Theory Semester 2 - week 8 & 9

The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply. A) Administer stool softeners daily B) Ensure the pulse oximeter reading is higher than 93%. C) Maintain the head of the bed at 60 degrees of elevation D) Perform deep nasal suction every two (2) hours. E) Administer mild sedatives

A) Administer stool softeners daily B) ensure the pulse oximeter reading is higher than 93% E) Administer mild sedatives

A client has been found unresponsive at home for an undetermined period of time. A cerebrovascular accident (CVA) is suspected, and the family is demanding a clot buster be used to restore functioning. The nurse knows that successful use of tissue plasminogen activator (TPA) in a client with CVA requires which of the following? Select all that apply. A)Administer within 3 hours of onset of symptoms. ✓ B)The symptoms are no longer evolving. C)Used concurrently with heparin therapy D)Presence of an ischemic stroke ✓ E) Administer intramuscular for faster response.

A) Administer within 3 hours of onset of symptoms D) Presence of an ischemic stroke

The nurse is orienting a new nurse to the neurologic unit. When instructing on the typical care provided to a client with head injuries, which type of medications are frequently administered? Select all that apply. A)analgesics B)antibiotics C)anticunvulsants D) corticosteroids E) loop diuretics

A) Analgesics B) antibiotics C) anticonvulsants

The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement? A) Assess for bladder distention B) Dim the lights in the room C) Administer a narcotic analgesic D) Keep the client flat in bed.

A) Assess for bladder distention

A mother brings her 6-year-old child to the emergency department (ED) after the child fell off the bike. The physician diagnoses a concussion. The mother asks the nurse what a concussion is. What should the nurse's response be? A)"A concussion is a blow to the head that bruises the brain." B) "A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain." C)"A concussion is a blow to the head that is hard enough for the brain to bounce off the other side of the skull." D)"A concussion is a blow to the head that is minor and has no real consequences."

B) " A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain"

A client has experienced a transient ischemic attack (TIA) and presents with carotid bruits. Which is the priority action to be taken by the nurse, following a bilateral carotid endarterectomy? A)Resume antilipemic drugs. B) Observe for facial swelling. C) Encourage deep breathing and coughing. D)Anticipate need for endotracheal intubation.

D) Anticipate need for endotracheal intubation

When caring for a client who has had intracranial surgery, what is the most important parameter to monitor? A) extreme thirst B) intake and output C) nutritional status D) body temperature

D) Body temperature

A client diagnosed with migraine headaches asks the nurse what he can do to help control the headaches and minimize the number of attacks he is having. What instructions should the nurse give this client? A) Write down any adverse drug effects. B) Keep a record of activities following an attack. C) When an attack occurs, stay in a brightly lit area. D) Identify and avoid factors that precipitate or intensify an attack.

D) Identify and avoid factors that precipitate or intensify an attack

The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with steristrips. Which signs/symptoms would warrant transferring the resident to the emergency department? A) a 4 cm area of bright red drainage on the dressing B) pupils that are equal, react to light, and accomodate C) complaints of a headache that resolves with medication D) a weak pulse, shallow respirations, and cool pale skin

D) a weak pulse, shallow respirations, and cool pale skin

A client has sustained a head injury and is unconscious in the emergency room. A family member of the client arrives and is providing details of the client's medical history. Which information is of most concern to the nurse? A) The client is HIV positive. B) The client has a history of concussions from playing hockey. C) The client is a heart transplant recipient. D) The client's medications include warfarin.

D) the client's medications include warfarin

The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? A) The assistant praises the client for attempting to perform ADLs independently. B)The assistant places a gait belt around the client's waist prior to ambulating. C)The assistant places the client on the back with the client's head to the side. D)The assistant places a hand under the client's right axilla to move up in bed. ✓

The assistant places a hand under the client's right axilla to move up in bed

The rehabilitation nurse caring for the client with an Lumbar SCI is developing the nursing care plan. Which intervention should the nurse implement? A) Administer low-dose subcutaneous anticoagulants. B) Keep oxygen via nasal cannula on at all times C)Refer to a speech therapist for ventilator assisted speech D) Perform active lower extremity ROM exercises.

A) Administer low-dose subcutaneous anticoagulants

The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as "high risk for immobility complications." Which intervention would be included in the plan of care? A)Position the client with the head of the bed elevated at intervals B)Perform active range-of-motion (ROM) exercises every four (4) hours. C)Turn the client every shift and massage bony prominences D)Explain all procedures to the client before performing them.

A) Position the client with the head of the bed elevated at intervals

A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches? A)Relaxes muscles B)Increases appetite C) Relieves migraines D) Reduces hypotension

A) Relaxes muscles

The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first? A)Test the drainage for presence of glucose B)Notify the health-care provider immediately C) Place a 2 × 2 gauze under the nose to collect drainage. D)Prepare to administer an antihistamine

A) Test the drainage for presence of glucose

Which diagnostic evaluation tool would the nurse use to assess the client's cognitive functioning? Select all that apply. A)The Mini-Mental Status Examination (MMSE) scale. B)The Geriatric Depression Scale (GDS). C)The Manic Depression vs Elderly Depression (MDED) scale D)The St. Louis University Mental Status (SLUMS) scale E)The Functional Independence Measurement Scale (FIMS).

A) The Mini-mental status examination (MMSE) scale D) The St. Louis University Mental Status (SLUMS) scale

Which client would the nurse identify as being most at risk for experiencing a cerebrovascular accident (CVA)? A) a 55-year-old African American male ✓ B)a 39-year-old pregnant female C) a 84-year-old Japanese female D)a 67-year-old Caucasian male

A) a 55-year-old African American

A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? A) administer a stool softener bid B) encourage the client to cough hourly C) monitor neurological status every shift D) maintain the dopamine drip to keep BP at 160/90

A) administer a stool softener bid

Which nursing task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel? A) Assist with bowel training by placing the client on the bedside commode B) Administer the tube feeding to the client who is quadriplegic. C) Observe the client demonstrating self catheterization technique. D) Teach Credé's maneuver to the client needing to void.

A) assist with bowel training by placing the client on the bedside commode

The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? A)obtain a rubber mat to place under the dinner plate B)purchase clothes with Velcro closure devices C)purchase a long-handled bath sponge for showering D)obtain a raised toilet seat for the client's bathroom

A) obtain a rubber mat to place under the dinner plate

The 28-year-old client is on the rehabilitation unit post spinal cord injury at level T10. Which collaborative team members should participate with the nurse at the case conference? Select all that apply. A) Rehabilitation physician B) Registered dietitian (RD C) Physical therapist (PT). D) Social Worker (SW). E) Occupational Therapist (OT). F) Patient care tech (PCT)

A) rehabilitation physician B) registered dietitian C) physical therapist D) social worker

The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury? A) traction with weights and pulleys B) cervical collar C) turning frame D) cast

A) traction with weights and pulleys

A client is prescribed sumatriptan for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse? A)"It alleviates my sensitivity to light and sound." B)"I use this to prevent migraines." C)"It constricts the blood vessels in my head." D)"I take this when I get a headache."

B) "I use this to prevent migraines"

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? A)a right-sided carotid bruit B)a blood pressure of 220/120 mmHg ✓C)a blood glucose level of 480 mg/dL D)the presence of bronchogenic carcinoma

B) A blood pressure of 220/120 mmHg

. The nurse is caring for a client with a herniation of C4. What item does the nurse anticipate to use if conservative therapy is used? A)traction equipment B) a cervical collar C)bandages and tape D) a firm mattress

B) A cervical collar

The client diagnosed with atrial fibrillation complains of numbness and tingling of her left arm and leg. The nurse assesses facial drooping on the left side and slight slurring of speech. Which nursing interventions should the nurse implement first? A)Have the client swallow a glass of water B)Call a Code STROKE C)Notify the health-care provider (HCP). D)Schedule a STAT Magnetic Resonance Imaging of the brain

B) Call a code STROKE

A nurse is caring for a client with a spinal cord injury from a motorcycle accident. The nurse is instructing on the benefits of cell transplantation therapy. Which early outcome of treatment is anticipated? A) Cell transplantation therapy allowed organs to be brought from one person to another. B) Cell transplantation therapy allows the replacement of nerve cells that are damaged. C) Cell transplantation therapy produced a reduction in swelling and pain. D) Cell transplantation therapy improves the growth of new neurologic connections.

B) Cell transplantation therapy allows the replacement of nerve cells that are damaged

A client who complains of recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action? A) Tension headaches are easier to treat. B) Migraines often coincide with menstrual cycle. C) Cluster headaches can cause severe debilitating pain. D) Headaches are the most common type of reported pain.

B) Migraines often coincide with menstrual cycle

The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is "brain dead." Which data support that the client is brain dead? A) The electroencephalogram (EEG) has identifiable waveforms. B) No eye activity is observed when the cold caloric test is performed C) When the client's head is turned to the right, the eyes turn to the right. D) The client assumes decorticate posturing when painful stimuli are applied

B) No eye activity is observed when the cold caloric test is performed

The nurse suspects that a newly admitted client is in spinal shock. What are the symptoms of spinal shock? Select all that apply. A)loss of hunger sensation B) poikilothermia C)circulatory failure D) no perspiration below the level of the injury E)bladder distension

B) Poikilothermia D) no perspiration below the level of the injury E) bladder distention

The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. . A) Instruct the client to hold the fingers in a fist B)Position the client to prevent shoulder adduction. C) Turn and reposition the client every shift D)Perform quadriceps exercises three (3) times a day E)Encourage the client to move the affected side

B) Position the client to prevent shoulder adduction E) Encourage the client to move the affected side

The nurse is caring for a client with increased intracranial pressure (ICP) who has secretions pooled in the throat. Which intervention should the nurse implement first? A) Suction the client using the in-line suction, wait 30 seconds, and repeat. B) Turn the client to the side to allow the secretions to drain from the mouth C) Assess the client's lung sounds and check for peripheral cyanosis D) Set the ventilator to hyperventilate the client in preparation for suctioning

B) Turn the client to the side to allow the secretions to drain from the mouth

The nurse is working on a neurosurgical unit. Which of the following nursing interventions are included in the plan of care following spinal surgery? Select all that apply. A) PEARLA B) Dressing assessment C) Neurovascular assessment of the lower extremity D) Intake and output E) Coughing and deep breathing F) Monitor vital signs

B) dressing assessment C) neurovascular assessment of the lower extremity D) intake and output E) coughing and deep breathing F) Monitor vital signs

The nurse is caring for a client with a head injury after a fall from a hayloft. Which of the following indicates the presence of/leaking of cerebral spinal fluid (CSF)? A) Signs of increased intracranial pressure (IICP) B) Halo sign C) Change in the level of consciousness (LOC) D) Swelling

B) halo sign

The nurse is completing an assessment on a client with a history of migraines. The nurse would identify which of the following factors as a possible trigger for a migraine headache? Select all that apply. A) nausea B) red wine C) menstruation D) exposure to flashing light E) prolonged positioning F) change in environmental temperature

B) red wine C) mensuration D) exposure to flashing light

The nurse is caring for a client with a spinal cord injury leaving paralysis. When planning care related to the musculoskeletal system, which considerations are important? Select all that apply. A)Weight bearing B)Contractures C)Limited range of motion D)Spasticity E) Bone demineralization

B)Contractures C) limited range of motion D) spasticity E) bone demineralization

A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment? A) Lumbar puncture B) Chest x-ray C) Brain CT scan or MRI D) Prothrombin level

C) Brain CT scan or MRI

A 76-year-old male client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? Select all that apply. A) Administration of tissue plasminogen activator B)Removal of the carotid artery C) Carotid endarterectomy D) Balloon angioplasty of the carotid artery followed by stent placement E) Percutaneous transluminal coronary artery angioplasty

C) Carotid endarterectomy D) Balloon angioplasty of the carotid artery followed by stent placement

The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful? A) Adoption is an option to complete your family but not put your life in jeopardy. B) Sterilization is best; it would be difficult to care for a baby in your condition. C) Conception is not impaired; the birth process is determined with the physician. D)Birth via surrogate is best because your baby can be implanted in another woman.

C) Conception is not impaired; the birth process is determined with the physician

The nurse in the neurointensive care unit is caring for a client with a new Cervical SCI who is breathing independently. Which nursing interventions should be implemented? Select all that apply. A) Provide pureed foods six (6) times a day. B) Assess for autonomic dysreflexia C) Encourage coughing and deep breathing D) Monitor the pulse oximetry reading E) Administer intravenous corticosteroids

C) Encourage coughing and deep breathing D) monitor for the pulse oximetry E) Administer intravenous corticosteroids

A client is brought into the emergency department with a diagnosis of ruptured cerebral aneurysm. Which assessment data provides the most important information in preparing for the nursing care of this client? A)Complaint of severe splitting headache B)Alert and oriented times three C) Grade V on the Hunt-Hess Scale D) Blood pressure 180/98 mm Hg

C) Grade V on the Hunt-Hess Scale

The nurse is caring for a client who continues to have increasingly high intracranial pressure. Which complication is expected unless intracranial pressure is resolved? A) Additional inflammation occurs in the brain. B) Blood vessels dilate circulating blood. C) Herniation occurs through the foramen magnum. D) Venous congestion occurs, causing peripheral edema

C) Herniation occurs through the foramen magnum

The nurse is caring for a client experiencing autonomic dysreflexia. Which of the following does the nurse recognize as the source of symptoms? A) Peripheral nervous system B) Autonomic nervous system C) Sympathetic nervous system D) Central nervous system

C) Sympathetic nervous system

The nurse is caring for several clients. Which client would the nurse assess first after receiving the shift report? A) The 22-year-old male client diagnosed with a concussion who is complaining someone is waking him up every two (2) hours. B)The 36-year-old female client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan. C)The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale (GCS) score of 6. D)The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia.

C) The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale (GCS) score of 6.

The nurse is working on the neurologic unit at a local hospital. The nurse has four clients assigned who sustained head injuries as a result of an industrial accident. Which client would the nurse anticipate the physician sending for specialized care? A) The client who was in a bike accident last summer B) The client with history of seizures C) The client who played soccer in college D) The client whose father has Parkinson's disease

C) The client who played soccer in college

A client is being assessed for a possible transient ischemic attack (TIA). Which of the following assessment findings suggests to the nurse that the client is experiencing a TIA? A) Severe headache B) Respiratory distress C) Impaired muscle coordination D) Nausea and vomiting

C) impaired muscle coordination

The client with a cerebral aneurysm asks the nurse, "What's the big fuss over a headache?" Which is the best response from the nurse regarding to a cerebral aneurysm? A)"A headache means your aneurysm is leaking blood into the brain." B)"The headache can be an indication that the aneurysm is growing." C)"Don't worry. The aneurysm has probably been there since birth." D) "Your physician wants to evaluate the location and condition of the aneurysm."

D) "Your physician wants to evaluate the location and condition of the aneurysm"

A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include honey thickened liquids. Which of the following is the priority nursing diagnosis for this client? A) Risk for Fluid Volume Deficit B) Altered Nutrition: Less Than Body Requirements C) Risk for Electrolyte Imbalance D) Impaired Swallowing

D) Impaired swallowing

A client with impaired physical mobility has been hospitalized. What nursing intervention helps reduce the potential for formation of thrombi and renal calculi in a client with impaired physical mobility? A) Help the client perform exercises. B) Provide a well-balanced diet. C) Position the client. D) Keep the client hydrated.

D) Keep the client hydrated

A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care? A)Bleeding continues into the intracerebral area. B)The crash cart with defibrillator is kept nearby. C)Symptoms will evolve over a period of 1 week. D)Monitoring is needed as rapid neurologic deterioration may occur.

D) Monitoring is needed as rapid neurologic deterioration may occur

A middle-aged client has scheduled a sick visit to the physician's office, stating symptoms of lower back pain with exacerbation upon movement. The nurse draws a picture of the components of the spinal cord and surrounding structures and identified potential causes of the pain. Which area of the drawing would the nurse emphasize? A)associated musculature B) spinal cord pathway C) bony vertebrae D) nucleus pulposus

D) Nucleus pulposus

The male client is admitted to the emergency department following a motorcycle accident. The client was not wearing a helmet and struck his head on the pavement. The nurse identifies the concept as impaired intracranial regulation. Which interventions should the emergency department nurse implement in the first five (5) minutes? Select all that apply. A)Contact the organ procurement organization to speak with the family B)Stabilize the client's neck and spine C)Check the client's driver's license to see if he will accept blood D)Perform a Glasgow Coma Scale assessment E)Ensure the client has a patent peripheral venous catheter in place F)Elevate the head of the bed to 70 degrees

D) Perform a glasgow coma scale assessment E) Ensure the client has a patent peripheral venous catheter in place

The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region? A) Respiratory pattern B)Pain level C)Numbness and tingling D) Pulse and blood pressure

D) Pulse and blood pressure

The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative A) Position the client in a semi-Fowler's position when sleeping. B) Place a suction setup at the client's bedside during meals. C) Observe the client swallowing for possible aspiration. D) Refer the client to an occupational therapist for evaluation.

D) Refer the client to an occupational therapist for evaluation

The 34-year-old male client with an SCI is sharing with the nurse that he is worried about finding employment after being discharged from the rehabilitation unit. Which intervention should the nurse implement? A) Suggest that the client talk with his significant other about this concern. B) Refer the client to the American Spinal Cord Injury Association (ASIA C) Ask the social worker (SW) about applying for disability. D) Refer the client to the state rehabilitation commission.

D) Refer the client to the state rehabilitation commission

. The nurse is caring for a client following intracranial surgery. In the plan of care, the nurse states to remove antiembolism stockings. What would the nurse do to accurately complete this intervention? A) Apply the antiembolism stocking before ambulation daily. B)Place the antiembolism stockings on the lower extremities as tolerated. C)Remove the antiembolism stockings nightly and reapply by 8 AM. D) Remove the antiembolism stockings briefly every 8 hours.

D) Remove the antiembolism stockings briefly every 8 hours

Which nursing assessment finding is most indicative of a hemorrhagic stroke? A)Client history of hyperlipidemia B)Client history of atrial fibrillation C)Symptoms evolving over 24 to 48 hours D)Sudden onset of breathing alterations ✓

D) Sudden onset of breathing alterations

The nurse received report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate? A)The client has an elevated temperature. B)The client has ecchymosis in the periorbital region. C)The client has serous drainage from the nose. D)The client has cerebral spinal fluid (CSF) leaking from the ear.

D) The client has a cerebral spinal fluid (CSF) leaking from the ear

The 29-year-old client who was employed as a forklift operator sustains a traumatic brain injury (TBI) secondary to a motor-vehicle accident. The client is being discharged from the rehabilitation unit after three (3) months and has cognitive deficits. Which goal would be most realistic for this client? A)The client will regain bowel and bladder control. B)The client will be able to dress self without assistance C) The client will return to work within six (6) months D)The client is able to focus and stay on task for 10 minutes

D) The client is able to focus and stay on task for 10 minutes

The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician? A) The client's level of consciousness has improved. B) The client has periorbital edema and ecchymosis. C) The client prefers to rest in the semi-Fowler's position. D)The client's vital signs are temperature, 100.9 °F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg.

D) The client's vital signs are temperature, 100.9 °F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg.

The nurse is performing a Glascow Coma Scale (GCS) assessment on a client with a problem with intracranial regulation. The client's GCS one (1) hour ago was scored at 10. Which data indicates the client is improving? A) The current GSC rating is 10. B) The current GSC rating is 9 C) The current GSC rating is 3. D) The current GSC rating is 12.

D) The current GSC rating is 12

The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia clients. When instructing family members on the difference between the sites of impairment, which location differentiates the two disorders? A)The second cervical vertebrae B) The seventh thoracic vertebrae C)The first lumbar vertebrae D)The first thoracic vertebrae

D) The first thoracic vertebrae

The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members with the client with an aneurysm? A) The interaction may cause migraine in the client. B)The interaction may cause the client to become violent. C)The client may become emotional and lose interest in the treatment. D) The stimulation can increase intracranial pressure (ICP) or trigger a seizure.

D) The stimulation can increase intracranial pressure (ICP) or trigger a seizure

A client presents to the walk-in clinic complaining of a migraine. The client is prescribed an antileptic. What should the nurse suggest to the client? A) Avoid caffeine and alcohol. B) Avoid crowds. C) Take drugs only after meals at night. D) Use caution while driving or performing hazardous activities.

D) Use caution while driving or performing hazardous activities