be used instead. The client does not need to be NPO, and daily medications do not need to be withheld prior to MRI.

A nurse cares for a client with amyotrophic lateral sclerosis (ALS). The client states, "I do not want to be placed on a mechanical ventilator." How should the nurse respond? a. "You should discuss this with your family and health care provider." b. "Why are you afraid of being placed on a breathing machine?" c. "Using the incentive spirometer each hour will delay the need for a ventilator." d. "What would you like to be done if you begin to have difficulty breathing?"

D. What would you like to be done if you begin to have difficulty breathing?" ALS is an adult-onset upper and lower motor neuron disease characterized by progressive weakness, muscle wasting, and spasticity, eventually leading to paralysis. Once muscles of breathing are involved, the client must indicate in the advance directive what is to be done when breathing is no longer possible without intervention. The other statements do not address the client's needs.

A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which statement should the nurse include in this client's teaching? a. "Stroke the inner aspect of your thigh to initiate voiding." b. "Use a clean technique for intermittent catheterization." c. "Implement digital anal stimulation when your bladder is full." d. "Tighten your abdominal muscles to stimulate urine flow."

D: "Tighten your abdominal muscles to stimulate urine flow." In clients with lower motor neuron problems such as spinal cord injury, performing a Valsalva maneuver or tightening the abdominal muscles are interventions that can initiate voiding. Stroking the inner aspect of the thigh may initiate voiding in a client who has an upper motor neuron problem. Intermittent catheterization and digital anal stimulation do not initiate voiding or bladder control.

A client was diagnosed with a thrombotic stroke of the vertebral artery. Which assessment does the nurse expect to​ make? Stupor Global aphasia Contralateral paralysis Dysphagia

Dysphagia Dysphagia is the clinical manifestation that is associated with a stroke that affects the vertebral artery. The other clinical manifestations are seen with internal carotid and middle cerebral artery involvement.

The nurse is reviewing interventions aimed at maintaining cerebral perfusion in a client who had a thrombotic stroke. Which intervention should the nurse​ question? Encouraging active​ range-of-motion exercises Placing the client in a​ side-lying position Monitoring mental status and level of consciousness Monitoring respiratory status

Encouraging active​ range-of-motion exercises Active​ range-of-motion exercises promote physical mobility but will not directly assist in maintaining cerebral perfusion. The initial focus of care is to identify changes in​ airway, breathing, and circulation that could indicate decreased cerebral perfusion. Maintaining adequate oxygenation and positioning to facilitate breathing is appropriate.

The nurse is reviewing the plan of care for a client who is unresponsive following a stroke. Which intervention should the nurse​ question? Encouraging active​ range-of-motion exercises Elevating the head of the bed 30 degrees Turning the client every 2 hours Monitoring lower extremities for symptoms of thrombophlebitis

Encouraging active​ range-of-motion exercises Each of the nursing implementations listed are appropriate for promoting physical mobility.​ However, the client is unresponsive and therefore cannot complete active​ range-of-motion exercises; they would require passive​ range-of-motion exercises.

The nurse is caring for a client recovering from a stroke in the rehabilitation setting. Which is the goal of care during this​ stage? Minimizing brain injury Dispatching rapid emergency medical services​ (EMS) Diagnosing the type and cause of stroke Improving muscle strength and coordination

Improving muscle strength and coordination During the rehabilitation treatment stage of​ stroke, the focus is on client safety and improvement of muscle strength and coordination. Priorities during the treatment stage of acute care immediately following a stroke include rapid EMS​ dispatch, diagnosing the type and cause of​ stroke, and other interventions to minimize brain injury and maximize client recovery.

The nurse is reviewing documentation of a physical examination of a client who is suspected of having a stroke. Which documentation requires​ follow-up? Alert and oriented to person but not oriented to place or time Onset of facial drooping at 1430 ​Right-sided grip stronger than​ left-sided grip Stroke scale completed

Onset of facial drooping at 1430 Time of onset of stroke symptoms should be included in the client interview. All other assessments are part of the physical assessment.

Classifications of primary brain injuries

Open or Closed

A client diagnosed with a stroke is having difficulty walking and may require the use of a walker. Which area should the nurse make a referral​ to? Speech and language therapy Occupational therapy Home health Physical therapy

Physical therapy Occupational therapy can help a client learn to use assistive devices and create a plan for regaining motor skills. Physical therapy helps increase physical strength and coordination and prevent contractures. Speech and language therapy improve communication and swallowing. Home health may be​ needed, but the priority is learning to use the assistive device.

The nurse on the stroke rehabilitation unit is planning care for a client who is experiencing vision and equilibrium​ deficits, altered​ proprioception, hemianopia, and neglect syndrome. Which nursing therapy is the most important to​ include? Maintaining​ fluid, oxygen, and nutritional status Providing reassurance and support Developing an alternate means of communicating Providing behavioral and cognitive therapy when the condition stabilizes

Providing reassurance and support The client with​ sensory-perceptual deficits needs reassurance and support. There is no indication that the client cannot maintain​ fluid, oxygen, and nutritional​ status, cannot communicate​ well, or has cognitive or behavioral changes.

Which nursing intervention is best for preventing complications of immobility when caring for a patient with spinal cord problems?

Regular turning and repositioning

The nurse is teaching a class about the causes of a hemorrhagic stroke. Which should the nurse​ include? (Select all that​ apply.) Damage to the blood-brain barrier Ruptured aneurysm in the brain Atherosclerotic plaque breaking off in the artery Rupture of a fragile arterial vessel in the brain Traumatic injury to the brain

Ruptured aneurysm in the brain Rupture of a fragile arterial vessel in the brain Traumatic injury to the brain Arterial bleeds in the brain cause hemorrhagic stroke. Blood enters the brain and puts pressure on brain tissue. Manifestations occur suddenly because of the rapid rise in intracranial pressure​ (ICP). Aneurysms in the brain enlarge over time. This causes the arterial walls to become thin and subject to rupturing. Falls and other traumatic injuries can cause the arterial walls to rupture. This causes intracranial bleeding with accompanying increased ICP. Stroke caused by traumatic injury has the poorest outcome with greater likelihood of death. Atherosclerotic plaque that breaks off causes obstruction in the vessel lumen. This is ischemic​ stroke, rather than hemorrhagic. Hemorrhagic stroke involves bleeding into the brain. The blood-brain barrier prevents potentially harmful substances from entering the brain. Hemorrhagic stroke is not caused by damage to the blood-brain barrier. However, hemorrhagic stroke could cause damage to the blood-brain barrier and therefore allow harmful substances to enter the brain.

An adult client had a stroke involving the internal carotid artery of the dominant hemisphere. The nurse should anticipate that the client will have difficulty with which​ function? Speaking Staying alert Retaining urine Swallowing

Speaking Clinical manifestations of a stroke involving the internal carotid artery include contralateral paralysis of face and​ limbs, contralateral sensory deficits of face and​ limbs, aphasia,​ apraxia, agnosia, unilateral​ neglect, and homonymous hemianopia. Difficulty​ swallowing, drowsiness, and urine retention are not expected in this type of stroke.

The nurse is planning care for a client who has unilateral neglect and​ left-sided paralysis after experiencing a thrombotic stroke. Which goal of care should the nurse​ choose? The client will maintain bedrest. The client will participate in therapies to prevent contractures. The client will improve communication techniques. The​ client's blood pressure will remain within​ 40% of normal.

The client will participate in therapies to prevent contractures. Preventing contractures is a good goal for a client with​ left-sided paralysis and unilateral neglect. The client will be taught active​ range-of-motion exercises and ambulate as​ able, so maintaining bedrest is not appropriate. An appropriate goal for blood pressure is within normal​ limits, rather than​ 40% of normal. There is no indication that the client needs assistance with communication.

The nurse taught a group of clients recovering from a stroke how to perform active​ range-of-motion exercises. Which client requires further​ teaching? The client performing​ flexion, extension, and hyperextension of the hips bilaterally The client with​ right-sided paralysis flexing and extending only the left knee The client performing extension and hyperextension of the neck The client with​ left-sided paralysis using the right arm to help flex and extend the left wrist

The client with​ right-sided paralysis flexing and extending only the left knee The client can use the left side to help flex and extend the right knee. Both sides should be exercised. All the other​ range-of-motion exercises are appropriate.

The emergency room nurse is assessing a patient who presents with a stroke. The nurse finds that the patient shows perseveration, loss of deep sensation, and decreased touch sensation. What should the nurse infer from these symptoms?

The patient had a posterior cerebral artery stroke The posterior cerebral arteries are a pair of blood vessels that supply oxygenated blood to the occipital lobe. Perseveration, loss of deep sensation, and decreased touch sensation are the symptoms of posterior cerebral artery strokes. Perseveration is not a symptom of internal carotid artery, middle cerebral artery, and vertebrobasilar artery strokes. The vertebrobasilar artery supplies blood to the posterior part of the circle of Willis. The middle cerebral artery supplies blood to the cerebrum. The internal carotid artery supplies blood to the brain.

The laboratory results for a patient who sustained a stroke shows the presence of proteins in the cerebrospinal fluid. What should the nurse infer from the reports?

The patient had a thrombotic stroke.

The nurse is caring for a patient one day after the patient suffered a stroke. The patient is fully alert and has weakness of the right side of the body. Which assessment finding indicates an increasing intracranial pressure (ICP)?

The patient is no longer oriented to place The patient with a recent stroke is at risk of increased intracranial pressure (ICP) because of cerebral edema or ongoing intracranial hemorrhage. The first indication of increasing ICP is a change in the level of consciousness. If the patient seems confused and disoriented to place, it indicates an increased ICP, and the primary health care provider should be immediately notified. Urinary incontinence in the patient may indicate focal deficit. Numbness in the right leg may be due to weakness and may be an effect of the stroke, but it does not indicate an increased ICP. A BP of 90/62 mm Hg indicates hypotension. Hypertension is a key feature of increased ICP.

A client who is diagnosed with a stroke has an order for a tissue plasminogen activator​ (tPA). Which circumstance does the nurse suspect is​ present? The stroke must be hemorrhagic in nature. Aspirin therapy must have been received for 6 months for tPA to be effective. The stroke must have occurred within 3 hours of administering the medication. Atherosclerotic buildup in affected arteries must be greater than​ 90%.

The stroke must have occurred within 3 hours of administering the medication. For the safe administration of​ tPA, the medication must be administered within 3 hours of the onset of the symptoms of stroke. The stroke cannot be hemorrhagic in nature because the action of the medication is to dissolve the​ clot, which would not be intended for a reclotted ruptured hemorrhagic vessel. There is no minimal or maximal degree of plaque buildup that is necessary for the safe administration of the medication. Aspirin therapy is not a requirement for tPA to be administered.

After teaching a client with a spinal cord tumor, the nurse assesses the client's understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.) a. "Even though turning hurts, I will remind you to turn me every 2 hours." b. "Radiation therapy can shrink the tumor but also can cause more problems." c. "Surgery will be scheduled to remove the tumor and reverse my symptoms." d. "I put my affairs in order because this type of cancer is almost always fatal." e. "My family is moving my bedroom downstairs for when I am discharged home."

a. "Even though turning hurts, I will remind you to turn me every 2 hours." b. "Radiation therapy can shrink the tumor but also can cause more problems." e. "My family is moving my bedroom downstairs for when I am discharged home." Although surgery may relieve symptoms by reducing pressure on the spine and debulking the tumor, some motor and sensory deficits may remain. Spinal tumors usually cause disability but are not usually fatal. Radiation therapy is often used to shrink spinal tumors but can cause progressive spinal cord degeneration and neurologic deficits. The client should be turned every 2 hours to prevent skin breakdown and arrangements should be made at home so that the client can complete activities of daily living without needing to go up and down stairs.

A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which complication should alert the nurse to urgently communicate with the health care provider? a. Auscultated stridor b. Weak pedal pulses c. Difficulty swallowing d. Inability to shrug shoulders

a. Auscultated stridor

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation

a. Heart rate of 34 beats/min c. Urine output less than 30 mL/hr d. Decreased level of consciousness Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension.

A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data should the nurse obtain to assess the client's coping strategies? (Select all that apply.) a. Spiritual beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies

a. Spiritual beliefs c. Family support d. Level of independence f. Previous coping strategies Information about the client's preinjury psychosocial status, usual methods of coping with illness, difficult situations, and disappointments should be obtained. Determine the client's level of independence or dependence and his or her comfort level in discussing feelings and emotions with family members or close friends. Clients who are emotionally secure and have a positive self-image, a supportive family, and financial and job security often adapt to their injury. Information about the client's spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care. The other options do not supply as much information about coping.

A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Tape a halo wrench to the client's vest. b. Assess the pin sites for signs of infection. c. Loosen the pins when sleeping. d. Decrease the client's oral fluid intake. e. Assess the chest and back for skin breakdown.

a. Tape a halo wrench to the client's vest. b. Assess the pin sites for signs of infection. e. Assess the chest and back for skin breakdown. A special halo wrench should be taped to the client's vest in case of a cardiopulmonary emergency. The nurse should assess the pin sites for signs of infection or loose pins and for complications from the halo. The nurse should also increase fluids and fiber to decrease bowel straining and assess the client's chest and back for skin breakdown from the halo vest.

A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in this client's postoperative instructions? a. "Only lift items that are 10 pounds or less." b. "Wear your brace whenever you are out of bed." c. "You must remain in bed for 3 weeks after surgery." d. "You are prescribed medications to prevent rejection."

b. "Wear your brace whenever you are out of bed."

A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern. Which actions should the nurse take to assist in relieving this client's constipation? (Select all that apply.) a. Pour warm water over the perineum. b. Provide a diet high in fluids and fiber. c. Administer daily tap water enemas. d. Implement a consistent daily time for elimination. e. Massage the abdomen from left to right. f. Perform manual disimpaction.

b. Provide a diet high in fluids and fiber. d. Implement a consistent daily time for elimination. f. Perform manual disimpaction. For the client with a lower motor neuron injury, the resulting flaccid bowel may require a bowel program for the client that includes stool softeners, increased fluid intake, a high-fiber diet, and a consistent elimination time. If the client becomes impacted, the nurse would need to perform manual disimpaction. Pouring warm water over the perineum, administering daily enemas, and massaging the abdomen would not assist this client.

After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply.) a. "I will explore other ways besides intercourse to please my partner." b. "I will not be able to have an erection because of my injury." c. "Ejaculation may not be as predictable as before." d. "I may urinate with ejaculation but this will not cause infection." e. "I should be able to have an erection with stimulation."

c. "Ejaculation may not be as predictable as before." d. "I may urinate with ejaculation but this will not cause infection." e. "I should be able to have an erection with stimulation." Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the client's partner will not get an infection.

A nurse assesses clients at a community center. Which client is at greatest risk for lower back pain? a. A 24-year-old female who is 25 weeks pregnant b. A 36-year-old male who uses ergonomic techniques c. A 45-year-old male with osteoarthritis d. A 53-year-old female who uses a walker

c. A 45-year-old male with osteoarthritis

A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should the nurse include in this client's plan of care? a. Encourage the client to stretch the back by reaching toward the toes. b. Massage the affected area with ice twice a day. c. Apply a heating pad for 20 minutes at least four times daily. d. Advise the client to avoid warm baths or showers.

c. Apply a heating pad for 20 minutes at least four times daily.

A nurse assesses a client who is recovering from a lumbar laminectomy. Which complications should alert the nurse to urgently communicate with the health care provider? (Select all that apply.) a. Surgical discomfort b. Redness and itching at the incision site c. Incisional bulging d. Clear drainage on the dressing e. Sudden and severe headache

c. Incisional bulging d. Clear drainage on the dressing e. Sudden and severe headache Bulging at the incision site or clear fluid on the dressing after a laminectomy strongly suggests a cerebrospinal fluid leak, which constitutes an emergency. Loss of cerebral spinal fluid may cause a sudden and severe headache, which is also an emergency situation. Pain, redness, and itching at the site are normal.

A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? a. Initiate oxygen via a nasal cannula. b. Place the client in a supine position. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker.

c. Palpate the bladder for distention.

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. Which actions should the nurse take? (Select all that apply.) a. Apply a barrier cream to protect the skin from excoriation. b. Perform range-of-motion (ROM) exercises for the hip joint. c. Re-position the client off of the reddened areas. d. Get the client out of bed and into a chair once a day. e. Obtain a low-air-loss mattress to minimize pressure.

c. Re-position the client off of the reddened areas. e. Obtain a low-air-loss mattress to minimize pressure. Appropriate interventions to relieve pressure on these areas include frequent re-positioning and a low-air-loss mattress. Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system. Barrier cream will not protect the skin from pressure wounds. ROM exercises are used to prevent contractures. Sitting the client in a chair once a day will decrease the client's risk of respiratory complications but will not decrease pressure on the client's hips and sacrum.

A nurse assesses a client who is recovering from a diskectomy 6 hours ago. Which assessment finding should the nurse address first? a. Sleepy but arouses to voice b. Dry and cracked oral mucosa c. Pain present in lower back d. Bladder palpated above pubis

d. Bladder palpated above pubis

An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status

d. Evaluate respiratory status

open traumatic brain injury (TBI)?

skull is fractured or pierced by a penetrating object, t

The nurse is observing the unlicensed assistive personnel​ (UAP) helping a client with unilateral neglect of the right side perform​ self-care. Which statement by the UAP requires an intervention by the​ nurse? ​"When getting​ dressed, first put clothing on the left​ side." ​"Use the left arm to​ bathe, brush​ teeth, comb​ hair, and​ eat." ​"The occupational therapist will teach you how to promote upper extremity​ strength." ​"The occupational therapist will assist you in learning to walk using a​ walker."

​"When getting​ dressed, first put clothing on the left​ side." The client should be taught to dress the affected extremities first and then the unaffected extremities. This will enable the client to dress herself with minimal assistance. The other options are all appropriate instructions to teach the client to perform​ self-care.

A client with Parkinson disease​ (PD) is prescribed an anticholinergic agent to treat tremors and rigidity. The nurse should teach the client about which adverse effect they may experience from this​ medication? (Select all that​ apply.) A. Drooling B. Dry mouth C. Rigidity D. Loss of perspiration E.Tremors

​Answer: B, D Rationale: Anticholinergic medications can cause a decrease in​ salivation, causing dry mouth. This medication decreases tremors and reduces rigidity by blocking acetylcholine. The client taking this medication will have problems with temperature control because the client will not be able to perspire to cool off.

A client with a traumatic brain injury is agitated and fighting the ventilator. What drug should the nurse prepare to administer? a. Carbamazepine (Tegretol) b. Dexmedetomidine (Precedex) c. Diazepam (Valium) d. Mannitol (Osmitrol)

ANS: B Dexmedetomidine is often used to manage agitation in the client with traumatic brain injury. Carbamazepine is an antiseizure drug. Diazepam is a benzodiazepine. Mannitol is an osmotic diuretic.

A client is being prepared for a mechanical embolectomy. What action by the nurse takes priority? a. Assess for contraindications to fibrinolytics. b. Ensure that informed consent is on the chart. c. Perform a full neurologic assessment. d. Review the client's medication lists.

ANS: B For this invasive procedure, the client needs to give informed consent. The nurse ensures that this is on the chart prior to the procedure beginning. Fibrinolytics are not used. A neurologic assessment and medication review are important, but the consent is the priority.

A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death? a. Client with a core temperature of 95° F (35° C) for 2 days b. Client in a coma for 2 weeks from a motor vehicle crash c. Client who is found unresponsive in a remote area of a field by a hunter d. Client with a systolic blood pressure of 92 mm Hg since admission

ANS: B In order to determine brain death, clients must meet four criteria: 1) coma from a known cause, 2) normal or near-normal core temperature, 3) normal systolic blood pressure, and 4) at least one neurologic examination. The client who was in the car crash meets two of these criteria. The clients with the lower temperature and lower blood pressure have only one of these criteria. There is no data to support assessment of brain death in the client found by the hunter.

A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best? a. Have the student ask the client if it is desired or not. b. Inform the student that the docusate should be given. c. Tell the student to document the rationale. d. Tell the student to give it unless the client refuses.

ANS: B Stool softeners should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Valsalva maneuver when constipated. The supervising nurse should instruct the student to administer the docusate. The other options are not appropriate. The medication could be held for diarrhea.

A client's mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the client's cerebral perfusion pressure, what should the nurse anticipate for this client? a. Impending brain herniation b. Poor prognosis and cognitive function c. Probable complete recovery d. Unable to tell from this information

ANS: B The cerebral perfusion pressure (CPP) is the intracranial pressure subtracted from the mean arterial pressure: in this case, 60 - 20 = 40. For optimal outcomes, CPP should be at least 70 mm Hg. This client has very low CPP, which will probably lead to a poorer prognosis with significant cognitive dysfunction should the client survive. This data does not indicate impending brain herniation or complete recovery.

After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse is best? a. Assess the client's magnesium level. b. Assess the client's sodium level. c. Increase the rate of the IV infusion. d. Provide oral care every hour.

ANS: B This client has manifestations of hypernatremia, which is a possible complication after craniotomy. The nurse should assess the client's serum sodium level. Magnesium level is not related. The nurse does not independently increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessing laboratory results.

A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the client's neurologic examination is normal. About what drug should the nurse plan to teach the client? a. Alteplase (Activase) b. Clopidogrel (Plavix) c. Heparin sodium d. Mannitol (Osmitrol)

ANS: B This client's manifestations are consistent with a transient ischemic attack, and the client would be prescribed aspirin or clopidogrel on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition.

A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometer b. Is allergic to acetaminophen (Tylenol) c. Laughing, says "Strenuous? What's that?" d. Lives alone and is new in town with no friends e. Plans to have a beer and go to bed once home

ANS: B, D, E Clients should take acetaminophen for headache. An allergy to this drug may mean the client takes aspirin or ibuprofen (Motrin), which should be avoided. The client needs neurologic checks every 1 to 2 hours, and this client does not seem to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A thermometer is not needed. The client laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this.

A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess neurologic status with the Glasgow Coma Scale. b. Check and document oxygen saturation every 1 to 2 hours. c. Cluster client care to allow periods of uninterrupted rest. d. Elevate the head of the bed to 45 degrees to prevent aspiration. e. Position the client supine with the head in a neutral midline position.

ANS: B, E The UAP can take and document vital signs, including oxygen saturation, and keep the client's head in a neutral, midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees.

A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met? a. Chooses preferred items from the menu b. Eats 75% to 100% of all meals and snacks c. Has clear lung sounds on auscultation d. Gains 2 pounds after 1 week

ANS: C Impaired swallowing can lead to aspiration, so the priority goal for this problem is no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration.

A nurse is caring for four clients in the neurologic/neurosurgical intensive care unit. Which client should the nurse assess first? a. Client who has been diagnosed with meningitis with a fever of 101° F (38.3° C) b. Client who had a transient ischemic attack and is waiting for teaching on clopidogrel (Plavix) c. Client receiving tissue plasminogen activator (t-PA) who has a change in respiratory pattern and rate d. Client who is waiting for subarachnoid bolt insertion with the consent form already signed

ANS: C The client receiving t-PA has a change in neurologic status while receiving this fibrinolytic therapy. The nurse assesses this client first as he or she may have an intracerebral bleed. The client with meningitis has expected manifestations. The client waiting for discharge teaching is a lower priority. The client waiting for surgery can be assessed quickly after the nurse sees the client who is receiving t-PA, or the nurse could delegate checking on this client to another nurse.

A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time? a. Inability to communicate b. Nutritional deficit c. Risk for acquiring an infection d. Risk for skin breakdown

ANS: C The positive halo sign indicates a leak of cerebrospinal fluid. This places the client at high risk of acquiring an infection. Communication and nutrition are not priorities compared with preventing a brain infection. The client has a definite risk for a skin breakdown, but it is not the immediate danger a brain infection would be.

A client had an embolectomy for an arteriovenous malformation (AVM). The client is now reporting a severe headache and has vomited. What action by the nurse takes priority? a. Administer pain medication. b. Assess the client's vital signs. c. Notify the Rapid Response Team. d. Raise the head of the bed.

ANS: C This client may be experiencing a rebleed from the AVM. The most important action is to call the Rapid Response Team as this is an emergency. The nurse can assess vital signs while someone else notifies the Team, but getting immediate medical attention is the priority. Administering pain medication may not be warranted if the client must return to surgery. The optimal position for the client with an AVM has not been determined, but calling the Rapid Response Team takes priority over positioning.

The nurse assesses a client's Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client? a. Can ambulate independently b. May have trouble swallowing c. Needs frequent re-orientation d. Will need near-total care

ANS: C This client will most likely be confused and need frequent re-orientation. The client may not be able to ambulate at all but should do so independently, not because of mental status. Swallowing is not assessed with the GCS. The client will not need near-total care.

The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first? a. Client with cerebral perfusion pressure of 72 mm Hg b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg who is on a ventilator d. Client who has a temperature of 102° F (38.9° C)

ANS: D A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and cerebral perfusion pressure of 72 mm Hg are all desired outcomes.

A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset

ANS: D The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this client. The other information is not as critical.

A client in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best? a. Ensure that informed consent is on the chart. b. Document these findings in the client's record. c. Give the prescribed preprocedure sedation. d. Notify the provider of the findings immediately.

ANS: D This client is exhibiting signs of increased intracranial pressure. The nurse should notify the provider immediately because performing the LP now could lead to herniation. Informed consent is needed for an LP, but this is not the priority. Documentation should be thorough, but again this is not the priority. The preprocedure sedation (or other preprocedure medications) should not be given as the LP will most likely be canceled.

A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client? a. Assess for bladder retention and/or incontinence. b. Listen to the client's lungs after eating or drinking. c. Prop the client's right side up when sitting in a chair. d. Rotate the client's meal tray when the client stops eating.

ANS: D This condition is blindness on the same side of both eyes. The client must turn his or her head to see the entire visual field. The client may not see all the food on the tray, so the nurse rotates it so uneaten food is now within the visual field. This condition is not related to bladder function, difficulty swallowing, or lack of trunk control.

A patient has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse perform to best prevent joint deformities? A)Place the patient in the prone position for 30 minutes/day. B)Assist the patient in acutely flexing the thigh to promote movement .C)Place a pillow in the axilla when there is limited external rotation. D)Place patients hand in pronation.

Ans: C Feedback: A pillow in the axilla prevents adduction of the affected shoulder and keeps the arm away from the chest. The prone position with a pillow under the pelvis, not flat, promotes hyperextension of the hip joints, essential for normal gait. To promote venous return and prevent edema, the upper thigh should not be flexed acutely. The hand is placed in slight supination, not pronation, which is its most functional position.

A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose? A)To decrease cerebral edema B)To prevent seizure activity that is common following a TIA C)To remove atherosclerotic plaques blocking cerebral flow D)To determine the cause of the TIA

Ans: C Feedback: The main surgical procedure for select patients with TIAs is carotid endarterectomy, the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial arteries. An endarterectomy does not decrease cerebral edema, prevent seizure activity, or determine the cause of a TIA.

The nurse is teaching a patient and family about home care after a stroke. Which statement made by the patient's spouse indicates a need for further teaching?

"I should spend all my time with my husband in case I'm needed. Family members can start to feel socially isolated when caring for a loved one. The family may need to plan for regular respite care in a structured daycare respite program or through relief provided by a friend or neighbor. The life changes associated with stroke often cause a change in the patient's self-esteem. The patient who has had a stroke should maintain a regular medication regimen, such as anticoagulant therapy, to prevent another stroke. Once the home health nurse has assessed the home environment, he or she will notify the health care provider of the need for ancillary services, such as a physical therapist. The physical therapist will identify adaptive equipment needs, will request them, and then will instruct the patient about their use, along with developing an exercise program.

A patient with Parkinson's disease is prescribed rasagiline mesylate (MAOI) for relieving freezing episodes. Which instruction by the nurse would be appropriate while administering the drug?

"Strictly avoid foods with cheese or cheese products."

A patient who sustained a transient ischemic attack (TIA) is admitted to emergency department. The nurse is teaching the student nurse about methods to prevent another TIA. Which statement made by the student nurse indicates a need for further teaching?

"The patient should be placed on a totally liquid diet." It is not necessary for the patient to maintain a totally liquid diet. The patient can eat any food that is healthy for the heart. Aspirin is an antiplatelet drug that prevents platelet aggregation and clot formation. Patients who sustain a TIA have high blood pressure; therefore, it is important to give antihypertensive medications in order to maintain a normal blood pressure. Oral hypoglycemic medications should be given to the patient to maintain blood sugar levels in the normal range, thereby preventing another attack.

How much time will it take for the symptoms of transient ischemic attack to resolve?

30-60 minutes Ischemic strokes often follow warning signs such as a transient ischemic attack (TIA). Symptoms of a TIA resolve within 30 to 60 minutes. TIA is a transient episode and may not last for more than an hour.

Which ethnic group has the highest prevalence of stroke over others?

American Indians and Alaskan Natives American Indian/Alaskan Native groups have the highest prevalence of stroke. African-American men and women have more strokes than Caucasian men and women. Hispanic or Latino men have more strokes than non-Hispanic men. The causes for these differences are not well known, but genetic, environmental, and/or lifestyle factors may play a role, including dietary habits.

A patient has impairments from a SCI at C4 classified as incomplete C on the American Spinal Injury Association, (ASIA) Impairment Sclae. Which patient assessment is the nurse likely to observe in this patient? A. poor propricopetor in the legs B. poor peristalsis in the intestines C. Absent gag and blinking reflexes D. Absent bladder fulness sensation

Answer is B A patient who has a SCI has neurologic impairment to all extremities and the diaphragm. However, because the injury is C on the ASIA impairment Scale, sensory function can be intact but motor function will be impaired significantly or absent.the patient can lose moderate to complete peristatlic action in the intestines but should reatine the ability to sense bladder fulnessand the position of the legs.

A client newly diagnosed with Parkinson disease asks the​ nurse, "What does dopamine do in the​ brain?" Which is the most appropriate​ response? A. "Dopamine enhances the action of​ acetylcholine." B. "Dopamine causes spinal cord neurons to transmit​ impulses." C. "Dopamine stimulates the neurons to transmit sensory and motor​ impulses." D. "Dopamine helps maintain coordinated motor​ movement."

Answer: ​Rationale: Dopamine is responsible for coordination. It balances the neurotransmitter​ acetylcholine, which stimulates the neurons. Dopamine prevents this stimulation from becoming excessive. Dopamine provides regulation rather than stimulation. Dopamine regulates motor neuron impulses and balances acetylcholine. Dopamine only works on certain brain neurons located in the basal​ ganglia, not the spinal cord. Dopamine minimizes and balances the effects of acetylcholine and does not enhance it.

The healthcare provider of an older adult client with advancing Parkinson disease suggested that the client start an exercise regime. Which exercise should the nurse​ recommend? A. T'ai chi B. Running C. Weight lifting D. Football

Answer: ​Rationale: For a client with Parkinson​ disease, an exercise regime that promotes balance and walking is the best.​ So, the nurse may recommend​ t'ai chi. Considering the​ client's age,​ football, running, and weight lifting may be too strenuous.

Which clinical manifestation would be required to confirm the diagnosis of Parkinson​ disease? A. Tremors at rest and bradykinesia B. Bradykinesia only C. Rigidity only D. Tremor at rest and flaccidity

Answer: A ​Rationale: A diagnosis of Parkinson disease requires the presence of two of the three cardinal​ manifestations: tremor,​ rigidity, and bradykinesia. Tremors at rest and bradykinesia are two of the cardinal signs. Bradykinesia alone would not be diagnostic. Tremors at rest are a cardinal​ sign, but flaccidity is not. Rigidity is a cardinal​ sign, but rigidity alone is not diagnostic.

Which recommendation should the nurse make to the client with Parkinson disease​ (PD) to improve gait and​ balance? (Select all that​ apply.) A. Looking ahead instead of down B. Not moving too quickly C. Not using an assistive device D. Standing straight E. Placing the heel on the ground before the toes

Answer: A, B, D, E Rationale: For improving gait and balance in the client with​ PD, the nurse may recommend walking technique that includes standing​ straight, not moving too​ quickly, looking ahead and not​ down, and placing the heel on the ground before the toes. The client may use assistive devices to improve balance and gait.

The nurse is assessing an older adult client. Which finding should cause the nurse to suspect the client has Parkinson disease (PD)? (Select all that​ apply.) A. The client has hand tremors at rest. B. The client does not remember what he ate for breakfast. C. The​ client's blood pressure increases when the client stands up. D. The client has a slurred speech. E. The​ client's facial expression shows no emotion.

Answer: A, B, D, E ​Rationale: PD causes slowed​ movements, including slurred speech. Tremors at rest are very common in PD and easy to identify. Tremors may occur in the​ hands, face,​ neck, lips,​ tongue, and jaw. PD causes a​ frozen, mask-like expression​ (lack of​ affect). The client will not have an expression that is consistent with the emotions the client is feeling. Memory loss occurs in Parkinson disease because of the loss of neurons and other changes in the brain. The client may develop dementia. Postural​ hypotension, not​ hypertension, is a common manifestation in clients with PD. This is caused by damage to the autonomic nervous system.

Which health promotion activity should be the focus of teaching for a client with Parkinson disease​ (PD)? (Select all that​ apply.) A. Participating in occupational therapy B. Improving balance C. Avoiding exercise D. Preventing injury from falls E. Promoting independence

Answer: A, B, D, E ​Rationale: The focus of teaching for the client with PD should be on improving​ balance, preventing​ falls, promoting​ independence, and participating in​ physical, occupational, and speech therapy. Clients should be taught to participate in exercise to optimize​ mobility, not avoid it.

The nurse is performing passive range of motion exercises for a client with Parkinson disease. Which nursing goal does this intervention​ address? (Select all that​ apply.) A. The client will remain free from injury. B. The client will participate in speech therapy for swallowing and verbal communication. C. The client will demonstrate normal bowel elimination patterns. D. The client will participate in occupational therapy to integrate assistive devices for​ self-care. E. The client will participate in physical therapy to improve walking and balance.

Answer: A, E ​Rationale: Physical​ therapy, including passive range of motion​ (ROM) exercises, will improve the​ client's walking and balance. This in turn helps prevent injury from falls. Assistive devices related to occupational therapy are different from those related to physical therapy. The occupational therapist would teach about devices that facilitate activities of daily​ living, such as button hooks and communication boards. Passive ROM exercises are not related to speech therapy or promoting normal bowel elimination patterns.

An older adult client was diagnosed with Parkinson disease 3 months ago. Since the​ diagnosis, the client has not gone out of the house. Which statement by the nurse is most​ appropriate? A. "Tell your family to come and take you out of the​ house." B. "Can I ask why you​ aren't going out of the​ house?" C. "You need to start getting​ out." D. ​"Getting out of the house will help you to feel less​ depressed."

Answer: B ​Rationale: Asking an​ open-ended question and inquiring about the reason why the client is not going out of the house will encourage the client to discuss and share information. Advising the client about going​ out, telling the client that they will feel better by going​ out, or involving the family will not encourage the client to discuss the reason behind staying at home.

A client with Parkinson disease​ (PD) complains of increased tremor while eating. Which action should the nurse​ recommend? A. Having someone feed them B. Liquefying all meals and drinking them through a straw C. Holding a piece of bread in the other hand while eating D. Using their nondominant hand to eat

Answer: B ​Rationale: Holding a piece of bread in the opposite hand or purposeful movement will decrease tremors while eating. The client should be encouraged to eat independently for as long as possible. Using the nondominant hand may lack coordination. As the client with PD is prone to​ choking, liquefying all meals would not be recommended.

Which is the main pathology of Parkinson disease that causes changes in muscular and sensory​ function? A. Reduction of acetylcholine in the brain B. Reduction of dopamine in the brain C. Genetic predisposition D. Presence of Lewy bodies

Answer: B ​Rationale: The changes in muscular and sensory function in Parkinson disease​ (PD) are caused by a decreased amount of dopamine in the​ brain, which in turn​ increases, not​ reduces, the amount of acetylcholine. The presence of Lewy bodies​ (abnormal aggregates of​ proteins) in the neurons is a characteristic of​ PD, but it is unclear whether they are helpful or harmful. Although there is a genetic link in approximately 15dash​25% of​ cases, it is a risk factor rather than a cause of PD manifestations.

The nurse is assessing a client with Parkinson disease​ (PD). Which factor should the nurse include in the​ assessment? (Select all that​ apply.) A. Difficulty waking B. Response to medication C. Cognitive deficits D. Dizziness when sitting E. Bowel changes

Answer: B, C, E ​Rationale: While assessing the current​ condition, the nurse should ask about bowel​ changes, as clients with PD face problems with​ peristalsis, which contributes to constipation. The client may also have cognitive deficits such as memory​ loss, slowed​ thinking, and​ confusion, which eventually progress to dementia. Another aspect that needs to be assessed is responses to​ medication, especially for​ "on-off" or​ "wearing off" effects that indicate that medication is losing its effectiveness. Clients with PD have difficult falling and staying​ asleep, so difficulty in waking up is not related. Postural hypotension is common in Parkinson​ disease, resulting in blood pressure that drops when the client stands​ up, not while sitting.

Which type of therapy is used to manage problems with eating and​ swallowing? A. Physical B. Occupational C. Speech D. Nutritional

Answer: C ​Rationale: Speech therapy is used to manage problems with eating and swallowing. Occupational therapy is used to maintain​ self-care activities, not specifically eating and swallowing. Physical therapy is used to improve coordination of balance and gait. There is no nutritional therapy needed for a client with Parkinson disease.

The daughter of an older adult client with advancing Parkinson disease tells the nurse that they need to dress their mother each​ morning, because the mother is​ "not fast​ enough." Which is the most appropriate response from the​ nurse? A. "It is important for you to get to work on​ time." B. "Can you let her dress​ herself? C. "It is best for you to let your mother dress herself for as long as she​ can." D. "That is really quite​ normal."

Answer: C ​Rationale: The nurse should tell the caregiver​ that, by allowing independence in​ dressing, the client will have an improved sense of​ well-being and lessened depression. Asking​ closed-ended questions or just remarking that it is normal will not support the​ client's needs.

The nurse is caring for a client with Parkinson disease​ (PD) who reports problems with stiffness and the ability to move. Which action by the nurse will address the​ client's mobility? A. Ask the client if they know about the medications to treat the stiffness B. Advise bedrest for muscle recovery C. Tell the client that this is part of the disease process that cannot be stopped D. Recommend a regular exercise routine and walking

Answer: D ​Rationale: The best way to promote mobility in the client with PD is to recommend the client ambulate daily and exercise on a regular basis. Bedrest would only make the stiffness worse. Although there are medications that can help with​ rigidity, it is outside of the​ nurse's scope of practice to recommend medication. Telling the client that this is just part of the disease process is not appropriate or therapeutic.

A nurse is preparing a presentation on Parkinson disease​ (PD) for a health fair at a local community center. Which information should the nurse include in the​ presentation? A. Parkinson disease affects both men and women at the same rate. B. Parkinson disease is the result of an infection. C. Parkinson disease is inherited in over​ 50% of those affected. D. Parkinson disease usually affects people older than the age of 60 years.

Answer: D ​Rationale: The cause of PD is not known. There is no evidence of an infection that causes Parkinson disease. It is inherited in only 15dash​25% of cases. Parkinson disease affects men more than it does women. Parkinson disease is more common in people over 60 years of age. It can also occur in younger​ people, but this is less common.

The nurse observed a client with Parkinson disease frequently wiping their mouth with a handkerchief. After the nurse requested a prescription for an anticholinergic medication from the healthcare​ provider, the client​ asked, "I feel​ better, why do I need another​ medication?" Which response by the nurse is​ correct? A. "It helps dopamine work​ better." B. ​"It will make you feel​ better." C. "The healthcare provider thinks it will help your​ symptoms." D. "It will help reduce tremors and uncontrolled​ drooling."

Answer: D ​Rationale: The client stated that they are feeling better. It is levodopa and not an anticholinergic that will make dopamine work better. Stating that the healthcare provider thinks it will help with the​ client's symptoms will be an incomplete answer. To give a complete​ response, the nurse would state that an anticholinergic reduces tremors and uncontrolled drooling.

Which recommendation should the nurse make to a client with Parkinson disease who reports​ constipation? (Select all that​ apply.) A. Decreasing fiber intake B. Limiting exercise C. Decreasing fluid intake D. Increasing fluid intake E. Increasing fiber intake

Answer: D, E ​Rationale: Increasing fluid and fiber intake is a known recommendation for the prevention of constipation. Decreasing the intake of fluids or fiber will not help to prevent constipation. Limiting exercise is not associated with constipation.

What is the most common complication of dysphagia?

Aspiration Aspiration is a frequent complication for patients with dysphagia. Many of these aspirations are "silent" and are not recognized until pulmonary complications occur. Choking and vomiting can occur with dysphagia, but are not as common as aspiration.

Damage to which cranial nerve (CN) would interact with gag reflex

CN IX (glossopharyngeal)

Damage to which cranial nerve (CN) can cause an inability to swallow

CN IX (glossopharyngeal) and X (vagus)

Damage to which cranial nerve (CN) would lead to facial paralysis in the patient?

CN VII (facial nerve)

Damage to which cranial nerve (CN) would lead to impaired tongue movement

CN XII (hypoglassal)

In addition to frequent repositioning, the nurse anticipates a consultation request for which special pressure relief device to help prevent pressure ulcers in the patient with a spinal cord injury?

Chair Pad

Which interventions may be needed in a patient with Parkinson's disease (PD) who has developed drug tolerance?

Changing the drug or its frequency of administration

Nurse is assessing a patient who has a spinal cord injury?Which should the nurse include in the nervous system assessment to determine the extent of the patient's injury? select all that apply. a. vital sign b. romberg test c. plantar reflexes d. bilatereal hand grasps e. description of trauma

Correct Answer (s): a, c, d, e the assessment to determine the level of spinal cord injury includes analyzing the -vital sign, plantar reflexes, bilatereal hand grasp, description of trauma. Romberg test must be performed while standing therefore not suitable for unstable patient

A 25-year-old patient has returned home following extensive rehabilitation for a C8 spinal cord injury. The home care nurse visits and notices that the patient's spouse and parents are performing many of the activities of daily living (ADLs) that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to a. tell the family members that the patient can perform ADLs independently. b. remind the patient about the importance of independence in daily activities. c. recognize that it is important for the patient's family to be involved in the patient's care and support their activities. d. develop a plan to increase the patient's independence in consultation with the with the patient, spouse, and parents.

Correct Answer((s): D Rationale: The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to feel that their input is important, telling the family that the patient can perform ADLs independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the family members. Supporting the activities of the spouse and parents will lead to ongoing dependency by the patient.

A male patient has a pinal cord injury at L 1-2 . Which clinical manifestation of the patient's injury is the nurse likely to observe before spinal shock resolves? A. opoiod analgesic Iv for foot pain B. able to blance in sitting position C. unresponsive quadriceps muscle D. requites asssist control ventilation

Correct Answer(s) : C during spinal shock neuromuscular function is lost below the level of the injury along with hyporeflexia and loss of sensation. So the pt will not be able to sit until the pinal shock resolves.

A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When the nurse develops a plan of care for this problem, which nursing action will be most appropriate? a. Teaching the patient how to self-catheterize b. Assisting the patient to the toilet q2-3hr c. Use of the Credé method to empty the bladder d. Catheterization for residual urine after voiding

Correct Answer(s): A Rationale: Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.

A patient who sustained a T1 spinal cord injury a week ago refuses to discuss the injury and becomes verbally abusive to the nurses and other staff. The patient demands to be transferred to another hospital, where "they know what they are doing." The best response by the nurse to the patient's behavior is to a. ask for the patient's input into the plan for care. b. clarify that abusive behavior will not be tolerated. c. reassure the patient that the anger will pass and rehabilitation will then progress. d. ignore the patient's anger and continue to perform needed assessments and care.

Correct Answer(s): A Rationale: The patient is demonstrating behaviors consistent with the anger phase of the mourning process, and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage and should be tolerated by the nurse. Refusal to acknowledge the patient's anger by telling the patient that the anger is just a phase is inappropriate. Continuing to perform needed assessments and care is appropriate, but the nurse should seek the patient's input into what care is needed.

Which of the following signs and symptoms in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? A) Headache and rising blood pressure B) Irregular respirations and shortness of breath C) Decreased level of consciousness or hallucinations D) Abdominal distention and absence of bowel sounds

Correct Answer(s): A Among the manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic) and a throbbing headache. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic.

Which of the following interventions should the nurse perform in the acute care of a patient with autonomic dysreflexia? A) Urinary catheterization B) Administration of benzodiazepines C) Suctioning of the patient's upper airway D) Placement of the patient in the Trendelenburg position

Correct Answer(s): A Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. The patient should be positioned upright. Benzodiazepines are contraindicated and suctioning is likely unnecessary.

A patient with a history of a T2 spinal cord tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first? a. Notify the patient's health care provider. b. Check the blood pressure (BP). c. Give the ordered antiemetic. d. Assess for a fecal impaction.

Correct Answer(s): B Rationale: The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is causing the symptoms, including hypertension. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP.

When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort, bibasilar crackles, and decreased breath sounds, the initial intervention by the nurse should be to a. administer oxygen at 7 to 9 L/min with a face mask. b. place the hands on the epigastric area and push upward when the patient coughs. c. encourage the patient to use an incentive spirometer every 2 hours during the day. d. suction the patient's oral and pharyngeal airway.

Correct Answer(s): B Rationale: The nurse has identified that the cough effort is poor, so the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia, and oxygen will not help expel respiratory secretions. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action.

A patient with a T1 spinal cord injury is admitted to the intensive care unit (ICU). The nurse will teach the patient and family that a. use of the shoulders will be preserved. b. full function of the patient's arms will be retained. c. total loss of respiratory function may occur temporarily. d. elevations in heart rate are common with this type of injury.

Correct Answer(s): B Rationale: The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Total loss of respiratory function occurs with injuries above the C4 level and is permanent. Bradycardia is associated with injuries above the T6 level.

The nurse admnisters methylprenisone(Solu-Medrol) as a continous IV fusion to a male patient who has fractures of the cervical vertebrae. Which intervention would prevent or detect adverse effects of the medication? A. record pt baseline weight B. adminster PPI( proton pump inhibitor) C. Check the hear rate for bradycardia D. suction the patient's oropharynx

Correct Answer(s): B the nurse should adminster PPI because they are at high risk for Gi erosion and bleeding. from the steroid.

When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority? a. Continuous cardiac monitoring for bradycardia b. Administration of methylprednisolone (Solu-Medrol) infusion c. Assessment of respiratory rate and depth d. Application of pneumatic compression devices to both legs

Correct Answer(s): C Rationale: Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions are also appropriate but are not as important as assessment of respiratory effort.

The health care provider orders administration of IV methylprednisolone (Solu-Medrol) for the first 24 hours to a patient who experienced a spinal cord injury at the T10 level 3 hours ago. When evaluating the effectiveness of the medication the nurse will assess a. blood pressure and heart rate. b. respiratory effort and O2 saturation. c. motor and sensory function of the legs. d. bowel sounds and abdominal distension.

Correct Answer(s): C Rationale: The purpose of methylprednisolone administration is to help preserve neurologic function; therefore, the nurse will assess this patient for lower-extremity function. Sympathetic nervous system dysfunction occurs with injuries at or above T6, so monitoring of BP and heart rate will not be useful in determining the effectiveness of the medication. Respiratory and GI function will not be impaired by a T10 injury, so assessments of these systems will not provide information about whether the medication is effective.

In which order will the nurse perform the following actions when caring for a patient with possible cervical spinal cord trauma who is admitted to the emergency department? a. Administer O2 using a non-rebreathing mask. b. Monitor cardiac rhythm and blood pressure. c. Immobilize the patient's head, neck, and spine. d. Transfer the patient to radiology for spinal CT.

Correct Answer(s): C, A, B, D Rationale: The first action should be to prevent further injury by stabilizing the patient's spinal cord. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, continuous monitoring of heart rhythm and BP is indicated. CT scan to determine the extent and level of injury is needed once initial assessment and stabilization is accomplished.

A patient with a neck fracture at the C5 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding a. hypotension, bradycardia, and warm extremities. b. involuntary, spastic movements of the arms and legs. c. the presence of hyperactive reflex activity below the level of the injury. d. flaccid paralysis and lack of sensation below the level of the injury.

Correct Answer(s): D Rationale: Clinical manifestations of spinal shock include decreased reflexes, loss of sensation, and flaccid paralysis below the area of injury. Hypotension, bradycardia, and warm extremities are evidence of neurogenic shock. Involuntary spastic movements and hyperactive reflexes are not seen in the patient at this stage of spinal cord injury.

A 26-year-old patient with a C8 spinal cord injury tells the nurse, "My wife and I have always had a very active sex life, and I am worried that she may leave me if I cannot function sexually." The most appropriate response by the nurse to the patient's comment is to a. advise the patient to talk to his wife to determine how she feels about his sexual function. b. tell the patient that sildenafil (Viagra) helps to decrease erectile dysfunction in patients with spinal cord injury. c. inform the patient that most patients with upper motor neuron injuries have reflex erections. d. suggest that the patient and his wife work with a nurse specially trained in sexual counseling.

Correct Answer(s): D Rationale: Maintenance of sexuality is an important aspect of rehabilitation after spinal cord injury and should be handled by someone with expertise in sexual counseling. Although the patient should discuss these issues with his wife, open communication about this issue may be difficult without the assistance of a counselor. Sildenafil does assist with erectile dysfunction after spinal cord injury, but the patient's sexuality is not determined solely by the ability to have an erection. Reflex erections are common after upper motor neuron injury, but these erections are uncontrolled and cannot be maintained during coitus.

The nurse discusses long-range goals with a patient with a C6 spinal cord injury. An appropriate patient outcome is a. transfers independently to a wheelchair. b. drives a car with powered hand controls. c. turns and repositions self independently when in bed. d. pushes a manual wheelchair on flat, smooth surfaces.

Correct Answer(s): D Rationale: The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority? A) Risk for impairment of tissue integrity caused by paralysis B) Altered patterns of urinary elimination caused by quadriplegia C) Altered family and individual coping caused by the extent of trauma D) Ineffective airway clearance caused by high cervical spinal cord injury

Correct Answer(s): D Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of these are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority. Remember the ABCs.

A 70 yr old patient who has a spinal cord injury at C8 resulting in central cord syndrome. Which effect of the patient's most likely to be life threatening after completeing rehabiliation? A. increased bone density loss B. higher tisk for tissue hpoxia C. vasomotor compensation lost D. Weakness of thoracic muscles

Correct Answer(s): D Weakness of thoracic muscle is most likely to cause life-threatening complications because affects patients oxygentation and ventilation.

The nurse is caring for a man who has experienced a spinal cord injury. Throughout his recovery, the client expects to gain control of his bowels. The nurse's best response to this client would be which of the following? a. "Over time, the nerve fibers will regrow new tracts, and you can have bowel movements again." b. "Wearing an undergarment will become more comfortable over time." c "Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact." d "It is not going to happen. Your nerve cells are too damaged."

Correct Answer(s: ) C Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact The act of defecation is a spinal reflex involving the parasympathetic nerve fibers. Normally, the external anal sphincter is maintained in a state of tonic contraction. With a spinal cord injury, the client no longer has this nervous system control and is often incontinent.

A female nurse is injured in an automobile accident and suffers acute compresssion of the anterior apinal cord at T8-10 Which nursing rols is a potential source of employment for the patients after completing rehabilitation ? A. Certified nurse practioner B. Community health nursing C. Hospital case mangement D. Inpatient behavioral health

Correct C. Hospital case management(s) the nurse in most likely to have an anterior cord syndrome resulting in the loss of neuromuscular and pain and temp sensation below t8. Pt will have full use of upper extremities , upper back, and resp muscles.thus she will be in a wheel chair.

A patient diagnosed with a stroke is receiving recombinant tissue plasminogen activator (rtPA) through one intravenous line. The nurse discovers that the second line has infiltrated and removes it. The insertion site continues to bleed even after the nurse applies pressure on it. What is the priority nursing action?

Discontinue the rtPA infusion Recombinant tissue plasminogen activator (rtPA) is a fibrinolytic agent, used for the treatment of ischemic or embolic stroke. Bleeding is a side effect of this medication caused by its pharmacotherapeutic action. Therefore, if the nurse observes any bleeding that is not easily controlled, then the rtPA infusion should be stopped immediately to prevent complications. Increasing the rtPA infusion may cause uncontrolled hemorrhage. The vital signs can be taken and the primary health care provider can be informed after stopping the infusion. Once the infusion is stopped, a pressure bandage should be applied on the puncture site to control the bleeding.

A patient experienced a stroke that caused damage to Broca's area. The nurse expects the patient to experience what phenomenon as a result of this injury?

Expressive aphasia The patient with damage to Broca's area will experience expressive aphasia, which is the result of damage to Broca's area of the frontal lobe; it is a motor speech problem in which the patient generally understands what is being said but cannot communicate verbally. Writing skills are also affected. Rote speech and automatic speech such as responses to a greeting are often intact. Receptive aphasia is due to injury involving Wernicke's area in the temporoparietal area; patients cannot understand the spoken and often the written word, and language is often meaningless. Dysarthria is due to a loss of motor function to the tongue or to the muscles of speech, causing facial weakness and slurred speech. Patients with damage to Broca's area will not experience stuttering.

The nurse is doing a neurological assessment on a patient admitted to the emergency department. The patient reports having had a slight headache, speech deficits, confusion, and blurred vision. What does the nurse suspect is happening to the patient?

Formation of a blood clot

Which action by unlicensed assistive personnel (UAP) in caring for a patient after a stroke requires immediate intervention by the nurse?

Gently pulling on a patient's flaccid arm to assist the patient up in bed UAP should avoid pulling on an affected or flaccid arm because it could result in subluxation or injury. Turning the patient's plate and using pictures are appropriate actions by UAP. It is appropriate (and correct) for UAP to tell the family that the patient may experience emotional lability after a stroke.

Which substances does the brain require continuously because the brain does not have the ability to store them? Select all that apply.

Glucose and Oxygen The brain cannot store oxygen or glucose; therefore, it must receive a constant flow of blood to provide these substances to maintain normal function.

The nurse is providing discharge teaching to a patient who had a carotid stent placement. The nurse instructs the patient to contact the health care provider at the occurrence of which symptoms? Select all that apply.

Headache Muscle weakness Neck swelling Severe neck pain A patient who is post-carotid stent placement should immediately report symptoms of headache, change in brain function, muscle weakness, neck pain and swelling, and hoarseness because they may be indicative of a potential stroke. Weight gain and constipation are not indicators of significant complications of endarterectomy.

Which type of spinal cord injury causes tearing of posterior ligaments and dislocation of vertebrae in the patient?

Hyperflexion

. A 70-year-old woman brought to the emergency department is diagnosed with acute ischemic stroke with a NIH Stroke Scale score of 20. A family member reports last seeing the patient as normal (LSN) 3.5 hours before evaluation. The patient has an INR of 1.4. The nurse anticipates that the patient will not be eligible for fibrinolytic therapy for which reason?

INR 1.4 Guidelines for treatment with fibrinolytic therapy recommend administering the treatment within 4.5 hours of LSN, unless the patient is over 80 years old, has a National Institutes of Health Stroke Scale score greater than 25, or an INR less than or equal to 1.7. While females do not receive fibrinolytic therapy at the same rate as males, female gender is not a contraindication.

. The patient is admitted with a diagnosis of stroke in the right cerebral hemisphere. Upon assessment, which primary deficit does the nurse expect to find?

Impaired proprioception Strokes that occur in the right hemisphere involve visual and special awareness and proprioception. The patient may also be disoriented to place and time. Agraphia (difficulty writing), aphasia (inability to use or comprehend language), and alexia (reading problems) are deficits associated with strokes that occur in the left hemisphere.

The patient is admitted with a diagnosis of stroke in the right cerebral hemisphere. Upon assessment, which primary deficit does the nurse expect to find?

Impaired proprioception Strokes that occur in the right hemisphere involve visual and special awareness and proprioception. The patient may also be disoriented to place and time. Agraphia (difficulty writing), aphasia (inability to use or comprehend language), and alexia (reading problems) are deficits associated with strokes that occur in the left hemisphere.

A patient is brought to the emergency department with sudden onset of right-sided paralysis and difficulty speaking. A family member is worried that these symptoms will be permanent. Based on the patient's symptoms, the nurse anticipates which outcome?

Improvement over several days Embolic strokes have a sudden onset of symptoms that include paralysis and expressive aphasia and tend to resolve over hours to days. Transient ischemic attacks resolve quickly, within 24 hours. Thrombotic strokes have a slower onset and resolve more slowly, sometimes taking weeks to months. Permanent deficits may occur with thrombotic strokes.

A patient has been admitted with a diagnosis of stroke (brain attack). The nurse suspects that the patient has had a right hemisphere stroke because the patient exhibits which symptoms?

Impulsiveness and smiling Impulsiveness and smiling are symptoms indicative of a right hemisphere stroke. Aphasia, cautiousness, quick anger, frustration, and the inability to discriminate words are symptoms indicative of a left hemisphere stroke.

A patient with a spinal cord injury is on medication to control severe muscle spasticity. After a few days of receiving the medication, the patient experiences sedation, fatigue, dizziness, and changes in mental status. Which medication does the nurse anticipate has contributed to these symptoms?

Intrathecal baclofen (ITB)

Which device is most invasive for monitoring intracranial pressure?

Intraventricular catheter

Which nursing intervention takes priority in a patient with dysphagia?

Keep the patient on strict NPO status until he or she can swallow safely The nurse should ensure that the patient remains completely NPO until the speech pathologist determines the patient can safely tolerate liquids or foods without aspirating.

A patient is brought to the emergency department with aphasia and right-sided hemiplegia. The nurse suspects a stroke in which area of the brain?

Left Cerebral hemisphere The left cerebral hemisphere is the center for language and analytical thinking and also controls motor nerves on the right side of the body. A patient with deficits in these areas most likely has left cerebral involvement. Patients with brainstem or cerebellum involvement will have ataxia and may experience hemiparesis or quadriparesis. The right cerebral hemisphere is involved with visual and spatial awareness.

Which location is the most common site for an embolic stroke?

Middle cerebral artery The most common site for an embolic stroke is the middle cerebral artery. It is not common for an embolic stroke to occur in the common carotid artery, basilar artery, or superior cerebral artery.

Which stroke syndrome has clinical features such as perpetual, spatial, and visual field deficit?

Middle cerebral artery strokes

Which stroke syndrome has clinical features such as perpetual, spatial, and visual field deficit?

Middle cerebral artery strokes Perpetual, spatial, and visual deficits are key features of middle cerebral artery strokes. Contralateral hemiparesis, hemianopsia, blurred vision, and blindness are key features of internal carotid artery strokes. Contralateral hemiparesis, aphasia, and amnesia are clinical features of anterior cerebral artery strokes. Loss of deep sensation, decreased touch sensation, aphasia, and amnesia are clinical features of posterior cerebral artery strokes.

A patient has Parkinson disease (PD). Which nursing intervention best protects the patient from injury?

Monitor the patients sleep pattern

A patient weighing 165 pounds will begin receiving recombinant tissue plasminogen activator (rtPA) to treat an ischemic stroke. The nurse expects an order to administer how many milligrams of rtPA in the first minute of the infusion? Record your answer using two decimal places. Use a leading zero if applicable. ___ mg

Patients receiving rtPA should receive 0.9 mg/kg over 60 minutes with 10% of that dose given as a bolus over the first minute. This patient weighs 165 lbs, or 75 kg. The total dose for this patient is 67.5 mg (0.9 × 75 = 67.5). Ten percent of that is 6.75 mg. 6.75mg

Which clinical findings helped the nurse conclude that a patient is in the moderate stage of Parkinson's disease (PD)?

Postural instability and increased gait disturbances

A patient is having difficulty understanding spoken and written words and is saying made-up words and meaningless speech. What would be the possible reason behind the patient's condition?

Receptive aphasia Receptive aphasia occurs due to injury in Wernicke's area in the temporoparietal area. This leads to the patient having difficulty understanding spoken and written words, creating made-up words, and using meaningless speech. Mixed aphasia is difficulty in expression and reception, which includes difficulty speaking and writing. Global aphasia occurs due to severe damage in the receptive and expressive skills. Expressive aphasia occurs due to difficulty speaking and writing.

A patient with Parkinson's disease is undergoing a stereotactic pallidotomy. The patient has no reduction of tremor and rigidity on receiving a mild electrical stimulation on the target area within pallidum. Which intervention would be beneficial in this situation?

Repositioning the probe

Which condition is a patient at risk for following cervical spinal cord injury?

Respiratory compromise

A patient reports difficulty swallowing, fatigue while talking, difficulty controlling crying or laughing, and weakness of the hands and arms. The blood report of the patient shows increased creatine kinase. Which medication does the nurse anticipate will help manage the patient's condition?

Riluzole - used for the treatment of amyotrophic lateral sclerosis (ALS)

The nurse explains to patients at a health camp that there are multiple risk factors responsible for a stroke. Which risk factors does the nurse explain cannot be changed? Select all that apply.

Sickle cell disease and berry aneurysms Sickle cell disease and berry aneurysms are risk factors for developing a stroke that cannot be changed. Patients with sickle cell disease are at risk of stroke at a young age. Berry aneurysms are small, sac-like areas in the artery wall that can rupture at any time, causing bleeding in the brain. Patients with clotting problems or with symptoms of transient ischemic attacks are treated with anticoagulant therapy to prevent the possibility of stroke. Patients with sleep apnea can reduce their weight and use a breathing device at night to prevent stroke.

A patient has experienced a right-hemisphere stroke. What is an important nursing action while caring for this patient?

Stand on the patients left side when talking to increase the visual field Patients with right hemisphere involvement often have an inability to recognize physical impairment and will exhibit neglect of the left visual field. The nurse should stand in the left visual field to encourage the patient to expand the range of vision. Independent ambulation should be discouraged because these patients have poor judgment and may overestimate their abilities. Patients should be encouraged to wash and dress themselves with instructions to care for the affected side first to improve independence.

The nurse performing an assessment on a patient 6 hours postoperative for diskectomy notices the presence of clear drainage from the incision site. The nurse suspects the drainage may be cerebrospinal fluid (CSF) and evaluates the patient for which accompanying sign/symptom?

Sudden Headache

A patient is placed in a halo device to stabilize a cervical fracture. Which nursing action is a priority for this patient's safety?

Taping the wrench to the vest if needed to loosen the vest in emergencies such as cardiopulmonary arrest.

Which statement best characterizes the manifestation of symptoms of a transient ischemic attack (TIA)?

They typically resolve within 30-60 minutes Symptoms of a TIA typically resolve within 30-60 minutes. Manifestations can occur in upper and lower extremities and are not limited to the speech area.

A patient in the emergency department (ED) has slurred speech, confusion, and visual problems, and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The patient also has a history of hypertension and atherosclerosis. What does the nurse suspect that the patient is probably experiencing?

Thrombotic stroke The patient's symptoms fit the description of a thrombotic stroke. Symptoms of embolic stroke have a sudden onset, unlike this patient's symptoms. The patient would be in a coma if a hemorrhagic stroke had occurred. Intermittent episodes of slurred speech, confusion, and visual problems are transient ischemic attacks, which often are warning signs of an impending ischemic stroke.

Which type of stroke syndrome would most likely cause a coma in a patient?

Vertebrobasilar artery strokes Vertebrobasilar artery strokes occur when blood flow through the vertebrobasilar region is reduced or stopped. This may lead to a coma. The internal carotid artery strokes, middle cerebral artery strokes, and anterior cerebral artery strokes may not lead to coma. The internal carotid artery supplies blood to the brain. The middle cerebral artery supplies blood to the cerebrum. The anterior cerebral artery supplies oxygenated blood to most of the portions of the frontal lobes and superior medial parietal lobes

Which stroke syndrome has clinical features such as contralateral hemiparesis, aphasia, and amnesia

anterior cerebral artery strokes

Which symptoms can be present with a transient ischemic attack (TIA)?

blurred vision, vertigo, and aphasia

Which type of stroke is caused by aneurysm or hypertension?

hemorrhagic stroke

Which stroke syndrome has clinical features such as contralateral hemiparesis, hemianopsia, blurred vision, and blindness

internal carotid artery strokes

Which stroke syndrome has clinical features such as loss of deep sensation, decreased touch sensation, aphasia, and amnesia

posterior cerebral artery strokes