Unit 7

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Any ICP greater than____ mmHg in an adult is a medical emergency.

A preschool-age client with myoclonic seizures has been following a ketogenic diet for the last 6 months to reduce seizure activity and is complaining of left-sided lower abdominal pain. Which complication of the ketogenic diet should the nurse suspect the client is experiencing? A) Bowel obstruction B) Kidney stone C) Urinary tract infection D) Appendicitis

B) Kidney stone

Purpose of Measure

Discriminative Predictive Evaluative

Treat for hemorrhagic stroke

Lower BP

What is the drug classification for Naproxen?

NSAID

right or left brain damage? aphasia, inability to remember words, hemiplegia of the right side of the body

left

Name a common medication that patients will be prescribed if they have atrial fibrillation?

warfarin (Coumadin)

In a completed stroke, the damage has been stable for at least ___.

1 day

7. The nurse is reviewing the medication administration record of a female patient who possesses numerous risk factors for stroke. Which of the woman's 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. Aspirin 81 mg PO o.d.

The patient comes to the emergency department (ED) with cortical blindness and visual field defects. Which type of head injury does the nurse suspect? a. Cerebral contusion c. Posterior fossa fracture b. Orbital skull fracture d. Frontal lobe skull fracture

c. The posterior fossa fracture causes occipital bruising resulting in cortical blindness or visual field defects. A cerebral contusion is bruising of brain tissue within a focal area. An orbital skull fracture would cause periorbital ecchymosis (raccoon eyes) and possible optic nerve injury. A frontal lobe skull fracture would expose the brain to contaminants through the frontal air sinus and the patient would have CSF rhinorrhea or pneumocranium.

___ is the most common type of stroke. a. embolic b. hemorrhagic c. thrombotic d. they are equally likely

c. thrombotic

This lobe is responsible for speech, thought, learning, emotion, and voluntary movement. The advanced processes of judgment, reasoning, and concern for others are also controlled by this lobe.

frontal

The nurse is conducting a teaching clinic for older adults about risk factors for stroke. Although the nurse includes all of the following as risk factors, which factor presents the greatest risk for stroke?

hypertension

One of the most significant concerns for medical and nursing management of hypertension is

noncompliance with plan of care

A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is: a) 170 mm Hg/105 mm Hg b) 185 mm Hg/110 mm Hg c) 190 mm Hg/120 mm Hg d) 175 mm Hg/100 mm Hg

190 mm Hg/120 mm Hg Elevated blood pressure (systolic >185; diastolic >110 mm Hg) is a contraindication to tPA.

See First at diabetic specialty unit? 1. 17 yr old with irritability complaining of fatigue 2. 28 yr old woman with fruity breath smell complaining of thirst 3. 38 yr old with bp of 120/50 complaining of frequent urination and thirst 4. 45 yr old woman with bp of 90/60 and skin is hot and dry to touch

2. indicated DKA, increased risk of injury to client 1. Hypoglycemia 3. Diabetes 4. dehydration; first stage of DKA Note: All have to do with diabetes because in a diabetes specialty unit.

The nurse is planning care for a client admitted with a stroke. Which intervention would support the client's sensorimotor needs? A) Encourage use of nonaffected arm to feed self, bathe, and dress. B) Speak in normal conversational pattern and tones. C) Provide complete care. D) Talk loudly and distinctly.

The patient has a blood pressure of 130/88 and ICP reading of 12. What is the patient's cerebral perfusion pressure, and how do you interpret this as the nurse? A. 90 mmHg, normal B. 62 mmHg, abnormal C. 36 mmHg, abnormal D. 56 mmHg, normal

7. Practice Question •A patient has been diagnosed with subarachnoid hemorrhage. Which drug does the nurse anticipate will be ordered to control cerebral vasospasm? •A. nimodipine •B. phenytoin •C. dexamethasone •D. clopidogrel.

A. nimodipine

Select all the signs and symptoms that occur with increased ICP: A. Decorticate posturing B. Tachycardia C. Decrease in pulse pressure D. Cheyne-stokes E. Hemiplegia F. Decerebrate posturing

ADEF

After a stroke, sensory-perceptual changes increase the client's risk for what? A) Aspiration B) Injury C) Bleeding D) Infection

Answer: B Strokes often alter the ability to integrate, interpret, and attend to sensory data. The client may experience deficits in vision, hearing, equilibrium, taste, and smell. The ability to perceive vibration, pain, warmth, cold, and pressure may be impaired, as may proprioception (the body's sense of its position). The loss of these sensory abilities increases the risk for injury. Sensory-perceptual changes do not increase the risk for aspiration, bleeding, or infection, although stroke may cause these other complications.

A client arrives at the ED with ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is priority nursing assessment? A: Current medications B: Complete physical and history C: Time of onset of current stroke D: Upcoming surgical procedures

Answer: C

A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? A) Impulse control difficulty B) Poor judgement C) Inability to recognize familiar objects D) Loss of depth perception

Answer: C

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop).

B. Following a transient ischemic attack (TIA), patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.

What is the cause of increased intracranial pressure (ICP)?

CEREBRAL EDEMA

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? Documenting the results of the swallowing studies Calling the healthcare provider about the results Ordering a pureed diet Carefully monitoring for coughing after giving the client a thickened beverage

Carefully monitoring for coughing after giving the client a thickened beverage

A patient with ICP monitoring has pressure of 12 mm Hg. The nurse understand that this pressure reflects a. a severe decrease in cerebral perfusion pressure b. an alteration in the production of CSF c. the loss of autoregulatory control of ICP d. a normal balance between brain tissue, blood, and CSF

D. A normal balance between brain tissue, blood, and CSF- normal is 10- 15 mm Hg

4. A patient who suffered a stroke one month ago is experiencing hearing problems along with issues learning and showing emotion. On the MRI what lobe in the brain do you expect to be affected? A. Frontal lobe B. Occipital lobe C. Parietal lobe D. Temporal

D. Temporal The answer is D. The temporal lobe is responsible for hearing, learning, and feelings/emotions.

This is the relay center for all information coming into the brain

Thalamus

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? A Vomiting continues B Intracranial pressure (ICP) is increased C The client needs mechanical ventilation D Blood is anticipated in the cerebrospinal fluid (CSF)

A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates that treatment options that would be evaluated for the patient include a. hyperventilation therapy b. surgical clipping of the aneurysm c. administration of hyperosmotic agents d. administration of thrombolytic therapy

in promoting health maintenance for prevention of strokes, the nurse understands that the highest risk for the most common type of stroke is present in which people? a. blacks b. women who smoke c. persons with hypertension and diabetes d. those who are obese with high dietary fat intake

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's blood pressure will remain within 40% of normal. The client will improve communication techniques. The client will maintain bedrest. The client will participate in therapies to prevent contractures.

The client will participate in therapies to prevent contractures.

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 has a history of concussions from playing hockey. b. The client is HIV positive. c. The client's medications include warfarin. d. The client is a heart transplant recipient.

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. Swelling b. Change in the level of consciousness (LOC) c. Halo Sign d. Signs of increased intracranial pressure (IICP) e. High pulse rate

The spouse of a client with terminal brain cancer asks the nurse about hospice. Which statement by the nurse best describes hospice care? a. Hospice care uses a team approach and provides complete care. b. All hospice clients die at home. c. Clients and families are the focus of hospice care. d. The physician coordinates all the care delivered.

Which patient below with ICP is experiencing Cushing's Triad? A patient with the following: A. BP 150/112, HR 110, RR 8 B. BP 90/60, HR 80, RR 22 C. BP 200/60, HR 50, RR 8 D. BP 80/40, HR 49, RR 12

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 with right-sided paralysis flexing and extending only the left knee The client performing flexion, extension, and hyperextension of the hips bilaterally 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

Why do embolic strokes tend to be more severe than thrombotic strokes?

They occur rapidly & there is no opportunity for a collateral blood supply to develop (so they tend to have more serious effects)

Feasibility

Time, space, and equipment Training required Cost Respondent burden Culture and language Proprietary Issues

Which finding would alert the nurse that the client has experienced a transient ischemic attack (TIA)?

Tingling at the corner of the mouth with aphasia

While cooking, your client couldn't feel the temperature of a hot oven. Which lobe could be dysfunctional? a.) Frontal b.) Occipital c.) Parietal d.) Temporal

C ~ The parietal lobe regulates sensory function, which would include the ability to sense hot or cold objects. The frontal lobe regulates thinking, planning, and judgment, and the occipital lobe is primarily responsible for vision function. The temporal lobe regulates memory.

The nurse is reviewing the medication administration record of a female patient who possesses numerous risk factors for stroke. Which of the woman's 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) Aspirin 81 mg PO o.d.

The earliest signs of increased ICP the nurse should assess for include a. Cushing's triad b. unexpected vomiting c. decreasing level of consciousness (LOC) d. dilated pupil with sluggish response to light

C. One of the most sensitive signs of increased intracranial pressure (ICP) is a decreasing LOC. A decrease in LOC will occur before changes in vital signs, ocular signs, and projectile vomiting occur

Characteristics of a thrombotic stroke

Type most often signaled by TIAs, commonly occurs during or after sleep, strong association with hypertension

The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following? a) Cerebral aneurysm b) Cardiogenic emboli c) Intracerebral hemorrhage d) Arteriovenous malformation

Cardiogenic emboli Aneurysms, hemorrhages, and malformations are all examples of a hemorrhagic stroke. An embolism can block blood flow, leading to ischemia.

TRUE

Careful maintenance of cerebral hemodynamics to maintain cerebral perfusion is extremely important after a stroke.

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.

When caring for a client who has had intracranial surgery, what is the most important parameter to monitor? a. Intake and output b. Extreme thirst c. Nutritional status d. Body temperature

After a subarachnoid hemorrhage, the patient's laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurse's 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) Prepare to administer 3% NaCl by IV as ordered.

Which of the following is characteristic of triggers for seizures? A) They are externalized. B) They are generalized. C) They are internalized. D) They are variable.

D) They are variable.

A client is classified as Grade 4 for risk of cerebral vasospasm because of intracerebral clotting and absence of blood in the basal cisterns. Which diagnostic test is most useful to assess intracerebral hemorrhage and grade cerebral vasospasms? A) Cerebrospinal fluid (CSF) analysis B) CT scan C) MRI D) Transcranial Doppler

D) Transcranial Doppler

The nurse is planning discharge teaching for a child with epilepsy who is prescribed phenytoin (Dilantin). The nurse should recommend a diet rich in which of the following to this client? A) Carbohydrates B) Fats C) Protein D) Vitamin D

D) Vitamin D

What is the purpose of a serum osmolality test in the diagnosis of increased intracranial pressure? a To determine hydration status b To indicate adequacy of serum protein levels c To identify serum lactic acid levels d To assess serum pH

a For a client with an altered intracranial pressure, serum osmolality measures hydration status. Overly hydrated clients have additional pressure within the intracranial cavity. Serum osmolality does not measure serum protein levels, lactic acid levels, or serum pH.

When assessing the body function of a patient with increased ICP, the nurse should initially assess a. corneal reflex testing b. extremity strength testing c. pupillary reaction to light d. circulatory and respiratory status

D. Circulatory and respiratory status- Of the body functions that should be assessed in an unconscious patient, cardiopulmonary status is the most vital function and gives priorities to the ABCs (airway, breathing, and circulation)

The nurse continues to monitor Nancy's condition closely. Which finding would require immediate intervention by the nurse? A. Nancy's pulse oximeter reading is greater than 95% B. Nancy's serum potassium level is 3.9 mEq/L C. Nancy's telemetry shows normal sinus rhythm with occasional premature ventricular contractions D. Nancy's cardiac output is less than 4 L/min

D. Nancy's cardiac output is less than 4 L/min - The normal range for cardiac output to ensure cerebral blood flow and oxygen delivery is 4 to 8 L/min.

Which set of vital signs would BEST indicate to the nurse that a client has an increase in intracranial pressure? a. BP 180/70 Pulse 50, RR 16, Temp 101 F b. BP 100/70, pulse 64, RR 20, Temp 98.6 c. BP 96/70, pulse 132, RR 20. Temp 98.6 d. BP 130/80. pulse 50. RR 18. Temp 99.6

a elevated BP, widening pulse pressure, decreased HR, temp elevation

A Dr ordered neurological checks every 30 minutes for a client injured in a bike accident. Which finding indicates that the clients condition is satisfactory? a. a score of 13 on the Glascow coma scale b. the presence of dolls eye movements c. the absence of deep tendon reflexes d, decerebate posturing

a scale ranges 0-15 a 13 is satisfactory

A client with a hemorrhagic stroke has a temp of 103F. Efforts to reduce the temp have not been effective. The most likely explanation for the elevated temp is the damage has occured to the : a. hypothalamus b. pituitary c. carotid baroreceptors d. frontal lobe

a they hypothalamus helps to regulate body temp

Which rehabilitation team member is responsible for evaluating Nancy's dysphagia? A. The occupational therapist B. The rehabilitation physician C. The case manager D. The speech therapist

D. The speech therapist - The speech therapist evaluates the e client's gag reflex and ability to swallow, then makes recommendations regarding feeding techniques and diet.

Which pts. are at increased risk for stroke?

a 66yo man with diabetes mellitus, a 35yo healthy woman who uses oral contraceptives, a 35yo man with history of multiple TIA's & a 53yo man with chronic alcoholism

A client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which of the following activities? A. blowing the nose B. isometric exercises C. coughing vigorously D. exhaling during repositioning

D. exhaling during repositioning (activities that increase intra-throacic and intra-abdominal pressures cause indirect elevation of the ICP. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intra-thoracic pressure from rising).

A client is admitted with an L4-L5 injury. Which diagnostic tests should the nurse anticipate would be prescribed for this client? (Select all that apply.) a MRI b Myelogram c Nerve conduction studies d Brain echogram e Cerebral angiogram

a,b,c Rationale An L4-L5 injury is a low spinal cord injury. Diagnostic tests most likely to be prescribed for this client include an MRI, myelogram, and nerve conduction studies. Brain echogram and cerebral angiogram would not be indicated because the client does not have a brain injury.

A nurse is providing care for a client with a traumatic head injury. The nurse should monitor the client for which manifestations consistent with increased intracranial pressure? (Select all that apply.) a Headache b Blurred vision c Double vision d Increased heart rate e Drowsiness

a,b,c,e Rationale Double vision and blurred vision can occur with IICP. Headache is common with IICP. Drowsiness can occur with IICP. The client may also report other generalized manifestations such as dizziness. The heart rate generally decreases with IICP.

A client with a stroke is demonstrating signs of increasing intracranial pressure. Which actions should the nurse take at this time? (Select all that apply.) a Reduce environmental stimuli b Assess vital signs c Assess cranial nerve function d Provide hypotonic fluids e Monitor pupillary response

a,b,c,e Rationale Nursing actions for the client demonstrating signs of increasing intracranial pressure include assessing vital signs, monitoring pupillary response, assessing cranial nerve function, and reducing environmental stimuli. Intravenous fluids administered at this time would be isotonic or hypertonic.

A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? SELECT ALL THAT APPLY a. headache b dilated pupils c tachycardia d decorticate posturing e hypotension

a,b,d

Which tasks should NOT be delegated to the UAP? Select all that apply a bathing a client with a closed head injury b performing a tube feeding on a client with an established line c admin of parenteral meds d providing perineal care to a client with an indwelling cath

a,c

The nurse is caring for a patient on the stroke rehabilitation unit. Which intervention should the nurse question? Decreasing fluid intake to prevent aspiration and decrease urinary frequency Encouraging bladder training by having the patient void on a schedule Teaching the patient Kegel exercises Using positive reinforcement

Decreasing fluid intake to prevent aspiration and decrease urinary frequency

What does the Glasgow Coma Scale assess? (Select all that apply.) a Verbal response b Corneal reflex c Cerebellar function d Motor response e Eye opening

a,d,e

What is obtundation? (Select all that apply.) a Responsive to stimuli but drifts back to sleep b Easily bewildered, with poor memory and short attention span c Unresponsive but may be aroused by vigorous, repeated, or painful stimuli d Not aware of or not oriented to time, place, or person e Lethargic and somnolent

a,e

Pt. has expressive aphasia after a left hemisphere stroke. What will work BEST when nurse is speaking to pt.?

Develop a picture board with objects and activities

The nurse is caring for a patient diagnosed with stroke. Which complication is the nurse least likely to expect? Constipation Stool impaction Diarrhea Dysphagia

Diarrhea

Type of Measure

Disease-specific or generic Self-report or performance-based

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

Dysphagia

Get an order to decrease IV fluids

Characteristics of subarachnoid hemorrhage

High initial mortality, symptoms of meningeal irritation, caused by rupture of intracranial aneurysm, associated with sudden, severe headache

Which disturbance results in loss of half of the visual field? a) Anisocoria b) Homonymous hemianopsia c) Nystagmus d) Diplopia

Homonymous hemianopsia Homonymous hemianopsia (loss of half of the visual field) may occur from stroke and may be temporary or permanent. Double vision is documented as diplopia. Nystagmus is ocular bobbing and may be seen in multiple sclerosis. Anisocoria is unequal pupils.

After teaching about stroke in a child, the nurse asked a group of parents to list the clinical manifestations. Which response by a parent indicates a need for further education? Hyperalertness Dizziness and mood changes Severe headaches Unilateral neglect

Hyperalertness

The nurse is administering oxygen to a client experiencing a stroke in order to prevent hypoxia and hypercapnia. This will also lessen the risk for:

Increased intracranial pressure (IICP)

Most common artery involved

Internal Carotid Artery

Which method gives more/better information on the extent of damage from a stroke, CT or MRI?

MRI

This lobe contains the visual cortex to process vision.

Occipital

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

Onset of facial drooping at 1430

What is the trade name of Clopidogrel?

PLAVIX

A nursing diagnosis of Risk for Aspiration has been identified for patient who was admitted for a CVA/stroke. Intervention BEST to delegate to the nursing professional?

Place pt. in high fowlers position and slowly feed small spoonfuls of pudding, pausing between each spoonful

Tests and Measures in Stroke Rehab that are specific to stroke population (4)

1. Fugl-Meyer 2. Orpington prognostic scale 3. Postural assessment scale for stroke 4. Stroke impact scale

People who have thrombotic strokes also usually have which 3 comorbidities?

1. HTN 2. diabetes 3. vascular disease

See first on oncology floor? 1. The client diagnosed with breast cancer with extensive bone metastasis who is irritable and confused 4. The client with a WBC of 1.600/mm3 who reports burning with urination

1. Hypercalcemia may occur as a result of bone destruction by the tumors; elevated levels affect mental status and can negatively affect multiple organ systems. 4. UTI eval needed but not most concerning.

Arterial sources of stroke (3)

1. Intracranial vascular disease 2. Carotid vascular disease 3. Aortic arch

112. The newborn nursery nurse has received report. Which client should the nurse assess first? 1. The 2-hour-old infant who has nasal flaring and is grunting. 2. The 6-hour-old infant who has not passed meconium stool. 3. The 12-hour-old infant who refuses to latch onto the breast. 4. The 24-hour-old infant who has a positive startle reflex.

1. The 2-hour-old infant who has nasal flaring and is grunting.

Secondary prevention: Risk factor modification (4)

1. smoking cessation 2. diabetes control 3. aggressive cholesterol lowering 4. hypertension control

97. The 65-year-old client is being discharged from the hospital following major abdominal surgery and is unable to drive. Which referral should the nurse make to ensure continuity of care? 1. A church that can provide transportation. 2. A home health agency. 3. An outpatient clinic. 4. The healthcare provider's office.

2. A home health agency.

The nurse is administering oxygen to a client experiencing a stroke in order to prevent hypoxia and hypercapnia. This will also lessen the risk for which finding? 1.Fluid accumulation in the lungs 2.Pulmonary emboli 3.Increased intracranial pressure (IICP) 4.Rebleeding

66. The client with a below-the-knee amputation (BKA) has a large amount of bright red blood on the residual limb dressing and the nurse suspects an arterial bleed. Which intervention should the nurse implement first? 1. Increase the client's intravenous rate. 2. Assess the client's vital signs. 3. Apply a tourniquet above the amputation. 4. Notify the client's healthcare provider.

3. Apply a tourniquet above the amputation.

54. The medical unit is governed by a system of shared governance. Which statement best describes an advantage of this system? 1. It guarantees that unions will not be able to come into the hospital. 2. It makes the manager responsible for sharing information with the staff. 3. It involves staff nurses in the decision-making process of the unit. 4. It is a system used to represent the nurses in labor disputes.

3. It involves staff nurses in the decision-making process of the unit.

9. The nurse is caring for clients on a skilled nursing unit. Which task should not be delegated to the unlicensed assistive personnel (UAP)? 1. Instruct the UAP to apply sequential compression devices to the client on strict bed rest. 2. Ask the UAP to assist the radiology tech to perform a STAT portable chest x-ray. 3. Request the UAP to prepare the client for a wound debridement at the bedside. 4. Tell the UAP to obtain the intakes and outputs (I&Os) for all the clients on the unit.

3. Request the UAP to prepare the client for a wound debridement at the bedside.

93. The male client in a long-term care facility complains that the staff does not listen to his complaints unless a family member also complains. Which action should the director of nurses implement? 1. Call a staff meeting and tell the staff to listen to the resident when he talks to them. 2. Determine who neglected to listen to the resident and place the staff member on leave. 3. Ignore the situation because a resident in long-term care cannot determine his needs. 4. Talk with the resident about his concerns and then initiate a plan of action.

4. Talk with the resident about his concerns and then initiate a plan of action.

36. Which client would most benefit from acupuncture, a traditional Chinese medicine considered complementary alternative medicine? 1. The client who is diagnosed with deep vein thrombosis. 2. The client who is diagnosed with Alzheimer's disease. 3. The client diagnosed with reactive airway disease. 4. The client diagnosed with osteoarthritis.

4. The client diagnosed with osteoarthritis.

49. The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a pediatric unit. Which task should the nurse delegate to the UAP? 1. Sit with the 6-year-old client while the parent goes outside to smoke. 2. Stay with the 4-year-old client during scheduled play therapy sessions. 3. Position the 2-year-old client for the postural drainage therapy. 4. Weigh the diaper of the 6-month-old client who is on intake and output (I&O).

4. Weigh the diaper of the 6-month-old client who is on intake and output (I&O).

12. While conversing with a patient who had a stroke six months ago, you note their speech is hard to understand and slurred. This is known as:* A. Dysarthria B. Apraxia C. Alexia D. Dysphagia

A. Dysarthria

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 Retaining urine Staying alert Swallowing

Speaking

Nurse is caring for pt. with ischemic stroke. Which position is the pt. placed in according to current nursing practice?

Supine with extremities in anatomical position

A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client? a. No bowel movement since yesterday b. Nausea c. Frequent voiding d. Complaint of headache off and on for past month

An area of swelling or enlargement in a weakened arterial wall is called:

an aneurysm.

What is the drug classification of Lorazepam and what is the trade name?

benzodiazepine, Ativan

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? A To reduce intraocular pressure B To prevent acute tubular necrosis C To promote osmotic diuresis to decrease ICP D To draw water into the vascular system to increase blood pressure

1. A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take? a. Use one long sentence to say everything that needs to be said. b. Keep the television on while she speaks. c. Talk in a louder than normal voice. d. Face the client and establish eye contact.

d. Face the client and establish eye contact.

How long does the typical neurological deficit last with a TIA?

less than 24 hrs, lasting 1-2 hrs

106

...

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 3 2 0

Normal ICP ranges from:

5 to 15 mm Hg

A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these findings you would? A. Administered PRN dose of a vasopressor B. Administer 2 L of oxygen C. Remove extra blankets and give the patient a cool bath D. Perform suctioning

Patient with ischemic stroke is placed on a cardiac monitor. Which cardiac dysrhythmia places the pt. at risk for an emboli?

Atrial fibrillation

Patients with a decreased field of vision should be approached on the side where the visual perception is intact or the opposite side of the defect?

Approach the patient from side of intact field of vision.

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 constricts the blood vessels in my head. b. I use this to prevent migraines. c. It alleviates my sensitivity to light and sound. d. I take this when I get a headache.

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. Take drugs only after meals at night. b. Use caution while driving or performing hazardous activities. c. Avoid caffeine and alcohol. d. Avoid crowds.

A nurse is providing care for a client with a traumatic head injury. The nurse should monitor the client for which manifestations consistent with increased intracranial pressure? (Select all that apply.) Headache Drowsiness Increased heart rate Double vision Blurred vision

Headache Drowsiness Double vision Blurred vision Rationale Double vision and blurred vision can occur with IICP. Headache is common with IICP. Drowsiness can occur with IICP. The client may also report other generalized manifestations such as dizziness. The heart rate generally decreases with IICP.

which type of stroke is associated with endocardial disorders, has a rapid onset and is likely to occur during activity? a. embolic b. thrombotic c. intracerebral hemorrhage d. subarachnoid hemorrhage

The nurse should initiate which nonpharmacologic therapy early in hospitalization for clients who have sustained paralysis due to a disruption in intracranial regulation? A.Speech B.Psychological C.Occupational D.Physical

D Rationale: The nurse should initiate a physical therapy referral for clients who have sustained paralysis early in the hospital admission. This therapy will generally continue after discharge. Speech, psychological, and occupational therapy may also be needed, but physical therapy is the most important to initiate early for this client.

Which option indicates a sign of Cushing's triad, an indication of increased intracranial pressure (ICP)? A. Heart rate increases from 90 to 110 beats/minute B. Kussmaul respirations C. Temperature over 100.4° F (38° C) D. Heart rate decreases from 75 to 55 beats/minute

D Cushing's triad is systolic hypertension with a widening pulse pressure, bradycardia with a full and bounding pulse, and slowed respirations. The rise in blood pressure is an attempt to maintain cerebral perfusion, and it is a neurologic emergency because decompensation is imminent. The other options are not part of Cushing's triad.

A 58-year-old male presents with confusion, right-sided weakness, and slurred speech. His wife is present and is very upset. As your partner is applying oxygen, it is MOST important for you to:

ask his wife when she noticed the symptoms.

Problems with memory and learning would relate to which of the following lobes? A Frontal B Occipital C Parietal D Temporal

Which lobe of the brain stores memory and interprets auditory stimuli? A) Frontal B) Occipital C) Parietal D) Temporal

D) Temporal

Permissive hypertension

If you drop blood pressure then more green tissue (ischemic) turns red (infarcted) (only treat BP if >200)

Which of the following antiseizure medication has been found to be effective for post-stroke pain? a) Carbamazepine (Tegretol) b) Lamotrigine (Lamictal) c) Topiramate (Topamax) d) Phenytoin (Dilantin)

Lamotrigine (Lamictal) The antiseizure medication lamotrigine (Lamictal) has been found to be effective for post-stroke pain.

86. The nurse is preparing to administer medications to clients on a surgical unit. Which medication should the nurse question administering? 1. The antiplatelet clopidogrel (Plavix) to a client scheduled for surgery. 2. The anticoagulant enoxaparin (Lovenox) to a client who had a TKR. 3. The sliding scale insulin Humalog to a client who had a Whipple procedure. 4. The aminoglycoside vancomycin to a client allergic to the antibiotic penicillin.

1. The antiplatelet clopidogrel (Plavix) to a client scheduled for surgery.

Which statement is true for a patient who has pathology in Wernicke's area of the cerebrum? A. Receptive speech is affected. B. The parietal lobe is involved. C. Sight processing is abnormal. D. An abnormal Romberg test is present.

A The temporal, not parietal, lobe contains the Wernicke area, which is responsible for receptive speech and integration of somatic, visual, and auditory data. Sight processing occurs in the occipital lobe. The Romberg test is used to assess the position sense of the lower extremities.

The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury? a. Neurologic examination b. Computed tomography (CT) scan c. Radiography d. Myelography

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? a.) Urine output increases b.) Pupils are 8 mm and nonreactive c.) Systolic blood pressure remains at 150 mm Hg d.) BUN and creatinine levels return to normal

A ~ Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. No information is given about abnormal BUN and creatinine levels or that mannitol is being given for renal dysfunction or blood pressure maintenance.

Which of the following statements best describes the state of dynamic equilibrium of the Monro-Kellie hypothesis? A) An imbalance in the volumes of the brain, blood, and cerebrospinal fluid (CSF) will trigger a compensatory response. B) Normal intracranial pressure requires that the volumes of the brain, blood, and CSF are low. C) The brain can compress dynamically to compensate for an increase in blood or CSF volume. D) The volume of the blood must remain constant regardless of the volume of the brain and CSF. Answer: A

A) An imbalance in the volumes of the brain, blood, and cerebrospinal fluid (CSF) will trigger a compensatory response.

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

Answer: A Rationale: Time of onset of stroke symptoms should be included in the client interview. All other assessments are part of the physical assessment.

Answer: A Rationale: 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.

A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? (Select all that apply.) A) Impulse control difficulty B) Left hemiplegia C) Loss of depth perception D) Aphasia E) Lack of situational awareness

Answer: A, B, C, E

A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply.) A) Have suction equipment available for use. B) Feed the client thickended liquids. C) Place food on the unaffected side of the client's mouth. D) Assign an assistive personnel to feed the client slowly. E) Teach the client to swallow with her neck flexed.

Answer: A, B, C, E

A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (Select all that apply.) A) Speak to the client at a slower rate. B) Assist the client to use flash cards with pictures. C) Speak to the client in a loud voice. D) Complete sentences that the client cannot finish. E) Give instructions one step at a time.

Answer: A, B, E

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? A. Ordering a pureed diet B. Carefully monitoring for coughing after giving the client a thickened beverage C. Documenting the results of the swallowing studies D. Calling the healthcare provider about the results

Answer: B Rationale: 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.

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

Answer: B Rationale: 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 Nurse and UAP are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? A: Place gait belt around client's waster prior to ambulating B: Places client on back with client's head to the side C: Places her hand under the client's right axilla to help them move up in bed D: Praises the client for attempting to perform ADL's independently

Answer: C

The nurse is providing community health teaching on stroke in children and adolescents. Which risk factors for this population should the nurse identify? A) Hypertension B) Dysrhythmias C) Arteriosclerosis D) Head trauma

Answer: D Common causes of adult strokes such as hypertension, dysrhythmias, and arteriosclerosis are rare in children, whose risk factors for stroke include congenital heart defects, sickle-cell disease, immune disorders, arterial diseases, abnormal blood clotting, trauma to the head or neck, and maternal history of infertility.

Which of the following terms refer to the inability to perform previously learned purposeful motor acts on a voluntary basis? a) Agraphia b) Perseveration c) Agnosia d) Apraxia

Apraxia Verbal apraxia refers to difficulty in forming and organizing intelligible words although the musculature is intact. Agnosia is failure to recognize familiar objects perceived by the senses. Agraphia refers to disturbances in writing intelligible words. Perseveration is the continued and automatic repetition of an activity or word or phrase that is no longer appropriate. (less)

How do you assess the accessory nerve? A. Assess the gag reflex by stroking the posterior pharynx. B. Ask the patient to shrug the shoulders against resistance. C. Ask the patient to push the tongue to either side against resistance. D. Have the patient say "ah" while visualizing elevation of the soft palate

B The spinal accessory nerve is tested by asking the patient to shrug the shoulders against resistance and to turn the head to either side against resistance. The other options are used to test the glossopharyngeal and vagus nerves.

What to measure

Body function/Structure Activity Participation

TRUE

Brain function depends on delivery of oxygen to the tissues

The nurse is caring for a patient with increased intracranial pressure (IICP). The nurse realizes that some nursing actions are contraindicated with IICP. Which nursing action should be avoided? 1. Reposition the patient every two hours. 2. Position the patient with the head elevated 30 degrees. 3. Suction the airway every two hours per standing orders. 4. Provide continuous oxygen as ordered.

Correct Answer: C Rationale: If the drainage is cerebrospinal fluid (CSF) leakage from a dural tear, glucose will be present. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. A dural tear does increase the risk for infections such as meningitis, but the nurse should first determine whether the clear drainage is CSF. Blowing the nose is avoided to prevent CSF leakage.

The nurse notes that a patient with a head injury has a clear nasal drainage. The most appropriate nursing action for this finding is to a. obtain a specimen of the fluid and send for culture and sensitivity. b. take the patient's temperature to determine whether a fever is present. c. check the nasal drainage for glucose with a Dextrostik or Testape. d. have the patient to blow the nose and then check the nares for redness.

The nurse is caring for a stuporous client in the intensive care unit. Which assessment finding is documented to reflect an improvement in the client's level of consciousness? a. Stuporous b. Semicomatose c. Conscious d. Somnolent

When assessing motor function of a patient admitted with a stroke, you notice mild weakness of the arm demonstrated by downward drifting of the extremity. How would you accurately document this finding? A. Athetosis B. Hypotonia C. Hemiparesis D. Pronator drift

D Downward drifting of the arm or pronation of the palm is identified as pronator drift. Hemiparesis is weakness of one side of the body, hypotonia describes flaccid muscle tone, and athetosis is a slow, writhing, involuntary movement of the extremities

The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? A. A 92-year-old female who takes warfarin (Coumadin) for atrial fibrillation. B. A 28-year-old male who uses marijuana after chemotherapy to control nausea. C. A 42-year-old female who takes oral contraceptives and has migraine headaches. D. A 72-year-old male who has hypertension and diabetes mellitus and smokes tobacco.

D. A 72-year-old male who has hypertension and diabetes mellitus and smokes tobacco. Stroke risk increases after 65 years of age. Strokes are more common in men. Hypertension is the single most important modifiable risk factor for stroke. Diabetes mellitus is a significant stroke risk factor; and smoking nearly doubles the risk of a stroke. Other risk factors include drug abuse (especially cocaine), high-dose oral contraception use, migraine headaches, and untreated heart disease such as atrial fibrillation.

This part of the brain is made up of the thalamus and hypothalamus: Thalamus: This is the relay center for all information coming into the brain. Hypothalamus: This is the autonomic control center of the body and regulates heart rate, blood pressure, respirations, pain, pleasure, fear, body temperature, food and water intake and balance, sleep cycles, and digestion.

Diencephalon

Which of the following statements reflect nursing management of the patient with expressive aphasia? a) Frequently reorient the patient to time, place, and situation b) Speak clearly to the patient in simple sentences, use gestures or pictures when able c) Speak slowly and clearly to assist the patient in forming the sounds d) Encourage the patient to repeat sounds of the alphabet

Encourage the patient to repeat sounds of the alphabet Nursing management of the patient with expressive aphasia includes encouraging the patient to repeat sounds of the alphabet. Nursing management of the patient with global aphasia includes speaking clearly to the patient in simple sentences and using gestures or pictures when able. Nursing management of the patient with receptive aphasia includes speaking slowing and clearly to assist the patient in forming the sounds. Nursing management of the patient with cognitive deficits, such as memory loss, includes frequently reorienting the patient to time, place, and situation. (less)

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.

A patient has been diagnosed as having global aphasia. The nurse recognizes that the patient will be unable to do which of the following actions? a) Form words that are understandable b) Speak at all c) Form words that are understandable or comprehend the spoken word d) Comprehend the spoken word

Form words that are understandable or comprehend the spoken word Global aphasia is a combination of expressive and receptive aphasia and presents tremendous challenge to the nurse to effectively communicate with the patient. In receptive aphasia, the patient is unable to form words that are understandable. In expressive aphasia, the patient is unable to form words that are understandable. The patient who is unable to speak at all is referred to as mute.

A client experiences fractures of the left leg and a traumatic brain injury in a dirt bike accident and is admitted to the intensive care unit. Which assessment finding indicates increased intracranial pressure (IICP)? Oliguria Irritability Hypotension Nausea

Irritability Rationale Irritability may indicate that the client is experiencing an increase in intracranial pressure, especially if associated with additional signs of bradycardia, increased systolic pressure, increased pulse pressure, vomiting, headache, lethargy, and change in mental status. Nausea does not accompany the vomiting associated with increased intracranial pressure. Hypotension and oliguria are not associated with increased intracranial pressure.

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? a) Maintaining the client in a quiet environment b) Positioning the client to prevent airway obstruction c) Keeping the client in one position to decrease bleeding d) Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess

Keeping the client in one position to decrease bleeding The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.

The nurse is assessing a 30-year-old woman who states that her mother had a stroke recently. Which risk factor should the nurse consider significant for this patient? Active lifestyle Oral contraceptive use Insomnia Menopause

Oral contraceptive use The patient, a woman of childbearing age, has disclosed her mother recently experienced a stroke. Family history of stroke is a risk factor. The nurse would provide information about this risk factor. Oral contraceptives are a known risk factor for stroke. If the patient wishes to use a contraceptive, a choice other than oral contraceptives would be the best choice. The patient's sedentary lifestyle is a modifiable risk factor for stroke. The patient can increase activity to help prevent stroke. Menopause is a risk factor for stroke; however, this patient is 30 years old, and she would not normally enter menopause until much older. So this risk factor is not pertinent for the patient at her stage of life. Insomnia is not a risk factor; however, sleep apnea is a risk factor.

8. 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 nurse's 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.

Report this to the physician as a possible sign of clinical deterioration.

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: a) Footdrop and external hip rotation b) Severe headache and early change in level of consciousness c) Weakness on one side of the body and difficulty with speech d) Confusion or change in mental status

Severe headache and early change in level of consciousness The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Footdrop and external hip rotation can occur if a stroke victim is not turned or positioned correctly. (less)

16. The patient has a blood pressure of 130/88 and ICP reading of 12. What is the patient's cerebral perfusion pressure, and how do you interpret this as the nurse? A. 90 mmHg, normal B. 62 mmHg, abnormal C. 36 mmHg, abnormal D. 56 mmHg, normal

The answer is A. CPP is calculated by the following formula: CPP=MAP-ICP. The patient's CPP is 90 and this is normal. A normal CPP is 60-100 mmHg.

7. A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these findings you would? A. Administered PRN dose of a vasopressor B. Administer 2 L of oxygen C. Remove extra blankets and give the patient a cool bath D. Perform suctioning

The answer is C. It is important to monitor the patient for hyperthermia (a fever). A fever increases ICP and cerebral blood volume, and metabolic needs of the patient. The nurse can administer antipyretics per MD order, remove extra blankets, decrease room temperature, give a cool bath or use a cooling system. Remember it is important to prevent shivering (this also increases metabolic needs and ICP).

12. A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication? A. Bradycardia B. Decerebrate posturing C. Restlessness D. Unequal pupil size

The answer is C. Mental status changes are the earliest indicator a patient is experiencing increased ICP. All the other signs and symptoms listed happen later.

A patient diagnosed with a thrombotic stroke is receiving treatment to restore normal cerebral blood flow. Which process does the nurse understand may cause further damage to the brain? The damaged cells release chemicals affecting other cells around them. The blood supply is cut off to part of the brain. The cell membranes allow water to enter the cell, causing damage to the cells. Localized blood flow gets restored.

The damaged cells release chemicals affecting other cells around them. Damage can still continue to occur, even after initiating the treatment to restore normal blood flow to the brain. The damaged cells release chemicals that affect other cells around the damaged part of the brain. Cellular damage has already occurred due to sodium pulling fluid into the cells and making them swell. Although localized blood flow may have been restored, the penumbra may still not survive due to the amount of toxins released by the dead cells.

Which factor related to cerebral blood flow most often determines the extent of cerebral damage from a stroke? A. Amount of cardiac output B. Oxygen content of the blood C. Degree of collateral circulation D. Level of carbon dioxide in the blood

The extent of the stroke depends on rapidity of onset, the size of the lesion, and the presence of collateral circulation.

A patient is preparing to go home following a recent stroke. Which behavior indicates that the patient has met nursing care plan goals? The patient has experienced minimal complications from reduced mobility and dysphagia. The patient's family is at the bedside daily assisting the patient with all activities of daily living. The patient is participating in range of motion exercises each day. The patient is sipping water with meals to help with swallowing.

The patient has experienced minimal complications from reduced mobility and dysphagia. A poststroke patient will have successfully achieved the identified patient goals and outcomes if the patient participated in assigned therapies; the patient communicated effectively; the patient's significant other and family members participated in the patient's care; and the patient experienced minimal complications resulting from immobility, dysphagia, and reduced motor or sensory function. The other answer options do not indicate goal achievement by the patient.

A client is hospitalized when they present to the Emergency Department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to their presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? a) Cerebral aneurysm b) Transient ischemic attack c) Left-sided stroke d) Right-sided stroke

Transient ischemic attack A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm.

A previously asymptomatic 84-year-old client presents with aphasia but is otherwise alert and responsive. The nurse would suspect that this client has which condition? a. A stroke in the left cerebral hemisphere b. Damage to the brainstem c. A stroke in the right cerebral hemisphere d. A lesion in the occipital lobe

a. A stroke in the left cerebral hemisphere Rationale Aphasia, defective or absent language function, can occur as a result of a stroke in speech center of the brain located in the left cerebral hemisphere. An individual with damage to the brainstem would present with marked cognitive, motor, and sensory dysfunction and a client with a lesion in the occipital area of the brain would manifest problems with vision.

A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? a hyperglycemia b hyponatremia c hypervolemia d oliguria

A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present? A Abnormal flexion of the upper extremities and extension of the lower extremities B Rigid extension and pronation of the arms and legs C Rigid pronation of all extremities D Flaccid paralysis of all extremities

A client has signs of ICP, which of the following is an early indicator of deterioration in the clients condition? a widening pulse pressure b decrease in pulse rate c dilated, fixed pupils d decrease LOC

The nurse is conducting a teaching clinic for Older adults about risk factors for stroke. Although the nurse includes all of the following as risk factors, which of the following presents the greatest risk for stroke?

Hypertension

This is the autonomic control center of the body and regulates heart rate, blood pressure, respirations, pain, pleasure, fear, body temperature, food and water intake and balance, sleep cycles, and digestion.

Hypothalamus

Characteristics of intracerebral hemorrhage

Rupture of atherosclerotic vessels, carries the poorest prognosis, creates mass that compresses the brain

Why should the neurological assessment of an older client be modified? a Easily fatigued b Less efficient long-term memory c Increased reaction to stimuli d Shorter attention span

The nurse is aware that reduction of stress is an important part of controlling hypertension. The nurse encourages the client with hypertension to reduce stress in what way? 1. Weekly visits to a yoga class 2. Sleeping late daily 3. Working from home 4. Adopting a juice diet

weekly visits to a yoga class

This lobe stores memory, interprets auditory stimuli, and interprets smell.

Temporal

15. You're assessing your patient's pupil size and vision after a stroke. The patient says they can only see half of the objects in the room. You document this finding as:* A. Hemianopia B. Opticopsia C. Alexia D. Dysoptic

A. Hemianopia

The nurse is planning care for a client who is experiencing increased intracranial pressure (IICP) secondary to a head injury sustained during a motor vehicle crash. Which intervention is a priority for this client? A) Ensuring adequate oxygenation B) Maintaining a calm environment C) Monitoring for nausea and vomiting D) Controlling pain

A) Ensuring adequate oxygenation

The nurse is planning care for an older adult client with a head injury secondary to a motor vehicle crash. Which information should the nurse keep in mind when planning this client's care? Select all that apply. A) Anxiety, illness, and pain can alter the ability to learn. B) Baseline reflexes may be slower or diminished. C) Impulse transmission and reactions to stimuli are slower. D) Neurologic assessment should be completed in a single session. E) Impairment in vision and hearing should be taken into consideration.

A) Anxiety, illness, and pain can alter the ability to learn. B) Baseline reflexes may be slower or diminished. C) Impulse transmission and reactions to stimuli are slower. E) Impairment in vision and hearing should be taken into consideration.

TRUE

Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order (HEPARIN ) to prevent additional hemorrhage in the brain.

Which client would the nurse identify as being MOST at risk for experiencing a CVA? A: 55yr. old African American Male B: 84yr. old Japanese female C: 67yr. old white male D: 39yr. old prego female

Answer: A

A patient diagnosed with a stroke is ordered to receive warfarin (Coumadin). Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is which of the following? a) Ticlodipine (Ticlid) b) Dipyridamole (Persantine) c) Clopidogrel (Plavix) d) Aspirin

Aspirin If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.

A client diagnosed with a stroke is going to receive treatment with fibrinolytic therapy using the recombinant tissue plasminogen activator alteplase. What should the nurse explain to the client's family about the use of this medication? A) Used to treat thrombotic and hemorrhagic strokes B) Not associated with serious complications C) Indicated if the stroke symptoms have occurred within the last 6 hours D) Administered to dissolve the clot that is occluding the cerebral circulation and reestablish circulation to the involved part of the brain

Answer: D Explanation: D) Thrombolytic therapy using recombinant tissue plasminogen activator is used to dissolve the clot formed with a thrombotic stroke. Dissolving the clot reestablishes cerebral circulation. The treatment can be used if the symptoms have occurred within the last 3 hours. Bleeding is a complication associated with the treatment, which may result in cerebral hemorrhage causing extensive brain damage and disability. The treatment is only used with thrombotic strokes.

A client recovering from a stroke is being discharged on warfarin sodium (Coumadin). During discharge teaching, which statement by the client would reflect an understanding of the effects of this medication? A) "It will be okay for me to eat anything, as long as it is low-fat." B) "I will stop taking this medicine if I notice any bruising." C) "I'll check my blood pressure frequently while taking this medication." D) "I will not eat spinach while I'm taking this medicine."

Answer: D Explanation: D) Warfarin sodium suppresses the synthesis of vitamin K coagulation factors. Green, leafy vegetables contain vitamin K and will therefore interfere with the therapeutic effects of the drug. Bruising is a common side effect, and the drug should not be stopped unless prescribed by the physician. Low-fat foods do not interfere with warfarin sodium therapy. Anticoagulants do not affect the blood pressure.

Which intravenous fluid prescription noted by the nurse in orders for a client being treated for increased intracranial pressure (IICP) should the nurse contact the healthcare provider about for clarification? A.Lactated Ringer B.1/2 normal saline C.3% saline D.0.9% saline

B Rationale: Fluid management for the client with IICP includes the use of isotonic or slightly hypertonic solutions. Hypotonic fluids should be avoided because they can cause an increase in cerebral edema and serum osmolarity. Thus the nurse would question the order for 1/2 normal saline. The other solutions are either isotonic or slightly hypertonic.

The nurse provides teaching about phenytoin (Dilantin) to the mother of a school-age client with a seizure disorder. Which statement made by the mother indicates that teaching has been effective? A) "I will give his medicine on an empty stomach so he will absorb it better." B) "I will check his gums and increase visits to the dentist." C) "I will use a carbonated beverage to dilute his medication." D) "I will allow him to chew the tablet."

B) "I will check his gums and increase visits to the dentist."

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) Atrial fibrillation

The nurse is organizing care for the day for the assigned clients. Which client should the nurse give highest prioritization to ensure appropriate medication administration? A.A client with diabetes requiring insulin coverage QID B.A client with unstable vital signs receiving multiple blood pressure medications C.A client receiving several intravenous antibiotics, each to be infused over 30-60 minutes D.A client who is receiving daily dialysis

C Rationale: When the nurse is caring for multiple clients, setting of priorities is determined by the significance of the interventions for the clients. In this situation, the client receiving several intravenous antibiotics, each of which need to be infused over a specific time frame, would need to be prioritized to ensure adequate medication administration. QID insulin coverage, regularly scheduled blood pressure medications, and daily scheduled dialysis would not have higher prioritization than would the client receiving multiple intravenous antibiotics that must be administered in the correct order over the appropriate time frame.

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? Carotid endarterectomy Extracranial-intracranial bypass Carotid angioplasty with stenting Cautious observation only

Carotid angioplasty with stenting

This part of the brain is made up of gray and white matter and is responsible for muscle movement, balance, and control.

Cerebellum

Which of the following insults or abnormalities can cause an ischemic stroke? a) Arteriovenous malformation b) Intracerebral aneurysm rupture c) Cocaine use d) Trauma

Cocaine use Cocaine is a potent vasoconstrictor and may result in a life-threatening reaction, even with the individual's first use of the drug. Arteriovenous malformations are associated with hemorrhagic strokes. Trauma is associated with hemorrhagic strokes. Intracerebral aneurysm rupture is associated with hemorrhagic strokes.

The nurse is caring for a patient who is suspected of having a cerebral infarction. Which intervention should be the priority? Head computerized tomography (CT) scan PLAC test Complete history and physical assessment Lumbar puncture for cerebrospinal fluid (CSF) examination

Complete history and physical assessment

When the nurse applies a painful stimulus to the nailbeds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as a. decorticate posturing. b. decerebrate posturing. c. localization of pain. d. flexion withdrawal.

Correct Answer: A Rationale: Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is general, it does not indicate localization of pain or flexion withdrawal.

When assessing a patient with a head injury, the nurse recognizes that the earliest indication of increased intracranial pressure (ICP) is a. vomiting. b. headache. c. change in level of consciousness (LOC). d. sluggish pupil response to light.

Correct Answer: C Rationale: LOC is the most sensitive indicator of the patient's neurologic status and possible changes in ICP. Vomiting and sluggish pupil response to light are later signs of increased ICP. A headache can be caused by compression of intracranial structures as the brain swells, but it is not unexpected after a head injury.

The nurse is providing a community-based teaching course to a group of high school parents concerning brain injury. Which participant statement indicates accurate understanding of the population most at risk for traumatic brain injury (TBI)? A."TBIs most commonly occur in men between the ages of 18 and 25 years of age." B."Due to their age and the high number of falls and injuries, toddlers and children have higher levels of TBIs." C."TBIs are common across the lifespan, affecting men and women fairly equally." D."They are most common in the very young (0-4 years) or old (65 years and above)."

D Rationale: TBIs predominantly affect the very young (0-4 years) or older adults (65 years or older); thus, this is an accurate statement. They affect men and boys more commonly than females; thus, the statement that men and women are affected equally is not accurate. They do not most commonly occur in men between the ages of 18 and 25 years of age. While TBI injuries are high among toddlers, they are not high for children.

The nurse observes a school-age client have an absence seizure. Which statement will the nurse likely include when documenting this seizure? A) "Reported experiencing tingling sensations but denied loss of consciousness." B) "Became unconscious, and all four extremities were jerking uncontrollably for 2 minutes." C) "Repeatedly moved from the chair to the bed while touching the arms for a length of 2 minutes." D) "Sat very still and was unresponsive with a blank stare for 30 seconds."

D) "Sat very still and was unresponsive with a blank stare for 30 seconds."

The nurse prioritizes care for a client with diabetes mellitus using Maslow's hierarchy of needs. Which need is identified as the priority for this client? A. The nurse teaches the client proper home safety techniques to prevent diabetic wounds. B. The client joins the local American Diabetes Association support group. C. The client attends classes to deal with body image after amputation of the right leg. D. The nurse teaches the client how to properly change dressings on the right-leg amputation site.

D. The nurse teaches the client how to properly change dressings on the right-leg amputation site. Rationale: When prioritizing care based on Maslow's hierarchy of needs, physiological needs will come before safety, social, and esteem needs. Caring for an amputation site is meeting a physiological need. Attending a class to deal with body-image issues addresses an esteem need. Teaching the client about safety techniques to prevent diabetic wounds addresses a safety need. Joining a support group meets an esteem need.

The (deeper/shallower?) the location of the clot in the brain, the less damage it does.

Deeper (bc it's more localized & causes less generalized damage)

Which should the nurse state as a risk factor for cardiovascular accidents? Consumption of one glass of red wine with dinner History of type 1 diabetes mellitus since adolescence Cessation of cigarette smoking for a period of 5 years Hyperlipidemia controlled by prescribed oral medication

History of type 1 diabetes mellitus since adolescence

What is the trade name for Atorvastatin?

LIPITOR

A client is demonstrating signs of increasing intracranial pressure. Which intervention should the nurse implement? (Select all that apply.) Monitoring pupillary response Providing hypotonic fluids Reducing environmental stimuli Assessing cranial nerve function Assessing vital signs

Monitoring pupillary response Reducing environmental stimuli Assessing cranial nerve function Assessing vital signs Nursing actions for the client demonstrating signs of increasing intracranial pressure include assessing vital signs, monitoring pupillary response, assessing cranial nerve function, and reducing environmental stimuli. Intravenous fluids administered at this time would be isotonic or hypertonic.

1st thing you do when you suspect a stroke

Non-contrast CT scan (determines hemorrhagic vs ischemic)

The nurse is caring for a patient on the stroke unit. Which should be the nurse's priority action? Instructing the patient to hyperextend the neck while swallowing Ordering a pureed or soft diet Teaching the patient to place food behind the front teeth on the affected side of the mouth Monitoring swallowing studies prior to every meal

Ordering a pureed or soft diet A stroke patient should be on a soft or pureed diet. Swallowing studies should be reviewed prior to providing oral food or fluids the first time, not prior to every meal. The patient should tuck the chin while swallowing. The patient should be taught to place the food behind the front teeth on the unaffected side of the mouth.

Patient and Clinic factors

Patient recovery and ability Patient goals Clinic Requirements

A client has a CVP monitor in place via a central line. Which would be included in the nursing plan of care for this client? a notify the dr of readings less than 3 cm or more than 8 cm of water b. use the clean technique to change the dressing at the insertion site c elevate the had of the bed to 90 degrees to obtain cvp readings d the 0 mark on the manometer should align with the clients right clavicle for readings

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? A Urine output increases B Pupils are 8 mm and nonreactive C Systolic blood pressure remains at 150 mm Hg D BUN and creatinine levels return to normal

A nurse caring for a client who was recently admitted to the ER following a head on MVA. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on his forehead that is bleeding. Which is the priority nursing action at this time? a keep neck stabalized b insert nasogastric tube c monitor pulse and BP frequently d establish IV access and start fluid replacement

During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status every 4 hours. A cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow is a. hypertension b. fluid overload c. cardiac dysrhythmias d. S3 and S4 heart sounds

The nurse is conducting a teaching clinic for senior citizens about risk factors for stroke. Although the nurse includes all of the following as risk factors, which presents the greatest risk for stroke? a. Hypertension b. Heart disease c. Diabetes d. High cholesterol level

answer: a Rationale: Clients with hypertension have a 4-6 times greater risk for stroke than do clients without hypertension, because the sustained systolic and diastolic pressure causes damage to cerebral blood vessels.

When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval? a.) An interval when the client's speech is garbled b.) An interval when the client is alert but can't recall recent events c.) An interval when the client is oriented but then becomes somnolent d.) An interval when the client has a "warning" symptom, such as an odor or visual disturbance.

c.) An interval when the client is oriented but then becomes somnolent Rationale: A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours, the client again loses consciousness. Garbled speech is known as dysarthria. An interval in which the client is alert but can't recall recent events is known as amnesia. Warning symptoms or auras typically occur before seizures.

In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? a.) Complete set of vital signs b.) Palpation and auscultation of the abdomen c.) Brief neurologic assessment d.) Initiation of pulse oximetry

c.) Brief neurologic assessment Rationale: A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Vital signs, assessment of the abdomen, and initiation of pulse oximetry are considered part of the secondary survey.

Diabetes mellitus is a common cause of hypertension

false

Which of the following is NOT a risk factor for stroke? a. HTN b. smoking c. obesity d. contraceptives w/ high levels of progesterone e. all are risk factors

d. contraceptives w/ high levels of progesterone (should say estrogen)

The nurse questions a patient with hypertension about decreased visual acuity, which may indicate

retinopathy

right or left brain damage? impaired judgment, quick and impulse behavior, left homonymous hemianopsia, neglect of left side of body

right

Which nursing diagnosis would the nurse select for the client who has been treated for hypertension and continues to have high blood pressure? 1. Ineffective Coping 2. Anxiety 3. Risk for Noncompliance 4. Grieving

risk for noncompliance

The home care nurse is planning the order of clients for the day. Which client should the nurse prioritize as needing to be seen first? A. A newly diagnosed diabetic client who is administering morning insulin independently for the first time B. A client with daily dressing change, normally done at 0800 per client preference C. A client being seen poststroke for rehabilitation and education about poststroke care D. A client requiring indwelling catheter change due to leakage

A. A newly diagnosed diabetic client who is administering morning insulin independently for the first time Rationale: A newly diagnosed client who is administering insulin independently for the first time creates a time constraint. The nurse would see this client first to ensure that the insulin is being administered properly. While client preferences are an important consideration, the time constraint of the insulin would be a higher priority. A client being seen poststroke for rehabilitation and education as well as a client with a leaking indwelling catheter would also be lower priorities when planning the order of clients for the day.

When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result? a.) Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). b.) Emergent; the client is poorly oxygenated. c.) Normal d.) Significant; the client has alveolar hypoventilation.

A ~ A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Oxygenation is evaluated through PaO2 and oxygen saturation. Alveolar hypoventilation would be reflected in an increased PaCO2.

The nurse is caring for a client who has increased intracranial pressure and a fever of 102°F. Which nursing intervention promotes normal intracranial pressure? (Select all that apply.) Administering acetaminophen per order Flexing the neck to open the airway Providing supplemental oxygen Increasing environmental stimuli Monitoring level of consciousness

Administering acetaminophen per order Providing supplemental oxygen Monitoring level of consciousness Increased intracranial pressure can cause irregular and ineffective respirations. Supplemental oxygen helps prevent hypoxia and excess carbon dioxide, which is a vasodilator. A decreased level of consciousness can be a manifestation of pressure on the cerebral cortex. It can also be a manifestation of decreased oxygen levels in the brain. Hyperthermia increases intracranial pressure and affects hypothalamic function in clients with increased intracranial pressure; therefore, administering an antipyretic medication is appropriate. Excess environmental stimuli can increase intracranial pressure. Flexing the neck increases intracranial pressure by preventing blood return from the brain. The head and neck must be kept in neutral position.

Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention will be best to include in the initial plan for an effective bladder training program? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external "condom" catheter to protect the skin and prevent embarrassment.

B ~ Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200 mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke, but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown.

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 102 beats/min. b. The patient has difficulty speaking. c. The blood pressure is 144/86 mm Hg. d. There are fine crackles at the lung bases.

B ~ Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure. The nurse should have the patient take some deep breaths.

A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Monitor the blood pressure. b. Send the patient for a computed tomography (CT) scan. c. Check the respiratory rate and effort. d. Assess the Glasgow Coma Scale score.

C ~ The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed.

A 63-year-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? a. Obtain computed tomography (CT) scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient.

C, D, A, B ~ The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.

A 58-year-old patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should a. use a calm voice to ask the patient to stop the crying behavior. b. explain to the family that depression is normal following a stroke. c. have the family members leave the patient alone for a few minutes. d. teach the family that emotional outbursts are common after strokes.

D ~ Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control and asking the patient to stop will lead to embarrassment.

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine has the highest priority for the patient? a. Impaired physical mobility related to weakness b. Disturbed sensory perception related to brain injury c. Risk for impaired skin integrity related to immobility d. Risk for aspiration related to inability to protect airway

D ~ Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time.

Metabolic and nutritional needs of the patient with increased ICP are best met with a. enteral feedings that are low in sodium b. the simple glucose available in D5W IV solutions c. a fluid restriction that promotes a moderate dehydration d. balanced, essential nutrition in a form that the patient can tolerate

D. Balanced, essential nutrition in a form that the patient can tolerate= A patient with increased ICP is in a hypermetabolic and hypercatabolic state and needs adequate glucose to maintain fuel for the brain and other nutrients to meet metabolic needs. Malnutrition promotes cerebral edema, and if a patient cannot take oral nutrition, other means of providing nutrition should be used, such as tube feedings or parenteral nutrition. Glucose alone is not adequate to meet nutritional requirements, and 5% dextrose solutions may increase cerebral edema by lowering serum osmolarity. Patients should remain in a normovolemic fluid state with close monitoring of clinical factors such as urine output, fluid intake, serum and urine osmolality, serum electrolytes, and insensible losses.

The nurse is assessing a client with a traumatic head injury and suspects increased intracranial pressure (IICP). Which assessment finding supports this suspicion? (Select all that apply.) Hemiparesis Increased heart rate Drowsiness Double vision Blurred vision

Hemiparesis Drowsiness Double vision Blurred vision Hemiparesis or hemiplegia of the contralateral side may be an early sign of IICP. Drowsiness can occur with IICP. Double vision and blurred vision can occur with IICP. Headache is common with IICP. The client may also report other generalized manifestations such as dizziness. The heart rate generally decreases with IICP.

The nurse is preparing to discharge an older adult who was admitted to the hospital after hitting their head during a fall. Which service is most important for the client when at home? Home pharmacy delivery Home assessment In-home blood draws Meals on Wheels

Home assessment Health promotion education for older adults includes fall prevention and adhering to cautions that accompany prescription medications. Older adults who are at risk for falls may benefit from a home safety assessment. Other in-home services may be valuable but will not necessarily prevent a fall?which is why the client was admitted to the hospital.

19. While positioning a patient in bed with increased ICP, it important to avoid? A. Midline positioning of the head B. Placing the HOB at 30-35 degrees C. Preventing flexion of the neck D. Flexion of the hips

The answer is D. Avoid flexing the hips because this can increase intra-abdominal/thoracic pressure, which will increase ICP.

3. A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing? A. Coughing B. Sneezing C. Talking D. Valsalva maneuver E. Vomiting F. Keeping the head of the bed between 30- 35 degrees

The answers are A, B, D, and E. These activities can increase ICP.

1. Select the main structures below that play a role with altering intracranial pressure: A. Brain B. Neurons C. Cerebrospinal Fluid D. Blood E. Periosteum F. Dura mater

The answers are A, C, and D. Inside the skull are three structures that can alter intracranial pressure. They are the brain, cerebrospinal fluid (CSF), and blood.

You are working in the triage area of an ED, and four patients approach the triage desk at the same time. List the order in which you will assess these patients: a. An ambulatory, dazed 25-year-old male with a bandaged head wound b. An irritable infant with a fever, petechiae, and nuchal rigidity c. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity d. A 50-year-old female with moderate abdominal pain and occasional vomiting. 1.) A B D C 2.) B A D C 3.) C D B A 4.) C B A D

2.) B A D C ~ An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not unstable at this point. For the ankle injury, medical evaluation can be delayed 24 - 48 hours if necessary.

A patient is admitted with a subacute subdural hematoma. The nurse realizes this patient will most likely be treated with: a.) Emergency craniotomy. b.) Elective draining of the hematoma. c.) Burr holes to remove the hematoma. d.) Removal of the affected cranial lobe.

b.) Elective draining of the hematoma.

The nurse is teaching a patient about a transient ischemic attack (TIA). Which statement should the nurse include? "A TIA can be a warning sign of an impending larger stroke." "TIAs usually involve one large artery in the brain prior to stroke." "TIAs cause brain cells to die and leave a small cavity in the brain tissue." "TIAs are caused by blood clots that break off from larger clots in the body."

"A TIA can be a warning sign of an impending larger stroke."

The nurse is teaching a patient about a transient ischemic attack (TIA). Which statement should the nurse include? "TIAs usually involve one large artery in the brain prior to stroke." "TIAs are caused by blood clots that break off from larger clots in the body." "A TIA can be a warning sign of an impending larger stroke." "TIAs cause brain cells to die and leave a small cavity in the brain tissue."

"A TIA can be a warning sign of an impending larger stroke." A TIA is also called a ministroke. It involves a temporary interruption in the blood flow to a specific area in the brain. A large-vessel thrombus usually involves one large artery in the brain. The vessel is occluded by the thrombus, which means that blood flow is blocked to the affected area. Lacunar or small vessel infarct causes necrosis in the brain tissue. These areas slough off and leave small cavities in the brain tissue. Cardiogenic embolic strokes are caused by emboli from clots in the body, frequently in the heart. Clots may be the result of atrial fibrillation or other disease processes. Atherosclerotic plaques can also break off and lodge in the arteries in the brain.

The nurse is assessing a client who leads an active, healthy lifestyle. The client has no history of chronic health conditions, but is seeking health care due to visual changes and occasional headaches over the past few weeks. Upon assessment, which question should the nurse ask the client? "Have you noticed an increase in thirst?" "Do you feel nauseated after eating?" "Are you having trouble moving your bowels?" "Are your headaches worse upon rising in the morning?

"Are your headaches worse upon rising in the morning? Rationale With increased intracranial pressure, headaches are noted to be worse in the morning and with position changes. Projectile vomiting may occur, but nausea is not present. Thirst does not increase for clients with IICP. Clients with IICP typically do not experience constipation or trouble with bowel movements.

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer? a) "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation." b) "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing." c) "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved." d) "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client."

"Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation." Clinical manifestations following a stroke are highly variable and depend on the area of the cerebral cortex and the affected hemisphere, the degree of blockage (total, partial), and the presence or absence of adequate collateral circulation. (Collateral circulation is circulation formed by smaller blood vessels branching off from or near larger occluded vessels.) Clinical manifestations of a stroke do not depend on the cardiovascular health of the client or how quickly the clot can be dissolved. Clinical manifestations of a stroke are not "general" but individual.

A patient is diagnosed with stroke at the right anterior cerebral artery. The nurse asks the patient's daughter, "What changes have you noticed in your mother?" Which response by the daughter would be consistent with the patient's diagnosis? "She doesn't seem to see the food on her plate." "I have to really watch her when she's eating." "She has difficulty walking." "I have to make all the decisions for my mother."

"I have to make all the decisions for my mother."

A patient is diagnosed with stroke at the right anterior cerebral artery. The nurse asks the patient's daughter, "What changes have you noticed in your mother?" Which response by the daughter would be consistent with the patient's diagnosis? "She doesn't seem to see the food on her plate." "I have to make all the decisions for my mother." "She has difficulty walking." "I have to really watch her when she's eating."

"I have to make all the decisions for my mother." For a patient who experienced an ischemic stroke involving the right anterior cerebral artery, the nurse should expect to see weakness or paralysis of the left foot or leg; sensory loss in the left leg, foot, and toes; an inability to make decisions; and urinary incontinence. Homonymous hemianopia would be seen if the internal carotid artery or middle cerebral artery were affected by the ischemic stroke. Problems with gait and dysphagia would be evident with an ischemic stroke that involved the vertebral artery.

The nurse is teaching a patient who had a stroke how to perform active range of motion exercises. Which patient statement indicates an understanding of the teaching? "I will use slow movements and stop if pain occurs." "Performing range of motion exercises helps me to strengthen my unaffected side only." "I will perform each of the exercises three to four times per day, in the same order." "If my affected side cannot move independently, I will practice on the unaffected side only."

"I will use slow movements and stop if pain occurs."

The nurse provided teaching to a patient about the risk of stroke during pregnancy. Which patient statement indicates a need for further teaching? "Increased hormone levels cause increased clotting times." "Preeclampsia increases the risk for a stroke." "The increased blood pressure associated with pregnancy increases stroke risk." "Increased hormone levels change the blood vessel walls, which increases the risk of clotting."

"Increased hormone levels cause increased clotting times."

The nurse provided teaching to a patient about the risk of stroke during pregnancy. Which patient statement indicates a need for further teaching? "Increased hormone levels cause increased clotting times." "The increased blood pressure associated with pregnancy increases stroke risk." "Preeclampsia increases the risk for a stroke." "Increased hormone levels change the blood vessel walls, which increases the risk of clotting."

"Increased hormone levels cause increased clotting times." Increased hormones during pregnancy cause changes in the blood vessel walls and increase the risk of clotting by decreasing clotting times. The increase in blood pressure associated with pregnancy, especially in patients with preeclampsia, also increases stroke risk.

A patient who recently experienced a stroke asks the nurse, "How can I increase my strength and mobility?" How should the nurse respond? "I will assist you to the bathroom every 2 hours." "Leave your nasal cannula in place, so you receive adequate oxygen." "Try to maintain fluid intake of 2000 mL per day." "Performing range of motion exercises daily will help you to regain strength."

"Performing range of motion exercises daily will help you to regain strength."

A patient who recently experienced a stroke asks the nurse, "How can I increase my strength and mobility?" How should the nurse respond? "Try to maintain fluid intake of 2000 mL per day." "I will assist you to the bathroom every 2 hours." "Leave your nasal cannula in place, so you receive adequate oxygen." "Performing range of motion exercises daily will help you to regain strength."

"Performing range of motion exercises daily will help you to regain strength." A patient who is experiencing impaired mobility would benefit from range of motion exercises. The other interventions may be appropriate for this patient, but they do not address the patient's mobility needs.

A patient's family asks why the healthcare provider ordered heparin instead of tPA for a family member who experienced a thrombotic stroke 5 hours earlier. Which response by the nurse is accurate? "TPA must be given within 3 hours of the onset of symptoms because of serious side effects." "Heparin starts to break up the clot and is followed by warfarin to prevent further clotting." "Heparin is given initially followed by an infusion tPA to finish breaking up the clot." "Heparin is the best drug on the market to break up clots that are causing stroke."

"TPA must be given within 3 hours of the onset of symptoms because of serious side effects."

A patient's family asks why the healthcare provider ordered heparin instead of tPA for a family member who experienced a thrombotic stroke 5 hours earlier. Which response by the nurse is accurate? "Heparin starts to break up the clot and is followed by warfarin to prevent further clotting." "TPA must be given within 3 hours of the onset of symptoms because of serious side effects." "Heparin is given initially followed by an infusion tPA to finish breaking up the clot." "Heparin is the best drug on the market to break up clots that are causing stroke."

"TPA must be given within 3 hours of the onset of symptoms because of serious side effects." Drugs such as tPA are effective if given within 3 hours of symptom onset. There is some evidence that some improvement may occur if administered up to 4.5 hours after symptoms start. However, there is an increased risk of hemorrhage. Heparin prevents further clot formation and extension of the existing clot. Heparin does not break up existing clots. Heparin and warfarin (Coumadin) are given to prevent further clot formation and extension of the existing clot. Heparin can be given intravenously and subcutaneously. Warfarin is given orally.

The nurse is instructing a patient who is recovering from a stroke on how to perform active range of motion exercises. Which statement should the nurse include? "Performing range of motion exercises helps to strengthen the unaffected side only." "Perform each of the exercises three to four times per day, preferably in the same order." "If the affected side cannot move independently, practice on the unaffected side only." "Use slow movements and stop if pain occurs."

"Use slow movements and stop if pain occurs." Active range of motion exercises are performed independently by the patient , without the assistance of the nurse. The patient should use slow movements and stop if pain occurs. If the affected side cannot be move independently, the patient can use the unaffected side to assist. Each of the exercises should be completed once daily, at the same time each day and preferably in the same order. Range of motion exercises help the patient to use muscles on the affected side that lost functionality due to the stroke.

NCLEX Review Questions: The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions (select all that apply)? Clopidogrel (Plavix) Enoxaparin (Lovenox) Dipyridamole (Persantine) Enteric-coated aspirin (Ecotrin) Tissue plasminogen activator (tPA)

* Clopidogrel (Plavix), Dipyridamole (Persantine), Enteric-coated aspirin (Ecotrin)* Rationale: Aspirin is the most frequently used antiplatelet agent. Other drugs to prevent clot formation include clopidogrel (Plavix), dipyridamole (Persantine), ticlopidine (Ticlid), combined dipyridamole and aspirin (Aggrenox), and anticoagulant drugs, such as oral warfarin (Coumadin). Tissue plasminogen activator is a fibrinolytic medication used to treat ischemic stroke not prevent TIAs or strokes.

NCLEX Review Questions: Which modifiable risk factors for stroke would be most important for the nurse to include when planning a community education program? A) Hypertension B) Hyperlipidemia C) Alcohol consumption D) Oral contraceptive use

*A) Hypertension* Rationale: Hypertension is the single most important modifiable risk factor, but it is still often undetected and inadequately treated. The public is often more aware of hyperlipidemia and oral contraceptive use as risk factors for stroke. Alcohol is also a modifiable risk factor.

NCLEX Review Questions: Computed tomography (CT) of a 68-year-old male patient's head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? A) Maintenance of the patient's airway B) Positioning to promote cerebral perfusion C) Control of fluid and electrolyte imbalances D) Administration of tissue plasminogen activator (tPA)

*A) Maintenance of the patient's airway* Rationale: Maintenance of a patent airway is the priority in the acute care of a patient with a hemorrhagic stroke. It supersedes the importance of fluid and electrolyte imbalance and positioning. tPA is contraindicated in hemorrhagic stroke.

NCLEX Review Questions: The patient with diabetes mellitus has had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient related to expected manifestations of this stroke? A) Safety measures B) Patience with communication C) Mobility assistance on the right side D) Place food in the left side of patient's mouth.

*A) Safety measures* Rationale: A patient with a right-sided stroke has spatial-perceptual deficits, tends to minimize problems, has a short attention span, is impulsive, and may have impaired judgment. Safety is the biggest concern for this patient. Hemiplegia occurs on the left side of this patient's body. The patient with a left-sided stroke has hemiplegia on the right, is more likely to have communication problems, and needs mobility assistance on the right side with food placed on the left side if the patient needs to be fed after a swallow evaluation has taken place.

Pre-test questions: The nurse observes a student nurse assigned to initiate oral feedings for a 68-year-old woman with an ischemic stroke. The nurse should intervene if she observes the student nurse... A) giving the patient 8 ounces of ice water to swallow. B) telling the patient to perform a chin tuck before swallowing. C) assisting the patient to sit in a chair before feeding the patient. D) assessing cranial nerves IX and X before the patient attempts to eat.

*A) giving the patient 8 ounces of ice water to swallow.* Rationale: The majority of patients after a stroke have dysphagia. The gag reflex and swallowing ability (cranial nerves IX and X) should be assessed before the first oral feeding. To assess swallowing ability, the nurse should elevate the head of the bed to an upright position (unless contraindicated) and give the patient a very small amount (not 8 ounces) of crushed ice or ice water to swallow. The patient should remain in a high Fowler's position, preferably in a chair with the head flexed forward, for the feeding and for 30 minutes following.

NCLEX Review Questions: A female patient has left-sided hemiplegia following an ischemic stroke that she experienced 4 days earlier. How should the nurse best promote the health of the patient's integumentary system? A) Position the patient on her weak side the majority of the time. B) Alternate the patient's positioning between supine and side-lying. C) Avoid the use of pillows in order to promote independence in positioning. D) Establish a schedule for the massage of areas where skin breakdown emerges.

*B) Alternate the patient's positioning between supine and side-lying.* Rationale: A position change schedule should be established for stroke patients. An example is side-back-side, with a maximum duration of 2 hours for any position. The patient should be positioned on the weak or paralyzed side for only 30 minutes. Pillows may be used to facilitate positioning. Areas of skin breakdown should never be massaged.

NCLEX Review Questions: The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke? A) Impulsivity B) Impaired speech C) Left-side neglect D) Short attention span

*B) Impaired speech* Rationale: Clinical manifestations of left-sided brain damage include right hemiplegia, impaired speech/language, impaired right/left discrimination, and slow and cautious performance. Impulsivity, left-sided neglect, and short attention span are all manifestations of right-sided brain damage.

Pre-test questions: The physician orders alteplase (Activase) for a 58-year-old man diagnosed with an acute ischemic stroke. Which nursing action is most appropriate? A) Administer the medication by an IV route at 15 mL/hr for 24 hours. B) Insert two or three large-bore IV catheters before administering the medication. C) If gingival bleeding occurs, discontinue the medication and notify the physician. D) Reduce the medication infusion rate for a systolic blood pressure above 180 mm Hg.

*B) Insert two or three large-bore IV catheters before administering the medication.* Rationale: Before giving alteplase, the nurse should start two or three large bore IVs. Bleeding is a major complication with fibrinolytic therapy, and venipunctures should not be attempted after alteplase is administered. Altepase is administered IV with an initial bolus dose followed by an infusion of the remaining medication within the next 60 minutes. Gingival bleeding is a minor complication and may be controlled with pressure or ice packs. Control of blood pressure is critical prior to altepase administration and for the following 24 hours. Before administering altepase, a systolic pressure above 180 mm Hg or diastolic pressure above 110 mm Hg requires aggressive blood pressure treatment to reduce the risk of cerebral hemorrhage.

NCLEX Review Questions: The nurse is planning psychosocial support for the patient and family of the patient who suffered a stroke. What factor will most likely have the greatest impact on positive family coping with the situation? A) Specific patient neurologic deficits B) The patient's ability to communicate C) Rehabilitation potential of the patient D) Presence of complications of a stroke

*C) Rehabilitation potential of the patient* Rationale: Although a patient's neurologic deficit might initially be severe after a stroke, the ability of the patient to recover is most likely to positively impact the family's coping with the situation. Providing explanations and emotional support beginning in the acute phase through the rehabilitation phase will facilitate coping. Emphasizing successes will offer the most realistic hope for the patient's rehabilitation and helps maintain hope for the patient's future abilities.

NCLEX Review Questions: Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? A) Overestimation of physical abilities B) Difficulty judging position and distance C) Slow and possibly fearful performance of tasks D) Impulsivity and impatience at performing tasks

*C) Slow and possibly fearful performance of tasks* Rationale: Patients with a left-sided stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-sided stroke.

Pre-test questions: The nurse is teaching a senior citizen's group about signs and symptoms of a stroke. Which statement by the nurse would provide accurate information? A) "Take the person to the hospital if a headache lasts for more than 24 hours." B) "Stroke symptoms usually start when the person is awake and physically active." C) "A person with a transient ischemic attack has mild symptoms that will go away." D) "Call 911 immediately if a person develops slurred speech or difficulty speaking."

*D) "Call 911 immediately if a person develops slurred speech or difficulty speaking."* Rationale: Medical assistance should be obtained immediately for someone with signs and symptoms of a stroke such as sudden numbness; weakness; paralysis of the face, arm, or leg (especially on one side of the body); sudden confusion; trouble speaking or understanding; slurred speech; sudden trouble seeing in one or both eyes; sudden trouble walking; dizziness; loss of balance or coordination; or a sudden, severe headache with no known cause. A person with signs and symptoms of a transient ischemic attack should seek medical attention immediately because it is unknown if the symptoms will resolve or persist and progress to a stroke. Onset of signs and symptoms of a stroke vary depending on the type. Onset of an ischemic thrombotic stroke usually occurs at rest. Onset of an ischemic embolic stroke is not related to rest or activity, and onset of a hemorrhagic stroke usually occurs with activity.

Pre-test questions: The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? A) A 92-year-old female who takes warfarin (Coumadin) for atrial fibrillation. B) A 28-year-old male who uses marijuana after chemotherapy to control nausea. C) A 42-year-old female who takes oral contraceptives and has migraine headaches. D) A 72-year-old male who has hypertension and diabetes mellitus and smokes tobacco.

*D) A 72-year-old male who has hypertension and diabetes mellitus and smokes tobacco.* Rationale: Stroke risk increases after 65 years of age. Strokes are more common in men. Hypertension is the single most important modifiable risk factor for stroke. Diabetes mellitus is a significant stroke risk factor; and smoking nearly doubles the risk of a stroke. Other risk factors include drug abuse (especially cocaine), high-dose oral contraception use, migraine headaches, and untreated heart disease such as atrial fibrillation.

Pre-test questions: A 74-year-old man who has right-sided extremity paralysis related to a thrombotic stroke develops constipation. Which action should the nurse take first? A) Assist the patient to the bathroom every 2 hours. B) Provide incontinence briefs to wear during the day. C) Administer a bisacodyl (Dulcolax) rectal suppository every day. D) Arrange for several servings per day of cooked fruits and vegetables.

*D) Arrange for several servings per day of cooked fruits and vegetables.* Rationale: Patients after a stroke frequently have constipation. Dietary management includes the following: fluid intake of 2500 to 3000 mL daily, prune juice (120 mL) or stewed prunes daily, cooked fruit three times daily, cooked vegetables three times daily, and whole-grain cereal or bread three to five times daily. Patients with urinary incontinence should be assisted to the bathroom every 2 hours when appropriate. Suppositories may be ordered for short-term management if the patient does not respond to increased fluid and fiber. Incontinence briefs are indicated as a short-term intervention for urinary incontinence.

NCLEX Review Questions: The female patient has been brought to the ED with a sudden onset of a severe headache that is different from any other headache she has had previously. When considering the possibility of a stroke, which type of stroke should the nurse know is most likely occurring? A) TIA B) Embolic stroke C) Thrombotic stroke D) Subarachnoid hemorrhage

*D) Subarachnoid hemorrhage* Rationale: Headache is common in a patient who has a subarachnoid hemorrhage or an intracerebral hemorrhage. A TIA is a transient loss of neurologic function usually without a headache. A headache may occur with an ischemic embolic stroke, but severe neurologic deficits are the initial symptoms. The ischemic thrombotic stroke manifestations progress in the first 72 hours as infarction and cerebral edema increase.

NCLEX Review Questions: Which intervention is most appropriate when communicating with a patient suffering from aphasia following a stroke? A) Present several thoughts at once so that the patient can connect the ideas. B) Ask open-ended questions to provide the patient the opportunity to speak. C) Finish the patient's sentences to minimize frustration associated with slow speech. D) Use simple, short sentences accompanied by visual cues to enhance comprehension.

*D) Use simple, short sentences accompanied by visual cues to enhance comprehension.* Rationale: When communicating with a patient with aphasia, the nurse should present one thought or idea at a time. Ask questions that can be answered with a "yes," "no," or simple word. Use visual cues and allow time for the individual to comprehend and respond to conversation.

Bridge to NCLEX question: Common psychosocial reactions of the stroke patient to the stroke include (select all that apply) a. depression. b. disassociation. c. intellectualization. d. sleep disturbances. e. denial of severity of stroke.

*a. depression, d. sleep disturbances, e. denial of severity of stroke* Rationale: The patient with a stroke may experience many losses, including sensory, intellectual, communicative, functional, role behavior, emotional, social, and vocational losses. Some patients experience long-term depression, manifesting symptoms such as anxiety, weight loss, fatigue, poor appetite, and sleep disturbances. The time and energy required to perform previously simple tasks can result in anger and frustration. Frustration and depression are common in the first year after a stroke. A stroke is usually a sudden, extremely stressful event for the patient, caregiver, family, and significant others. The family is often affected emotionally, socially, and financially as their roles and responsibilities change. Reactions vary considerably but may involve fear, apprehension, denial of the severity of stroke, depression, anger, and sorrow.

For a patient who is suspected of having a stroke, one of the most important pieces of information that the nurse can obtain is a. time of the patient's last meal. b. time at which stroke symptoms first appeared. c. patient's hypertension history and management. d. family history of stroke and other cardiovascular diseases.

*b. time at which stroke symptoms first appeared.* Rationale: During initial evaluation, the most important point in the patient's history is the time since onset of stroke symptoms. If the stroke is ischemic, recombinant tissue plasminogen activator (tPA) must be administered within 3 to 4.5 hours of the onset of clinical signs of ischemic stroke; tPA reestablishes blood flow through a blocked artery and prevents brain cell death in patients with acute onset of ischemic stroke.

Bridge to NCLEX question: Bladder training in a male patient who has urinary incontinence after a stroke includes a. limiting fluid intake. b. keeping a urinal in place at all times. c. assisting the patient to stand to void. d. catheterizing the patient every 4 hours.

*c. assisting the patient to stand to void.* Rationale: In the acute stage of stroke, the primary urinary problem is poor bladder control and incontinence. Nurses should promote normal bladder function and avoid the use of indwelling catheters. A bladder retraining program consists of (1) adequate fluid intake, with most fluids administered between 7:00 am and 7:00 pm; (2) scheduled toileting every 2 hours with the use of a bedpan, commode, or bathroom; and (3) noting signs of restlessness, which may indicate the need for urination. Intermittent catheterization may be used for urinary retention (not urinary incontinence). During the rehabilitation phase after a stroke, nursing interventions focused on urinary continence include (1) assessment for bladder distention by palpation; (2) offering the bedpan, urinal, commode, or toilet every 2 hours during waking hours and every 3 to 4 hours at night; (3) using a direct command to help the patient focus on the need to urinate; (4) assistance with clothing and mobility; (5) scheduling most fluid intake between 7:00 am and 7:00 pm; and (6) encouraging the usual position for urinating (i.e., standing for men and sitting for women).

The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the a. amount of cardiac output. b. oxygen content of the blood. c. degree of collateral circulation. d. level of carbon dioxide in the blood.

*c. degree of collateral circulation.* Rationale: The extent of the stroke depends on the rapidity of onset, size of the lesion, and presence of collateral circulation.

4. A patient with right-sided hemiplegia and aphasia resulting from a stroke most likely has involvement of the a. brainstem. b. vertebral artery. c. left middle cerebral artery. d. right middle cerebral artery.

*c. left middle cerebral artery.* Rationale: If the middle cerebral artery is involved in a stroke, the expected clinical manifestations include aphasia, motor and sensory deficit, and hemianopsia on the dominant side and include neglect, motor and sensory deficit, and hemianopsia on the nondominant side.

The nurse explains to the patient with a stroke who is scheduled for angiography that this test is used to determine the a. presence of increased ICP. b. site and size of the infarction. c. patency of the cerebral blood vessels. d. presence of blood in the cerebrospinal fluid.

*c. patency of the cerebral blood vessels.* Rationale: Angiography provides visualization of cerebral blood vessels and can help estimate perfusion and detect filling defects in the cerebral arteries.

A patient experiencing TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to a. decrease cerebral edema. b. reduce the brain damage that occurs during a stroke in evolution. c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow. d. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation.

*c.prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow.* Rationale: In a carotid endarterectomy, the atheromatous lesion is removed from the carotid artery to improve blood flow.

Information provided by the patient that would help differentiate a hemorrhagic stroke from a thrombotic stroke includes a. sensory disturbance. b. a history of hypertension. c. presence of motor weakness. d. sudden onset of severe headache.

*d. sudden onset of severe headache.* Rationale: A hemorrhagic stroke usually causes a sudden onset of symptoms, which include neurologic deficits, headache, nausea, vomiting, decreased level of consciousness, and hypertension. Ischemic stroke symptoms may progress in the first 72 hours as infarction and cerebral edema increase.

Assisting the family to understand what is happening to the patient is an especially important role of the nurse when the patient has a tumor in which part of the brain? a. Ventricles c. Parietal lobe b. Frontal lobe d. Occipital lobe

. b. Frontal lobe tumors often lead to loss of emotional control, confusion, memory loss, disorientation, seizures, and personality and judgment changes that are very disturbing and frightening to the family. Physical symptoms, such as blindness, speech disturbances, or disturbances in sensation and perception that occur with other tumors, are more likely to be understood and accepted by the family

How is cranial nerve (CN) III, originating in the midbrain, assessed by the nurse for an early indication of pressure on the brainstem? a. Assess for nystagmus c. Test pupillary reaction to light b. Test the corneal reflex d. Test for oculocephalic (doll's eyes) reflex

. c. One of the functions of cranial nerve (CN) III, the oculomotor nerve, is pupillary constriction and testing for pupillary constriction is important to identify patients at risk for brainstem herniation caused by increased ICP. The corneal reflex is used to assess the functions of CN V and VII and the oculocephalic reflex tests all cranial nerves involved with eye movement. Nystagmus is commonly associated with specific lesions or chemical toxicities and is not a definitive sign of ICP

An early sign of increased ICP that the nurse should assess for is a. Cushing's triad. c. decreasing level of consciousness (LOC). b. unexpected vomiting. d. dilated pupil with sluggish response to light.

. c. One of the most sensitive signs of increased ICP is a decreasing level of consciousness (LOC). A decrease in LOC will occur before changes in vital signs, ocular signs, or projectile vomiting occur.

The clinic nurse assesses a client with a history of transient ischemic attacks (TIA) who was advised to lose weight, change the diet to lower cholesterol, and maintain treatment of hypertension. The client has chosen not to take this advice, leading the nurse to conclude the client is at increased risk for what complication? 1. Stroke 2. Aneurysm 3. Vasovagal syndrome 4. Myasthenia gravis

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 patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last? a) Up to 1 week b) Up to 24 hours c) 1 to 3 days d) Up to 2 weeks

1 to 3 days The acute phase of an ischemic stroke may last 1 to 3 days, but ongoing monitoring of all body systems is essential as long as the patient requires care.

1. A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty breathing. The nurse performs which intervention as a priority measure to assist the client with breathing? a) repositions side to side every 2 hours b) elevates the head of the bed 60 degrees c) auscultates the lung field every 4 hours d) encourages deep breathing exercises every 2 hours

1) B - The client is having difficulty breathing because of upward pressure on the diaphragm from the ascitic fluid. Elevating the head of the bed enlists the aid of gravity in relieving pressure on the diaphragm. The other options are general measures to promote lung expansion in the client with ascites, but the priority measure is the one that relieves diaphragmatic pressure.

Factors to consider when selecting outcome measures

1) What to measure 2) Purpose of Measure 3) Type of Measure 4) Patient and Clinic factors 5) Psychometric factors 6) Feasibility

4 major causes of hemorrhagic stroke

1)deep hypertensive intracerebral hemorrhages, 2)ruptured saccular aneurysms, 3)arteriovenous malformation,4)spontaneous lobar hemorrhages

The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which of the following positions are appropriate? 1. Placing a pillow in the axilla so the arm is away from the body. 2. Inserting a pillow under the slightly flexed arm so the hand is higher than the elbow. 3. Immobilizing the extremity in a sling. 4. Positioning a hand cone in the hand so the fingers are barely flexed. 5. Keeping the arm at the side using a pillow.

1, 2, 4. Placing a pillow in the axilla so the arm is away from the body keeps the arm abducted and prevents skin from touching skin to avoid skin breakdown. Placing a pillow under the slightly flexed arm so the hand is higher than the elbow prevents dependent edema. Positioning a hand cone (not a rolled washcloth) in the hand prevents hand contractures. Immobilization of the extremity may cause a painful shoulder-hand syndrome. Flexion contractures of the hand, wrist, and elbow can result from immobility of the weak or paralyzed extremity. It is better to extend the arms to prevent contractures

99. The resident in a long-term care facility tells the nurse, "I think my family just put me here to die because they think I am too much trouble." Which statement is the nurse's best response? 1. "Can you tell me more about how you feel since your family placed you here?" 2. "Your family did what they felt was best for your safety." 3. "Why would you think that about your family? They care for you." 4. "Tell me, how much trouble were you when you were at home?"

1. "Can you tell me more about how you feel since your family placed you here?"

Tests and Measures in Stroke Rehab that can be used for the general population (6)

1. 6 min walk test 2. 10 meter walk test 3. Ashworth scale 4. Berg Balance test 5. Dynamic gait index 6. Functional reach test

Regular oral hygiene is essential for the client who has had a stroke. Which of the following nursing measures is not appropriate when providing oral hygiene? 1. Placing the client on the back with a small pillow under the head. 2. Keeping portable suctioning equipment at the bedside. 3. Opening the client's mouth with a padded tongue blade. 4. Cleaning the client's mouth and teeth with a toothbrush.

1. A helpless client should be positioned on the side, not on the back, with the head on a small pillow. A lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction the client if he aspirates. Suction equipment should be nearby. It is safe to use a padded tongue blade, and the client should receive oral care, including brushing with a toothbrush.

40. The nurse and licensed practical nurse (LPN) have been assigned to care for clients on a pediatric unit. Which nursing task should be assigned to the LPN? 1. Administer PO medications to a client diagnosed with gastroenteritis. 2. Take the routine vital signs for all the clients on the pediatric unit. 3. Transcribe the HCP's orders into the computer. 4. Assess the urinary output of a client diagnosed with nephrotic syndrome.

1. Administer PO medications to a client diagnosed with gastroenteritis.

1. You are caring for a patient with esophageal cancer. Which task could be delegated to a UAP? 1. Assisting the patient with oral hygiene 2. Observing the patient's response to feedings 3. Facilitating expression of grief or anxiety 4. Initiating daily weighings

1. Ans: 1 Oral hygiene is within the scope of duties of the UAP. It is the responsibility of the nurse to observe response to treatments and to help the patient deal with loss or anxiety. The UAP can be directed to weigh the patient but should not be expected to know when to initiate that measurement. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 168). Elsevier Health Sciences. Kindle Edition.

1. What is the priority nursing diagnosis for a client experiencing a migraine headache? 1. Acute Pain related to biologic and chemical factors 2. Anxiety related to change in or threat to health status 3. Hopelessness related to deteriorating physiologic condition 4. Risk for Injury related to side effects of medical therapy

1. Ans: 1 The priority for interdisciplinary care for the client experiencing a migraine headache is pain management. All of the other nursing diagnoses are accurate, but none of them is urgent like the issue of pain, which is often incapacitating. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 182). Elsevier Health Sciences. Kindle Edition.

1. An experienced LPN/ LVN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN/ LVN? (Select all that apply.) 1. Auscultating breath sounds 2. Administering medications via metered-dose inhaler (MDI) 3. Completing in-depth admission assessment 4. Checking oxygen saturation using pulse oximetry 5. Developing the nursing care plan 6. Evaluating the patient's technique for using MDIs

1. Ans: 1, 2, 4 The experienced LPN/ LVN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN/ LVN. Independently completing the admission assessment, developing the nursing care plan, and evaluating a patient's abilities require additional education and skills within the scope of practice of the professional RN. LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 175). Elsevier Health Sciences. Kindle Edition.

1. You are working in the emergency department (ED) when a client arrives reporting substernal and left arm discomfort that has been going on for about 3 hours. Which laboratory test will be most useful in determining whether you should anticipate implementing the acute coronary syndrome (ACS) standard protocol? 1. Creatine kinase MB level 2. Troponin I level 3. Myoglobin level 4. C-reactive protein level

1. Ans: 2 Cardiac troponin levels are elevated 3 hours after the onset of ACS (unstable angina or myocardial infarction [MI]) and are very specific to cardiac muscle injury or infarction. Although levels of creatine kinase MB and myoglobin also increase with MI, the increases occur later and/ or are not as specific to myocardial damage as troponin levels. Elevated C-reactive protein levels are a risk factor for coronary artery disease but are not useful in detecting acute injury or infarction. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (pp. 177-178). Elsevier Health Sciences. Kindle Edition.

1. When a client is being prepared for a colonoscopy procedure, which task is most suitable to delegate to the UAP? 1. Explaining the need for a clear liquid diet 1 to 3 days before the procedure 2. Reinforcing "nothing by mouth" status 8 hours before the procedure 3. Administering laxatives 1 to 3 days before the procedure 4. Administering an enema the night before the procedure

1. Ans: 2 The UAP can reinforce dietary and fluid restrictions after the RN has explained the information to the client. It is also possible that the UAP can administer the enema; however, special training is required, and policies may vary among institutions. Medication administration should be performed by licensed personnel. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 187). Elsevier Health Sciences. Kindle Edition.

1. The client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a UAP? 1. Administering IV fluids as prescribed by the physician 2. Providing straws and offering fluids between meals 3. Developing a plan for added fluid intake over 24 hours 4. Teaching family members to assist the client with fluid intake

1. Ans: 2 UAPs can reinforce additional fluid intake once it is part of the care plan. Administering IV fluids, developing plans, and teaching families require additional education and skills that are within the scope of practice of an RN. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (pp. 171-172). Elsevier Health Sciences. Kindle Edition.

1. You are assessing a long-term-care client with a history of benign prostatic hyperplasia (BPH). Which information will require the most immediate action? 1. The client states that he always has trouble starting his urinary stream. 2. The chart shows an elevated level of prostate-specific antigen. 3. The bladder is palpable above the symphysis pubis and the client is restless. 4. The client says he has not voided since having a glass of juice 4 hours ago.

1. Ans: 3 A palpable bladder and restlessness are indicators of urinary retention, which would require action (such as insertion of a catheter) to empty the bladder. The other data would be consistent with the client's diagnosis of BPH. More detailed assessment may be indicated, but no immediate action is required. Focus: Prioritization

1. You are caring for a client who has just had a squamous cell carcinoma removed from the face. Which activity can you delegate to an experienced LPN/ LVN? 1. Teaching the client about risk factors for squamous cell carcinoma 2. Showing the client how to care for the surgical site at home 3. Monitoring the surgical site for swelling, bleeding, or pain 4. Discussing the reasons for avoiding aspirin use for a week after surgery

1. Ans: 3 An LPN/ LVN who is experienced in working with postoperative clients will know how to monitor for pain, bleeding, or swelling and will notify the supervising RN. Client teaching requires more education and a broader scope of practice and is appropriate for RN staff members. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 193). Elsevier Health Sciences. Kindle Edition.

1. A client who has recently traveled to China comes to the emergency department (ED) with increasing shortness of breath and is strongly suspected of having severe acute respiratory syndrome (SARS). Which of these prescribed actions will you take first? 1. Infuse normal saline at 75 mL/ hr. 2. Obtain blood, urine, and sputum for cultures. 3. Place the client on airborne and contact precautions. 4. Give methylprednisolone (Solu-Medrol) 1 g IV.

1. Ans: 3 Current Centers for Disease Control and Prevention (CDC) guidelines indicate that rapid implementation of standard, contact, and airborne precautions are needed for any client suspected of having SARS in order to protect other clients and health care workers. If an airborne-agent isolation (negative-pressure) room is not available in the ED, droplet precautions should be initiated until the client can be moved to a negative-pressure room. The other actions should also be taken rapidly but are not as important as preventing transmission of the disease. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 173). Elsevier Health Sciences. Kindle Edition.

1. A few minutes after you have given an intradermal injection of an allergen to a patient who is undergoing skin testing for allergies, the patient reports feeling anxious, short of breath, and dizzy. Which action included in the emergency protocol should you take first? 1. Start oxygen at 4 L/ min using a nasal cannula. 2. Obtain IV access with a large-bore IV catheter. 3. Give epinephrine (Adrenalin) 0.3 mL intramuscularly. 4. Administer 3 mL of nebulized albuterol (Proventil) 0.083%.

1. Ans: 3 Epinephrine is the initial drug of choice for treatment of anaphylaxis. Giving epinephrine rapidly at the onset of an anaphylactic reaction may prevent or reverse cardiovascular collapse as well as airway narrowing caused by bronchospasm and inflammation. Oxygen use is also appropriate, but oxygen would be administered using a nonrebreather mask in order to achieve a fraction of inspired oxygen closer to 100%. Albuterol may also be administered to decrease airway narrowing but would not be the first therapy used for anaphylaxis. IV access will take longer to establish and should not be the first intervention. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 170). Elsevier Health Sciences. Kindle Edition.

1. A patient is admitted to the medical unit with possible Graves disease (hyperthyroidism). Which assessment finding supports this diagnosis? 1. Periorbital edema 2. Bradycardia 3. Exophthalmos 4. Hoarse voice

1. Ans: 3 Exophthalmos (abnormal protrusion of the eyes) is characteristic of patients with hyperthyroidism due to Graves disease. Periorbital edema, bradycardia, and hoarse voice are all characteristics of patients with hypothyroidism. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 191). Elsevier Health Sciences. Kindle Edition.

1. You are working in an ambulatory care clinic. A client calls to report redness of the sclera, itching of the eyes, and increased lacrimation for several hours. What should you direct the caller to do first? 1. " Please call your physician" (i.e., refuse to advise). 2. " Apply a cool compress to your eyes." 3. " If you are wearing contact lenses, remove them." 4. " Take an over-the-counter antihistamine." LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 48). Elsevier Health Sciences. Kindle Edition.

1. Ans: 3 If the client is wearing contact lenses, the lenses may be causing the symptoms, and removing them will prevent further eye irritation or damage. Policies on giving telephone advice vary among institutions, and knowledge of your facility policy is essential. The other options may be appropriate, but you should gather additional information before suggesting anything else. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 185). Elsevier Health Sciences. Kindle Edition.

1. In caring for a 3-year-old with pain, which assessment question would be the most useful? 1. " Can you point to the pain with one finger and tell me what that pain feels like inside of you?" 2. " If number 1 were a little pain and number 10 were a big pain, what number would your pain be?" 3. " The smiling face has 'no hurting'; the crying face has a 'really big hurting.' Which face is most like your hurting?" 4. " One chip is 'a little bit of hurt' and four chips are 'the most hurt.' How many chips would you take for your hurt?"

1. Ans: 3 Pain rating scales using faces (depicting smiling, neutral, frowning, crying, etc.) are appropriate for young children who may have difficulty describing pain or understanding the correlation of pain to numerical or verbal descriptors. The other tools require abstract reasoning abilities to make analogies and the use of advanced vocabulary. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 201). Elsevier Health Sciences. Kindle Edition.

1. A patient with a diagnosis of hypochondriasis has made multiple clinic visits and undergone diagnostic tests for "cancer," with no evidence of organic disease. Today he declares, "I have a brain tumor. I can feel it growing. My appointment is tomorrow, but I can't wait!" What is the most therapeutic response? 1. Present reality: "Sir, you have been seen many times in this clinic and had many diagnostic tests. The results have always been negative." 2. Encourage expression of feelings: "Let me spend some time with you. Tell me about what you are feeling and why you think you have a brain tumor." 3. Set boundaries: "Sir, I will take your vital signs, but then I am going to call your case manager so that you can discuss the scheduled appointment." 4. Respect the patient's wishes: "Sir, sit down and I will make sure that you see the physician right away. Don't worry; we will take care of you."

1. Ans: 3 The case manager has a relationship with the patient, knows the specific details of agreements made with the patient, and is the most capable of helping him to decrease anxiety and preoccupation with physical symptoms. In general, presenting reality does not have an impact on patients with hypochondriasis. Encouraging expression of feelings and giving in to the patient's wishes contribute to secondary gains of maintaining the sick role. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 207). Elsevier Health Sciences. Kindle Edition.

1. You are preparing to review a teaching plan for a patient with type 2 diabetes mellitus. To determine the patient's level of compliance with his prescribed diabetic regimen, which value would you be sure to review? 1. Fasting glucose level 2. Oral glucose tolerance test results 3. Glycosylated hemoglobin (HgbA1c) level 4. Fingerstick glucose findings for 24 hours

1. Ans: 3 The higher the blood glucose level is over time, the more glycosylated the hemoglobin becomes. The HgbA1c level is a good indicator of the average blood glucose level over the previous 120 days. Fasting glucose and oral glucose tolerance tests are important diagnostic tools. Fingerstick blood glucose monitoring provides information that allows adjustment of the patient's therapeutic regimen. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 189). Elsevier Health Sciences. Kindle Edition.

1. You are the charge nurse in an emergency department (ED) and must assign two staff members to cover the triage area. Which team is the most appropriate for this assignment? 1. An advanced practice nurse and an experienced LPN/ LVN 2. An experienced LPN/ LVN and an inexperienced RN 3. An experienced RN and an inexperienced RN 4. An experienced RN and an experienced UAP

1. Ans: 3 Triage requires at least one experienced RN. Pairing an experienced RN with an inexperienced RN provides opportunities for mentoring. Advanced practice nurses are qualified to perform triage; however, their services are usually required in other areas of the ED. An LPN/ LVN is not qualified to perform the initial client assessment or decision making. Pairing an experienced RN with an experienced UAP is the second best option, because the UAP can measure vital signs and assist in transporting. Focus: Assignment LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 204). Elsevier Health Sciences. Kindle Edition.

1. You are the charge nurse. A client with chronic pain reports to you that the nurses have not been responding to requests for pain medication. What is your initial action? 1. Check the medication administration records (MARs) for the past several days. 2. Ask the nurse educator to provide in-service training about pain management. 3. Perform a complete pain assessment on the client and take a pain history. 4. Have a conference with the nurses responsible for the care of this client.

1. Ans: 4 As charge nurse, you must assess the performance and attitude of the staff in relation to this client. After data are gathered from the nurses, additional information can be obtained from the records and the client as necessary. The educator may be of assistance if a knowledge deficit or need for performance improvement is the problem. Focus: Supervision, prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 3). Elsevier Health Sciences. Kindle Edition.

1. You are initiating a nursing care plan for a patient with osteoporosis. All of these nursing interventions apply to the nursing diagnosis Risk for Falls. Which intervention should you delegate to the UAP? 1. Identifying environmental factors that increase risk for falls 2. Monitoring gait, balance, and fatigue level with ambulation 3. Collaborating with the physical therapist (PT) to provide the patient with a walker 4. Assisting the patient with ambulation to the bathroom and in the halls

1. Ans: 4 Assisting with activities of daily living (ADLs) is within the scope of the UAP's practice. The other three interventions require additional educational preparation and are within the scope of practice of licensed nurses. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 186). Elsevier Health Sciences. Kindle Edition.

1. You are reviewing the complete blood count for a patient who has been admitted for knee arthroscopy. Which value is most important to report to the physician before surgery? 1. Hematocrit of 33% 2. Hemoglobin level of 10.9 g/ dL 3. Platelet count of 426,000/ mm3 4. White blood cell count of 16,000/ mm3

1. Ans: 4 Centers for Disease Control and Prevention (CDC) guidelines for the prevention of surgical site infections indicate that surgery should be postponed when there is evidence of a pre-existing infection such as an elevation in white blood cell count. The other values are slightly abnormal, but would not be likely to cause postoperative problems for knee arthroscopy. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 180). Elsevier Health Sciences. Kindle Edition.

1. You are providing nursing care for a 24-year-old female patient admitted to the unit with a diagnosis of cystitis. Which intervention should you delegate to the UAP? 1. Teaching the patient how to secure a clean-catch urine sample 2. Assessing the patient's urine for color, odor, and sediment 3. Reviewing the nursing care plan and add nursing interventions 4. Providing the patient with a clean-catch urine sample container

1. Ans: 4 Providing the equipment that the patient needs to collect the urine sample is within the scope of practice of a UAP. Teaching, planning, and assessing all require additional education and skill, which is appropriate to the scope of practice of professional nurses. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 195). Elsevier Health Sciences. Kindle Edition.

1. A 30-year-old woman with type 1 diabetes mellitus comes to the clinic for preconception care. What is the priority education for her at this time? 1. Her insulin requirements will likely increase during the second and third trimesters of pregnancy. 2. Infants of diabetic mothers can be macrosomic, which can result in more difficult delivery and higher likelihood of cesarean section. 3. Breast feeding is highly recommended, and insulin use is not a contraindication. 4. Achievement of optimal glycemic control at this time is of utmost importance in preventing congenital anomalies.

1. Ans: 4 The incidence of congenital anomalies is three times higher in the offspring of diabetic women. Good glycemic control during preconception and early pregnancy significantly reduces this risk and would be the highest priority message to this patient at this point. The other responses are correct but are not of greatest importance at this time. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 199). Elsevier Health Sciences. Kindle Edition.

Secondary prevention of stroke (3)

1. Anticoagulants 2. Antiplatelets 3. Surgery

27. The wound care nurse in a long-term care facility asks the unlicensed assistive personnel (UAP) for assistance. Which task should not be delegated to the UAP? 1. Apply the wound debriding paste to the wound. 2. Keep the resident's heels off the surface of the bed. 3. Turn the resident at least every 2 hours. 4. Encourage the resident to drink a high-protein shake.

1. Apply the wound debriding paste to the wound.

117. The nurse manager of the maternal-child department is developing the budget for the next fiscal year. Which statement best explains the first step of the budgetary process? 1. Ask the staff for input about needed equipment. 2. Assess any new department project for costs. 3. Review the department's current year budget. 4. Explain the new budget requirements to the staff.

1. Ask the staff for input about needed equipment.

5. The nurse hung the wrong intravenous antibiotic for the postoperative client. Which intervention should the nurse implement first? 1. Assess the client for any adverse reactions. 2. Complete the incident or adverse occurrence report. 3. Administer the correct intravenous antibiotic medication. 4. Notify the client's healthcare provider.

1. Assess the client for any adverse reactions.

57. The nurse is preparing to administer the client's first intravenous antibiotic. Prioritize the nurse's actions from first (1) to last (5). 1. Check the healthcare provider's order in the chart. 2. Determine if the client has any known allergies. 3. Hang the secondary IV piggyback higher than the primary IV. 4. Set the intravenous pump at the correct rate. 5. Determine if the antibiotic is compatible with the primary IV.

1. Check the healthcare provider's order in the chart. 5. Determine if the antibiotic is compatible with the primary IV. 2. Determine if the client has any known allergies. 3. Hang the secondary IV piggyback higher than the primary IV. 4. Set the intravenous pump at the correct rate.

1. The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? a. A client scheduled for a chest x-ray b. A client requiring daily dressing changes c. A postoperative client preparing for discharge d. A client receiving nasal oxygen who had difficulty breathing during the previous shift.

1. D- Airway is always the highest priority, and the nurse would attend to the client who has been experiencing an airway problem first. The clients described in option 1, 2, and 3 have needs that would be identified as intermediate priorities.

29. The clinic nurse is caring for a client diagnosed with osteoarthritis. The client tells the nurse, "I am having problems getting in and out of my bathtub." Which intervention should the clinic nurse implement first? 1. Determine whether the client has grab bars in the bathroom. 2. Encourage the client to take a shower instead of a bath. 3. Initiate a referral to a physical therapist for the client. 4. Discuss whether the client takes nonsteroidal anti-inflammatory drugs (NSAIDs).

1. Determine whether the client has grab bars in the bathroom.

62. The charge nurse notices that one of the staff takes frequent breaks, has unpredictable mood swings, and often volunteers to care for clients who require narcotics. Which priority action should the charge nurse implement regarding this employee? 1. Discuss the nurse's actions with the unit manager. 2. Confront the nurse about the behavior. 3. Do not allow the nurse to take breaks alone. 4. Prepare an occurrence report on the employee.

1. Discuss the nurse's actions with the unit manager.

115. The 36-year-old client in the women's health clinic is being prescribed birth control pills. Which information is important for the nurse to teach the client? Select all that apply. 1. Do not smoke while taking birth control pills. 2. Take one pill at the same time every day. 3. If a birth control pill is missed, do not double up. 4. Stop taking the pill if breakthrough bleeding occurs. 5. There can be interactions with other medications.

1. Do not smoke while taking birth control pills. 2. Take one pill at the same time every day. 5. There can be interactions with other medications.

102. The charge nurse in an extended care facility notes an elderly male resident holding hands with an elderly female resident. Which intervention should the charge nurse implement? 1. Do nothing, because this is a natural human need. 2. Notify the family of the residents about the situation. 3. Separate the residents for all activities. 4. Call a care plan meeting with other staff members.

1. Do nothing, because this is a natural human need.

61. The nurse has accepted the position of clinical manager for a medical-surgical unit. Which role is an important aspect of this management position? 1. Evaluate the job performance of the staff. 2. Be the sole decision maker for the unit. 3. Take responsibility for the staff nurse's actions. 4. Attend the medical staff meetings.

1. Evaluate the job performance of the staff.

14. The home health (HH) nurse is discussing the care of a client with the female HH aide. Which task should the HH nurse delegate to the HH aide? 1. Instruct her to assist the client with a shower. 2. Ask her to prepare the breakfast meal for the client. 3. Request her to take the client to an HCP's appointment. 4. Tell her to show the client how to use a glucometer.

1. Instruct her to assist the client with a shower.

46. The unconscious 4-year-old child with bruises covering the torso in varying stages of healing is brought to the emergency department by paramedics. The nurse notes small burn marks on the child's genitalia. Which actions should the nurse implement? Select all that apply. 1. Notify Child Protective Services. 2. Ask the parent how the child was injured. 3. Perform a thorough examination for more injuries. 4. Tell the parents that the police have been called. 5. Prepare the child for skull x-rays and a CT scan.

1. Notify Child Protective Services. 3. Perform a thorough examination for more injuries. 5. Prepare the child for skull x-rays and a CT scan.

11. The clinic manager is discussing osteoporosis with the clinic staff. Which activity is an example of a secondary nursing intervention when discussing osteoporosis? 1. Obtain a bone density evaluation test on a female client older than 50. 2. Perform a spinal screening examination on all female clients. 3. Encourage the client to walk 30 minutes daily on a hard surface. 4. Discuss risk factors for developing osteoporosis.

1. Obtain a bone density evaluation test on a female client older than 50.

51. The nurse is preparing to perform a sterile dressing change on a client with full-thickness burns on the right leg. Which intervention should the nurse implement first? 1. Pre-medicate the client with a narcotic analgesic. 2. Prepare the equipment and bandages at the bedside. 3. Remove the old dressing with non-sterile gloves. 4. Place a sterile glove on the dominant hand.

1. Pre-medicate the client with a narcotic analgesic.

95. The charge nurse overhears two unlicensed assistive personnel (UAPs) discussing a client in the hallway. Which action should the charge nurse implement first? 1. Remind the UAPs that clients should not be discussed in a public area. 2. Tell the unit manager that the UAPs might have been overheard. 3. Have the UAPs review policies on client confidentiality and HIPAA. 4. Find some nursing tasks the UAPs can be performing at this time.

1. Remind the UAPs that clients should not be discussed in a public area.

81. The client is confused and pulling at the IV and indwelling catheter. Which order from the HCP should the nurse clarify concerning restraining the client? 1. Restrain the client's wrists, as needed. 2. Offer the client fluids every 2 hours. 3. Apply a hand mitt to the arm opposite the IV site for 12 hours. 4. Check circulation of the restrained limb every 2 hours.

1. Restrain the client's wrists, as needed.

39. The unlicensed assistive personnel (UAP) accidentally pulled the client's chest tube out while assisting the client to the bedside commode (BSC). Which intervention should the nurse implement first? 1. Securely tape petroleum gauze over the insertion site. 2. Instruct the UAP how to move a client with a chest tube. 3. Assess the client's respirations and lung sounds. 4. Obtain a chest tube and a chest tube insertion tray.

1. Securely tape petroleum gauze over the insertion site.

10. The nurse is assigned to a quality improvement committee to decide on a quality improvement project for the unit. Which issue should the nurse discuss at the committee meetings? 1. Systems that make it difficult for the nurses to do their job. 2. How unhappy the nurses are with their current pay scale. 3. Collective bargaining activity at a nearby hospital. 4. The number of medication errors committed by an individual nurse.

1. Systems that make it difficult for the nurses to do their job.

114. The psychiatric nurse and mental health worker (MHW) on a psychiatric unit are caring for a group of clients. Which nursing task should the nurse delegate to the MHW? 1. Take the school-aged children to the on-campus classroom. 2. Lead a group therapy session on behavior control. 3. Explain the purpose of recreation therapy to the client. 4. Give a bipolar client a bed bath and shampoo the hair.

1. Take the school-aged children to the on-campus classroom.

88. Which situation should the charge nurse in the critical care unit address first after receiving the shift report? 1. Talk to the family member who is irate over his loved one's nursing care. 2. Complete the 90-day probationary evaluation for a new ICU graduate intern. 3. Call the laboratory concerning the type and crossmatch for a client who needs blood. 4. Arrange for a client to be transferred to the telemetry step-down unit.

1. Talk to the family member who is irate over his loved one's nursing care.

63. A male HCP frequently tells jokes with sexual overtones at the nursing station. Which action should the female charge nurse implement? 1. Tell the HCP that the jokes are inappropriate and offensive. 2. Report the behavior to the medical staff committee. 3. Discuss the problem with the chief nursing of officer 4. Call a Code Purple and have the nurses surround the HCP.

1. Tell the HCP that the jokes are inappropriate and offensive.

50. The home health nurse is planning his rounds for the day. Which client should the nurse plan to see first? 1. The 56-year-old client diagnosed with multiple sclerosis who is complaining of a cough. 2. The 78-year-old client diagnosed with congestive heart failure (CHF) who reports losing 3 pounds. 3. The 42-year-old client diagnosed with an L-5 spinal cord injury who has developed a Stage 4 pressure ulcer. 4. The 80-year-old client diagnosed with a cerebrovascular accident (CVA) who has right-sided paralysis.

1. The 56-year-old client diagnosed with multiple sclerosis who is complaining of a cough.

48. The nurse has received the shift report. Which client should the nurse assess first? 1. The client diagnosed with a deep vein thrombosis (DVT) who complains of a feeling of doom. 2. The client diagnosed with gallbladder ulcer disease who refuses to eat the food served. 3. The client diagnosed with pancreatitis who wants the nasogastric tube removed. 4. The client diagnosed with osteoarthritis who is complaining of stiff joints.

1. The client diagnosed with a deep vein thrombosis (DVT) who complains of a feeling of doom.

22. The nurse on a medical unit has just received the evening shift report. Which client should the nurse assess first? 1. The client diagnosed with a deep vein thrombosis (DVT) who has a heparin drip infusion and a PTT of 92. 2. The client diagnosed with pneumonia who has an oral temperature of 100.2°F. 3. The client diagnosed with cystitis who complains of burning on urination. 4. The client diagnosed with pancreatitis who complains of pain that is an 8.

1. The client diagnosed with a deep vein thrombosis (DVT) who has a heparin drip infusion and a PTT of 92.

21. The charge nurse of a critical care unit is making assignments for the night shift. Which client should be assigned to the graduate nurse who has just completed an internship? 1. The client diagnosed with a head injury resulting from a motor vehicle accident (MVA) whose Glasgow Coma Scale score is 13. 2. The client diagnosed with inflammatory bowel disease (IBD) who has severe diarrhea and has a serum K+ level of 3.2 mEq/L. 3. The client diagnosed with Addison's disease who is lethargic and has a BP of 80/45, P of 124, and R rate of 28. 4. The client diagnosed with hyperthyroidism who has undergone a thyroidectomy and has a positive Trousseau's sign.

1. The client diagnosed with a head injury resulting from a motor vehicle accident (MVA) whose Glasgow Coma Scale score is 13.

20. The charge nurse is making assignments in the day surgery center. Which client should be assigned to the most experienced nurse? 1. The client who had surgery for an inguinal hernia and who is being prepared for discharge. 2. The client who is in the preoperative area and who is scheduled for laparoscopic cholecystectomy. 3. The client who has completed scheduled chemotherapy treatment and who is receiving two units of blood. 4. The client who has end-stage renal disease and who has had an arteriovenous fistula created.

1. The client who had surgery for an inguinal hernia and who is being prepared for discharge.

8. Which situation would prompt the healthcare team to utilize the client's advance directive when needing to make decisions for the client? 1. The client with a head injury who is exhibiting decerebrate posturing. 2. The client with a C-6 spinal cord injury (SCI) who is on a ventilator. 3. The client in chronic renal disease who is being placed on dialysis. 4. The client diagnosed with terminal cancer who is mentally retarded.

1. The client with a head injury who is exhibiting decerebrate posturing.

96. The family member of a client in a long-term care facility is unhappy with the care being provided for the loved one. Which person would be most appropriate to investigate the complaint and report the findings during a client care conference? 1. The ombudsperson for the facility. 2. The social worker for the facility. 3. The family member who is unhappy. 4. The director of nurses.

1. The ombudsperson for the facility.

108. Which statement best describes the role of the parish nurse? 1. The parish nurse practices holistic healthcare within a faith community. 2. The parish nurse cares for clients in a religious-based hospital. 3. The parish nurse practices nursing in a parish clinic. 4. The parish nurse is a licensed practical nurse (LPN) who cares for clients in the home.

1. The parish nurse practices holistic healthcare within a faith community.

In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because? 1. The rehabilitation plan will be guided by it. 2. Functional status before the stroke will help predict outcomes. 3. It will help the client recognize his physical limitations. 4. The client can be expected to regain much of his functioning.

1. The primary reason for the nursing assessment of a client's functional status before and after a stroke is to guide the plan. The assessment does not help to predict how far the rehabilitation team can help the client to recover from the residual effects of the stroke, only what plans can help a client who has moved from one functional level to another. The nursing assessment of the client's functional status is not a motivating factor.

First ACTION? 1. place client on droplet precautions 2. Monitor for increased ICP 3. Prepare the client for a lumbar puncture 4. Set up seizure precautions

1. symptoms of meninitis; haemophilus influenzae and Neisseria meningitidis = droplet precautions until confirmed or eliminated 4. spread of infection first then protect client 2. important to assess but not priority 3. culture, not priority

10. A nurse is assessing a 39 year old Caucasian female client. The client has a blood pressure (BP) of 152/92 mm Hg at rest, a total cholesterol of level of 190 mg/dL, and a fasting blood glucose level of 110 mg/dL. The nurse would place priority on which risk factor for coronary heart disease (CHD) in this client? a) age b) hypertension c) hyperlipidemia d) glucose intolerance

10) B - Hypertension, cigarette smoking, and hyperlipidemia are major risk factors for CHD. Glucose intolerance, obesity, and response to stress are also contributing factors. An age of more than 40 years is a nonmodifiable risk factor. A cholesterol level of 190 mg/dL and a blood glucose level of 110 mg/dL are within the normal range. The nurse places priority on major risk factors that need modification.

10. The nurse should use which guideline(s) to plan delegation and assignment-making activities? Select all that apply. a. Ensuring client safety b. Requests from the staff c. The clustering of the rooms on the unit d. The number of anticipated client discharges e. Client needs and workers' needs and abilities

10. A, E- There are guidelines that the nurse should use when delegating and planning assignments. These include the following: ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delegated and to whom; match the task to the delegate on the basis of the nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate and complete; validate the delegate's understanding of the directions; communicate a feeling of confidence to the delegate, and provide feedback promptly after the task is performed; and maintain continuity of care as much as possible when assigning client care. Staff requests, convenience as in clustering client rooms, and anticipated changes in unit census are not specific guidelines to use when delegating and planning assignments.

11. A labor room nurse is caring for a client in labor with a known history of sickle cell anemia. Which priority action would the nurse implement to assist in preventing a sickle cell crisis from occurring during labor? a) continually reassure and coach the client b) administer the prescribed oxygen throughout labor c) maintain strict asepsis throughout the labor process d) increase the intravenous (IV) fluids if the client complains of feeling thirsty

11) B - During the labor process the client is at high risk for being unable to meet the oxygen demands of labor and is at high risk for sickle cell crisis. An intervention to prevent sickle cell crisis during labor includes administering oxygen. Options A and C are appropriate interventions during labor but are not specific to sickle cell anemia. Intravenous fluids may need to be increased, but a physician's order is needed to do so.

12. A nurse is caring for a client with preeclampsia who suddenly progresses to an eclamptic state. The initial nursing action would be to: a) check the fetal heart rate b) check the maternal blood pressure c) maintain an open airway d) administer oxygen to the mother by face mask

12) C - The initial nursing action when a client progresses to an eclamptic state (has a seizure) is to maintain an open airway. Options A, B, and D are procedures that may be implemented but option 3 identifies the initial action.

13. A nurse is caring for a client who has wrist restraints applied. Which nursing intervention would receive highest priority regarding the wrist restraints? a) providing range-of-motion exercises to the wrists b) removing the restraints periodically per agency guidelines c) applying lotion to the skin under the restraints d) assessing color, sensation, and pulses distal to the restraint

13) D - Assessing color, sensation, and pulses distal to the restraint determines the presence of neurovascular compromise that is associated with the use of restraints. All of the other interventions should be implemented, but option 4 is the priority.

14. A registered nurse (RN) has delegated care of a newly postoperative client to a licensed practical nurse (LPN). The LPN notifies the RN that the client's blood pressure and respirations are elevated from the baseline readings and that the client is complaining of pain and dyspnea. The RN takes which action next? a) the RN need not to carry out further assessment because the LPN is very experienced and trustworthy b) the RN requests that the LPN offer the client a opioid analgesic, which has ordered postoperatively c) the RN places a call to the attending surgeon and reports that the client is having pain and dyspneic d) the RN assesses the client, checks the client's surgical notes, and gathers addition data before calling the surgeon

14) D - The RN must not depend exclusively on the judgment of an LPN because the RN is responsible for supervising those to whom client care has been delegated. The client has recently had surgery, and there is the potential for complications, which may be signaled by alterations in vital signs and respiratory status. An analgesic may be needed, but in order to make that determination, the RN must have more information. A call to the surgeon may be warranted, but the RN has insufficient data at this time. In order to provide the client with the degree of care required, the nurse must assess the client, gather additional information, and analyze that information before notifying the surgeon.

15. A primigravida is admitted to the labor unit. During the assessment of the client, her membranes rupture spontaneously. The priority nursing action is which of the following? a) monitor the contraction pattern b) assess the fetal heart rate c) note the amount, color, and odor of the amniotic fluid d) check maternal vital signs

15) B - When the membranes rupture in the birth setting, the nurse immediately checks the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Options A, C, and D may be a component of care but are not the priority action.

16. A nurse is assigned to provide care to a client in labor and will care for the client throughout labor and into the postpartum period. The nurse assists in developing a plan of care and determines that the priority assessment in the fourth stage of labor is which of the following? a) assessing the uterine fundus and lochia b) checking the mother's temperature c) encouraging food and fluid intake d) providing privacy for the parents and their newborn infant

16) A - The fourth stage of labor is the stage of physical recovery for the mother and newborn infant. It lasts from the delivery of the placenta through the first 1 to 4 hours after birth. A potential complication following delivery is hemorrhage. The most significant source of bleeding is the site where the placenta is implanted. It is critical that the uterus remain contracted and that vaginal blood flow is monitored every 15 minutes for the first 1 to 2 hours. Although options B, C, and D are also interventions during this stage, they are not the priority.

17. A client is brought to the emergency department by the police after having lacerated both wrists in a suicide attempt. The nurse should take which initial action? a) examine and treat the wound sites b) obtain and record a detailed history c) encourage and assist the client to ventilate feelings d) administer an anti-anxiety agent

17) A - The client has a physiological injury, and the nurse would initially examine and treat the wound sites because of bleeding. Although options B,C, and D may be appropriate at some point, the initial action would need to be to treat the wounds.

18. A nurse has just administered a dose of hydralazine hydrochloride (Apresoline) intravenously to a client. Based on the action of this medication, the nurse would initially assess the client's: a) cardiac rhythm b) oxygen saturation c) blood pressure d) respiratory rate

18) C Hydralazine is a powerful vasodilator that exerts it action on the smooth muscle walls of arterioles. After an intravenous dose is administered, the nurse should check the client's blood pressure every 5 minutes until stable and every 15 minutes thereafter (or per agency procedure). Although options A, B, and D are a component of the assessment, based on the action of the medication the nurse would initially check the client's blood pressure

19. A client is 3 hours postoperative following a right upper lobectomy. The collection chamber of the closed pleural drainage system contains 400 ml of bloody drainage. The client's vital signs are blood pressure 100/50 mmHg, heart rate of 100 beats per minute, and respiratory rate 26 breaths per minute. There is intermittent bubbling in the water seal chamber. One hour following the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant and the client appears dyspneic. The nurse should first check: a) lung sounds b) vital signs c) the chest tube connections d) the amount of drainage

19) C - Constant bubbling in the water seal chamber indicates an air leak. This is most likely related to an air leak caused by a loose connection. Other causes might be a tear or incision in the pulmonary pleura, which requires physician intervention. Although the items in options A, B, and D need to be assessed, they should be performed after initial attempts to locate and correct the air leak.

Which finding would alert the nurse that the client has experienced a transient ischemic attack (TIA)? 1.Sudden severe pain over the left eye 2.Tingling at the corner of the mouth with aphasia 3.Complete paralysis of the right arm and leg 4.Loss of sensation and reflexes in both legs

2. A nurse is scheduling a client for diagnostic studies of gastrointestinal (GI) system. Which of the following studies, if ordered, should the nurse schedule last? a) ultrasound b) colonoscopy c) barium enema d) computed tomography

2) C - When barium is instilled into the lower GI tract, it may take up to 72 hours to clear the GI tract. The presence of barium could cause interference with obtaining clear visualization and accurate results of the other tests listed, if performed before the client has fully excreted the barium. For this reason, diagnostic studies that involve barium contrast are scheduled at the conclusion of other medical imaging studies.

The nurse is teaching a client about taking prophylactic warfarin sodium (Coumadin). Which statement indicates that the client understands how to take the drug? Select all that apply. 1. "The drug's action peaks in 2 hours." 2. "Maximum dosage is not achieved until 3 to 4 days after starting the medication." 3. "Effects of the drug continue for 4 to 5 days after discontinuing the medication." 4. "Protamine sulfate is the antidote for warfarin." 5. "I should have my blood levels tested periodically."

2, 3, 5. The maximum dosage of warfarin sodium (Coumadin) is not achieved until 3 to 4 days after starting the medication, and the effects of the drug continue for 4 to 5 days after discontinuing the medication. The client should have his blood levels tested periodically to make sure that the desired level is maintained. Warfarin has a peak action of 9 hours. Vitamin K is the antidote for warfarin; protamine sulfate is the antidote for heparin.

55. The visitor on a medical unit is shouting and making threats about harming the staff because of perceived poor care his loved one has received. Which statement is the nurse's best initial response? 1. "If you don't stop shouting, I will have to call security." 2. "I hear that you are frustrated. Can we discuss the issues calmly?" 3. "Sir, you are disrupting the unit. Calm down or leave the hospital." 4. "This type of behavior is uncalled for and will not resolve anything."

2. "I hear that you are frustrated. Can we discuss the issues calmly?"

44. The nurse is taking a history on a client in a women's clinic when the client tells the nurse, "I have been trying to get pregnant for 3 years." Which question is the nurse's best response? 1. "How many attempts have you made to get pregnant?" 2. "What have you tried to help you get pregnant?" 3. "Does your insurance cover infertility treatments?" 4. "Have you considered adoption as an option?"

2. "What have you tried to help you get pregnant?"

. The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies is not appropriate? 1. Maintaining an upright position. 2. Restricting the diet to liquids until swallowing improves. 3. Introducing foods on the unaffected side of the mouth. 4. Keeping distractions to a minimum.

2. A client with dysphagia (difficulty swallowing) commonly has the most difficulty ingesting thin liquids, which are easily aspirated. Liquids should be thickened to avoid aspiration. Maintaining an upright position while eating is appropriate because it minimizes the risk of aspiration. Introducing foods on the unaffected side allows the client to have better control over the food bolus. The client should concentrate on chewing and swallowing; therefore, distractions should be avoided.

2. You are caring for a newly admitted client with increasing dyspnea, hypoxia, and dehydration who has possible avian influenza (" bird flu"). Which of these prescribed actions will you implement first? 1. Start oxygen using a nonrebreather mask. 2. Infuse 5% dextrose in water at 100 mL/ hr. 3. Administer first dose of oseltamivir (Tamiflu). 4. Obtain blood and sputum specimens for testing.

2. Ans: 1 Because the respiratory manifestations associated with avian influenza are potentially life-threatening, the nurse's initial action should be to start oxygen therapy. The other interventions should be implemented after addressing the client's respiratory problems. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 173). Elsevier Health Sciences. Kindle Edition.

2. The client also has the nursing diagnosis Decreased Cardiac Output related to decreased plasma volume. Which assessment finding supports this nursing diagnosis? 1. Flattened neck veins when the client is in the supine position 2. Full and bounding pedal and post-tibial pulses 3. Pitting edema located in the feet, ankles, and calves 4. Shallow respirations with crackles on auscultation

2. Ans: 1 Normally, neck veins are distended when the client is in the supine position. These veins flatten as the client moves to a sitting position. The other three responses are characteristic of the nursing diagnosis of Excess Fluid Volume. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 172). Elsevier Health Sciences. Kindle Edition.

2. As the nurse manager in a public health department, you are implementing a plan to reduce the incidence of infection with human immunodeficiency virus (HIV) in the community. Which nursing action will you delegate to health assistants working for the agency? 1. Supplying injection drug users with sterile injection equipment such as needles and syringes 2. Interviewing patients about behaviors that indicate a need for annual HIV testing 3. Teaching high-risk community members about the use of condoms in preventing HIV infection 4. Assessing the community to determine which population groups to target for education LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 18). Elsevier Health Sciences. Kindle Edition.

2. Ans: 1 Supplying sterile injection supplies to patients who are at risk for HIV infection can be done by staff members with health assistant education. Assessing for high-risk behaviors, education, and community assessment are RN-level skills. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 171). Elsevier Health Sciences. Kindle Edition.

2. Which task could be appropriately assigned to the UAP working with you at the obstetric clinic? 1. Checking the blood pressure of a patient who is 36 weeks pregnant and reports a headache 2. Removing the adhesive skin closure strips of a patient who had a cesarean section 2 weeks ago 3. Giving community resource information and emergency numbers to a prenatal patient whom you suspect is experiencing domestic violence 4. Dispensing a breast pump with instruction to a lactating patient having trouble with milk supply 4 weeks postpartum

2. Ans: 1 The UAP can check the blood pressure of this patient and report it to the RN. The RN would include this information in her full assessment of the patient, who may be showing signs of preeclampsia. The other tasks listed require nursing assessment, analysis, and planning, and should be performed by the RN. Provision of accurate and supportive education about breastfeeding and breast pumping supports the Perinatal Core Measure of increasing the percentage of women who exclusively breast-feed. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 199). Elsevier Health Sciences. Kindle Edition.

2. Which change in vital signs would you instruct the UAP to report immediately for a patient with hyperthyroidism? 1. Rapid heart rate 2. Decreased systolic blood pressure 3. Increased respiratory rate 4. Decreased oral temperature

2. Ans: 1 The cardiac problems associated with hyperthyroidism include tachycardia, increased systolic blood pressure, and decreased diastolic blood pressure. Patients with hyperthyroidism also may have increased body temperature related to increased metabolic rate. Respiratory changes are usually not symptomatic of this condition. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 191). Elsevier Health Sciences. Kindle Edition.

2. You are creating a teaching plan for a client with newly-diagnosed migraine headaches. Which key items will you include in the teaching plan? (Select all that apply.) 1. Foods that contain tyramine, such as alcohol and aged cheese, should be avoided. 2. Drugs such as nitroglycerin (Nitrostat) and nifedipine (Procardia) should be avoided. 3. Abortive therapy is aimed at eliminating the pain during the aura. 4. A potential side effect of medications is rebound headache. 5. Complementary therapies such as biofeedback and relaxation may be helpful. 6. Estrogen therapy should be continued as prescribed by your physician.

2. Ans: 1, 2, 3, 4, 5 Medications such as estrogen supplements may actually trigger a migraine headache attack. All of the other statements are accurate. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 182). Elsevier Health Sciences. Kindle Edition.

2. You are preparing to teach a patient with a new diagnosis of osteoporosis about strategies to prevent falls. Which teaching points will you be sure to include? (Select all that apply.) 1. Wear a hip protector when ambulating. 2. Remove throw rugs and other obstacles at home. 3. Exercise to help build your strength. 4. Expect a few bumps and bruises when you go home. 5. Rest when you are tired.

2. Ans: 1, 2, 3, 5 The purpose of the teaching is to help the patient prevent falls. The hip protector can prevent hip fractures if the patient falls. Throw rugs and obstacles in the home increase the risk of falls. Patients who are tired are also more likely to fall. Exercise helps to strengthen muscles LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 186). Elsevier Health Sciences. Kindle Edition.

2. You are evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/ min by nasal cannula. Which finding concerns you immediately? 1. Fine bibasilar crackles 2. Respiratory rate of 8 breaths/ min 3. The patient sitting up and leaning over the nightstand 4. A large barrel chest

2. Ans: 2 For patients with chronic emphysema, the stimulus to breathe is a low serum oxygen level (the normal stimulus is a high carbon dioxide level). This patient's oxygen flow is too high and is causing a high serum oxygen level, which results in a decreased respiratory rate. If you do not intervene, the patient is at risk for respiratory arrest. Crackles, barrel chest, and assumption of a sitting position leaning over the nightstand are common in patients with chronic emphysema. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 175). Elsevier Health Sciences. Kindle Edition.

2. Which pediatric pain patient should be assigned to a newly-graduated RN? 1. Adolescent who has sickle cell disease and was recently weaned from morphine delivered via a patient-controlled analgesia device to an oral analgesic; he has been continually asking for an increased dose 2. Child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures 3. Child who is receiving palliative end-of-life care; the child is receiving narcotics around the clock to relieve suffering, but there is a progressive decrease in alertness and responsiveness 4. Child who has chronic pain and whose medication and nonpharmacologic regimen has recently been changed; the mother is anxious to see if the new regimen is successful

2. Ans: 2 The set of circumstances is least complicated for the child with the fracture, and this would be the best patient for a new and relatively inexperienced nurse. The child is likely to have a good response to pain medication, and with gentle encouragement and pain management the anxiety will resolve. The other three children have more complex social and psychological issues related to pain management. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 201). Elsevier Health Sciences. Kindle Edition.

2. You are working in the triage area of an ED, and the following four clients approach the triage desk at the same time. List the order in which you will assess these clients. 1. Ambulatory, dazed 25-year-old man with a bandaged head wound 2. Irritable infant with a fever, petechiae, and nuchal rigidity 3. 35-year-old jogger with a twisted ankle who has a pedal pulse and no deformity 4. 50-year-old woman with moderate abdominal pain and occasional vomiting _____, _____, _____, _____

2. Ans: 2, 1, 4, 3 An irritable infant with fever and petechiae should be further assessed for other signs of meningitis. The client with the head wound needs additional history taking and assessment for intracranial pressure. The client with moderate abdominal pain is in discomfort, but her condition is not unstable at this point. For the ankle injury, medical evaluation could be delayed up to 24 to 48 hours if necessary, but the client should receive the appropriate first aid. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 204). Elsevier Health Sciences. Kindle Edition.

2. Family members are encouraging your client to "tough out the pain" rather than risk drug addiction to narcotics. The client is stoically abiding. You recognize that the sociocultural dimension of pain is the current priority for the client. Which question will you ask? 1. " Where is the pain located, and does it radiate to other parts of your body?" 2. " How would you describe the pain, and how is it affecting you?" 3. " What do you believe about pain medication and drug addiction?" 4. " How is the pain affecting your activity level and your ability to function?" 5. " What information do you need about pain, healing, and addiction?"

2. Ans: 3 Beliefs, attitudes, and familial influence are part of the sociocultural dimension of pain. Location and radiation of pain address the sensory dimension. Describing pain and its effects addresses the affective dimension. Activity level and function address the behavioral dimension. Asking about knowledge addresses the cognitive dimension. Focus: Prioritization 3. LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 3). Elsevier Health Sciences. Kindle Edition.

2. At a community health clinic, you are teaching a community group about the prevention of accidental eye injuries. What is the most important thing to stress? 1. Workplace policies for handling chemicals should be followed. 2. Children and parents should be cautious about aggressive play. 3. Protective eyewear should be worn during sports or hazardous work. 4. Emergency eyewash stations should be established in the workplace.

2. Ans: 3 Most accidental eye injuries (90%) could be prevented by wearing protective eyewear for sports and hazardous work. Other options should be considered in the overall prevention of injuries, but these have less impact. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 185). Elsevier Health Sciences. Kindle Edition.

2. You are providing orientation for a new RN who is preparing to administer packed red blood cells (PRBCs) to a patient who had blood loss during surgery. Which action by the new RN requires that you intervene immediately? 1. Waiting 20 minutes after obtaining the PRBCs before starting the infusion 2. Starting an IV line for the transfusion using a 22-gauge catheter 3. Priming the transfusion set using 5% dextrose in lactated Ringer's solution 4. Telling the patient that the PRBCs may cause a serious transfusion reaction

2. Ans: 3 Normal saline, an isotonic solution, should be used when priming the IV line to avoid causing hemolysis of red blood cells (RBCs). Ideally, blood products should be infused as soon as possible after they are obtained; however, a 20-minute delay would not be unsafe. Large-bore IV catheters are preferable for blood administration; if a smaller catheter must be used, normal saline may be used to dilute the RBCs. Although the new RN should avoid increasing patient anxiety by indicating that a serious transfusion reaction may occur, this action is not as high a concern as using an inappropriate fluid for priming the IV tubing. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 180). Elsevier Health Sciences. Kindle Edition.

2. Which laboratory result is of most concern to you for an adult patient with cystitis? 1. Serum white blood cell (WBC) count of 9000/ mm3 2. Urinalysis results showing 1 or 2 WBCs present 3. Urine bacteria count of 100,000 colonies per milliliter 4. Serum hematocrit of 36%

2. Ans: 3 The presence of 100,000 bacterial colonies per milliliter of urine or the presence of many white blood cells (WBCs) and red blood cells (RBCs) indicates a urinary tract infection. The WBC count is within normal limits and the hematocrit is a little low, which may need follow-up. Neither of these results indicates infection. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 195). Elsevier Health Sciences. Kindle Edition.

2. You would be most concerned about an order for a total parenteral nutrition (TPN) fat emulsion for a client with which condition? 1. Gastrointestinal (GI) obstruction 2. Severe anorexia nervosa 3. Chronic diarrhea and vomiting 4. Fractured femur

2. Ans: 4 A client with a fractured femur is at risk for fat embolism, so a fat emulsion should be used with caution. Vomiting may be a problem if the emulsion is infused too rapidly. TPN is commonly used in clients with GI obstruction, severe anorexia nervosa, and chronic diarrhea or vomiting. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 187). Elsevier Health Sciences. Kindle Edition.

2. You are monitoring a 53-year-old client who is undergoing a treadmill stress test. Which client finding will require the most immediate action? 1. Blood pressure of 152/ 88 mm Hg 2. Heart rate of 134 beats/ min 3. Oxygen saturation of 91% 4. Chest pain level of 3 (on a scale of 10)

2. Ans: 4 Chest pain in a client undergoing a stress test indicates myocardial ischemia and is an indication to stop the testing to avoid ongoing ischemia, injury, or infarction. Moderate elevations in blood pressure and heart rate and slight decreases in oxygen saturation are a normal response to exercise and are expected during stress testing. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 178). Elsevier Health Sciences. Kindle Edition.

2. While performing a breast examination on a 22-year-old client, you obtain the following data. Which finding is of most concern? 1. Both breasts have many nodules in the upper outer quadrants. 2. The client reports bilateral breast tenderness with palpation. 3. The breast on the right side is slightly larger than the left breast. 4. An irregularly shaped, nontender lump is palpable in the left breast.

2. Ans: 4 Irregularly shaped and nontender lumps are consistent with a diagnosis of breast cancer, so this client needs immediate referral for diagnostic tests such as mammography or ultrasound. The other information is not unusual and does not indicate the need for immediate action. Focus: Prioritization

2. You are employed as the charge nurse in a long-term care (LTC) facility that employs RNs, LPNs/ LVNs, and UAPs. When you are planning care for a resident with a stage III sacral pressure ulcer, which nursing intervention is best to delegate to an LPN/ LVN? 1. Choosing the type of dressing to be used on the ulcer 2. Using the Norton scale to assess for pressure ulcer risk factors 3. Assisting the client in changing position at frequent intervals 4. Cleaning and changing the dressing on the ulcer every morning

2. Ans: 4 LPN/ LVN education and scope of practice includes sterile and nonsterile wound care. LPNs/ LVNs do function as wound care nurses in some LTC facilities, but the choice of dressing type and assessment for risk factors are more complex skills that are appropriate to the RN level of practice. Assisting the client to change position is a task included in UAP education and would be more appropriate to delegate to the UAP. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 193). Elsevier Health Sciences. Kindle Edition.

2. You are caring for a patient in whom a conversion disorder was recently diagnosed. She is experiencing a sudden loss of vision after witnessing a violent fight between her husband and adult-age son. What is the priority therapeutic approach to use with this patient? 1. Reassure her that her blindness is temporary and will resolve with time 2. Gently point out that she seems to be able to see well enough to function independently 3. Encourage expression of feelings and link emotional trauma to the blindness 4. Teach ways to cope with blindness, such as methodically arranging personal items

2. Ans: 4 Patients with conversion disorders are experiencing symptoms, even though there is no identifiable organic cause; therefore, they should be assisted in learning ways to cope and live with the disability. Encouraging the expression of feelings is okay, but it is premature to expect the patient to link the fight to her blindness. It is likely that the sudden onset of blindness will quickly resolve, and the patient may also be physically able to see, but presenting facts would not be helpful at this time. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 207). Elsevier Health Sciences. Kindle Edition.

2. A patient has newly-diagnosed type 2 diabetes. Which task should you delegate to a UAP? 1. Arranging a consult with the dietitian 2. Assessing the patient's insulin injection technique 3. Teaching the patient to use a glucometer to monitor glucose at home 4. Reminding the patient to check glucose level before each meal

2. Ans: 4 The UAP's role includes reminding patients about interventions that are already part of the plan of care. Arranging for a consult with the dietitian is appropriate for the unit clerk. Teaching and assessing require additional education and should be carried out by licensed nurses. Focus: Delegation, supervision, assignment LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 189). Elsevier Health Sciences. Kindle Edition.

2. A 56-year-old patient comes to the walk-in clinic reporting scant rectal bleeding and intermittent diarrhea and constipation for the past several months. There is a history of polyps and a family history of colorectal cancer. While you are trying to teach about colonoscopy, the patient becomes angry and threatens to leave. What is the priority diagnosis? 1. Diarrhea/ Constipation related to altered bowel patterns 2. Deficient Knowledge related to the disease process and diagnostic procedure 3. Risk for Deficient Fluid Volume related to rectal bleeding and diarrhea 4. Anxiety related to unknown outcomes and perceived threats to body integrity

2. Ans: 4 The patient's physical condition is currently stable, but emotional needs are affecting his or her ability to receive the information required to make an informed decision. The other diagnoses are relevant, but if the patient leaves the clinic the interventions may be delayed or ignored. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 168). Elsevier Health Sciences. Kindle Edition.

75. The HCP is angry and yelling in the nurse's station because the client's laboratory data are not available. Which action should the charge nurse implement first? 1. Contact the laboratory for the client's results. 2. Ask the HCP to step into the nurse's office 3. Tell the HCP to discuss the issue with the laboratory. 4. Report the HCP's behavior to the chief nursing of officer.

2. Ask the HCP to step into the nurse's office

98. The nurse in an assisted living facility notes that the male client has several new bruises on both of his arms and hands. Which intervention should the nurse implement first? 1. File an elder abuse report with the Department of Human Services. 2. Ask the client whether he has fallen and hurt himself during the night. 3. Check the medication administration record (MAR) to determine which medications the client is receiving. 4. Notify the client's family of the bruises so they are not surprised on their visit.

2. Ask the client whether he has fallen and hurt himself during the night.

85. The nurse is caring for clients on a 12-bed intermediate care surgical unit. Which task should the nurse implement first? 1. Reinsert the nasogastric tube for the client who has pulled it out. 2. Complete the preoperative checklist for the client scheduled for surgery. 3. Instruct the client who is being discharged home about colostomy care. 4. Change the client's surgical dressing that has a 20 cm area of drainage.

2. Complete the preoperative checklist for the client scheduled for surgery.

76. The staff nurse is concerned about possible increasing infection rates among clients with peripherally inserted central catheters (PICCs). The nurse has noticed several clients with problems in the last few months. Which action would be appropriate for the staff nurse to implement first? 1. Discuss the infections with the chief nursing officer. 2. Contact the infection control nurse to discuss the problem. 3. Assume the employee health nurse is monitoring the situation. 4. Volunteer to be on an ad hoc committee to research the infection rate.

2. Contact the infection control nurse to discuss the problem.

2. The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? a. A client complaining of muscle aches, a headache, and malaise b. A client who twisted her ankle when she fell while rollerblading c. A client with a minor laceration on the index finger sustained while cutting an eggplant d. A client with chest pain who states that he just are pizza that was made with a very spicy sauce.

2. D- In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits, or who have sustained chemical splashes to the eyes, are classified as emergent and are the number 1 priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as a number 2 priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are a number 3 priority.

56. The experienced nurse has recently taken a position on a medical unit in a community hospital, but after 1 week on the job, he finds that the staffing is not what was discussed during his employment interview. Which approach would be most appropriate for the nurse to take when attempting to resolve the issue? 1. Immediately give a 2-week notice and find a different job. 2. Discuss the situation with the manager who interviewed him. 3. Talk with the other employees about the staffing situation. 4. Tell the charge nurse the staffing is not what was explained to him.

2. Discuss the situation with the manager who interviewed him.

26. The director of nurses in a long-term care facility observes the licensed practical nurse (LPN) charge nurse explaining to an unlicensed assistive personnel (UAP) how to calculate the amount of food a resident has eaten from the food tray. Which action should the director of nurses implement? 1. Ask the charge nurse to teach all the other UAPs. 2. Encourage the nurse to continue to work with the UAP. 3. Tell the charge nurse to discuss this in a private area. 4. Give the UAP a better explanation of the procedure.

2. Encourage the nurse to continue to work with the UAP.

91. The nurse in the burn unit is preparing to perform a wound dressing change at the bedside. Which interventions should the nurse implement? Rank in order of priority. 1. Obtain the needed supplies for the procedure. 2. Explain the procedure to the client. 3. Remove the old dressing with non-sterile gloves. 4. Medicate the client with narcotic analgesics. 5. Assess the client's burned area.

2. Explain the procedure to the client. 4. Medicate the client with narcotic analgesics. 1. Obtain the needed supplies for the procedure. 3. Remove the old dressing with non-sterile gloves. 5. Assess the client's burned area.

116. The nurse is caring for a female client 3 days post-knee replacement surgery when the client complains of vaginal itching. The medication administration report (MAR) indicates the client has been receiving the antacid calcium carbonate (Maalox), the antibiotic ceftriaxone (Rocephin), and the anticoagulant enoxaparin (Lovenox). Which priority intervention should the nurse implement? 1. Request the dietary department to send yogurt on each tray. 2. Explain to the client this is the result of the antibiotic therapy. 3. Notify the HCP on rounds of the client's vaginal itching. 4. Ask the client whether she is having unprotected sexual activity.

2. Explain to the client this is the result of the antibiotic therapy.

For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? 1. Speaking loudly. 2. Using a picture board. 3. Writing directions so client can read them. 4. Speaking in short sentences.

2. Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say. A communication or picture board helps the client communicate with others in that the client can point to objects or activities that he or she desires.

Name two more "tips' in communicating with a patient with Aphasia:

2. Face the patient and establish eye contact. 3. Speak in a clear, unhurried manner, and normal tone of voice. 4. Use short phrases, and pause between phrases to allow the patient time to understand what is being said. 5. Limit conversation to practical and concrete matters. 6. Use gestures, pictures, objects, and writing. 7. As the patient uses and handles an object, say what the object is. It helps to match the words with the object or action. 8. Be consistent in using the same words and gestures each time you give instructions or ask a question. 9. Keep extraneous noises and sounds to a minimum. Too much background noise can distract the patient or make it difficult to sort out the message being spoken.

See First when all patients receiving blood transfusions 1. A client complaining of a headache 2. A client vomiting 3. A client complaining of itching 4. A client with neck vein distention

2. Hemolytic reaction; most dangerous type of transfusion reaction; symptoms include nausea, vomiting, pain in lower back, hematuria; treatment is to stop blood, obtain urine specimen and maintain blood volume and kidney perfusion. 1. febrile reaction; symptoms include fever, chills, nausea, headache; treatment is to stop blood and administer aspirin 3. allergic reaction; symptoms include urticaria or hives, pruritus, fever; treatment is to stop blood, give diphenhydramine and administer oxygen 4. circulatory overload, treatment is to stop blood, position in an upright position and administer oxygen.

Which food-related behaviors are expected in a client who has had a stroke that has left him with homonymous hemianopia? 1. Increased preference for foods high in salt. 2. Eating food on only half of the plate. 3. Forgetting the names of foods. 4. Inability to swallow liquids.

2. Homonymous hemianopia is blindness in half of the visual field; therefore, the client would see only half of his plate. Eating only the food on half of the plate results from an inability to coordinate visual images and spatial relationships. There may be an increased preference for foods high in salt after a stroke, but this would not be related to homonymous hemianopia. Forgetting the names of foods would be aphasia, which involves a cerebral cortex lesion. Being unable to swallow liquids is dysphagia, which involves motor pathways of cranial nerves IX and X, including the lower brain stem.

45. The nurse working at the county hospital is admitting a client who is Rh-negative to the labor and delivery unit. The client is gravida 2, para 0. Which assessment data is most important for the nurse to assess? 1. Why the client did not have a viable baby with the first pregnancy. 2. If the mother received a Rhogam injection after the last pregnancy. 3. The period of time between the client's pregnancies. 4. When the mother terminated the previous pregnancy.

2. If the mother received a Rhogam injection after the last pregnancy.

79. The client tells the nurse, "I am having surgery on my right knee." However, the operative permit is for surgery on the left knee. Which action should the nurse implement first? 1. Notify the operating room team. 2. Initiate the time-out procedure. 3. Clarify the correct extremity with the client. 4. Call the surgeon to discuss the discrepancy.

2. Initiate the time-out procedure.

2. The charge nurse observes two unlicensed assistive personnel (UAPs) arguing in the hallway. Which action should the nurse implement first in this situation? 1. Tell the manager to check on the UAPs. 2. Instruct the UAPs to stop arguing in the hallway. 3. Have the UAPs go to a private room to talk. 4. Mediate the dispute between the UAPs.

2. Instruct the UAPs to stop arguing in the hallway.

74. A terrible storm causes the electricity to go out in the hospital and the emergency generator lights come on. Which action should the charge nurse implement? 1. Request all family members to leave the hospital as soon as possible. 2. Instruct the staff to plug critical electrical equipment into the red outlets. 3. Have the unlicensed assistive personnel (UAP) place a portable flashlight on each bedside table. 4. Contact the maintenance department to determine how long the electricity will be out.

2. Instruct the staff to plug critical electrical equipment into the red outlets.

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? 1. Cholesterol level. 2. Pupil size and pupillary response. 3. Bowel sounds. 4. Echocardiogram.

2. It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. The cholesterol level is not a priority assessment, although it may be an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but this is not a priority in the first 24 hours, when the primary concerns are cerebral hemorrhage and increased intracranial pressure. An echocardiogram is not needed for the client with a thrombotic stroke without heart problems.

103. The chief nursing officer (CNO) of an extended care facility is attending shift report with two charge nurses, and an argument about a resident's care ensues. Which ac- tion should the CNO implement first? 1. Ask the two charge nurses to stop arguing and go to a private area. 2. Listen to both sides of the argument and then implement a plan of care. 3. Ask the family to join the discussion before deciding how to implement care. 4. Tell the nurses to stop arguing and continue to give report.

2. Listen to both sides of the argument and then implement a plan of care.

28. The older adult client becomes confused and wanders in the hallways. Which fall precaution intervention should the nurse implement first? 1. Place a Posey vest restraint on the client. 2. Move the client to a room near the station. 3. Ask the HCP for an antipsychotic medication. 4. Raise all four side rails on the client's bed.

2. Move the client to a room near the station.

30. The employee health nurse has cared for six clients who have similar complaints. The clients have a fever, nausea, vomiting, and diarrhea. Which action should the nurse implement first after assessing the clients? 1. Have another employee drive the clients home. 2. Notify the public health department immediately. 3. Send the clients to the emergency department. 4. Obtain stool specimens from the clients.

2. Notify the public health department immediately.

69. Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP) working on a surgical unit? 1. Escort the client to the smoking area outside. 2. Obtain vital signs on a newly admitted client. 3. Administer a feeding to the client with a gastrostomy tube. 4. Check the toes of a client who just had a cast application.

2. Obtain vital signs on a newly admitted client.

38. Which legal intervention should the nurse implement on the initial visit when admitting a client to the home healthcare agency? 1. Discuss the professional boundary-crossing policy with the client. 2. Provide the client with a copy of the NAHC Bill of Rights. 3. Tell the client how many visits the client will have while on service. 4. Explain that the client must be homebound to be eligible for home healthcare

2. Provide the client with a copy of the NAHC Bill of Rights.

110. The 32-year-old male client with a traumatic right above-the-elbow amputation tells the home health (HH) nurse he is worried about supporting his family and finding employment since he can't be a mechanic anymore. Which intervention should the nurse implement? 1. Contact the HH agency's occupational therapist. 2. Refer the client to the state rehabilitation commission. 3. Ask the HH agency's social worker about disability. 4. Suggest he talk to his wife about his concerns.

2. Refer the client to the state rehabilitation commission.

68. The HCP writes an order for the client with a fractured right hip to ambulate with a walker four times per day. Which action should the nurse implement? 1. Tell the unlicensed assistive personnel (UAP) to ambulate the client with the walker. 2. Request a referral to the physical therapy department. 3. Obtain a walker that is appropriate for the client's height. 4. Notify the social worker of the HCP's order for a walker.

2. Request a referral to the physical therapy department.

60. The nurse has been named in a lawsuit concerning the care provided. Which action should the nurse take first? 1. Consult with the hospital's attorney. 2. Review the client's chart. 3. Purchase personal liability insurance. 4. Discuss the case with the supervisor.

2. Review the client's chart.

41. The hospital will be implementing a new medication administration record (MAR) for documenting medication administration. Which action should the clinical manager take first when implementing the new MAR? 1. Discuss the new MAR with each nurse individually. 2. Schedule meetings on all shifts to discuss the new MAR. 3. Require the nurse to read a handout explaining the new MAR. 4. Ask the nurses to watch a video explaining the new MAR.

2. Schedule meetings on all shifts to discuss the new MAR.

Which of the following techniques does the nurse avoid when changing a client's position in bed if the client has hemiparalysis? 1. Rolling the client onto the side. 2. Sliding the client to move up in bed. 3. Lifting the client when moving the client up in bed. 4. Having the client help lift off the bed using a trapeze.

2. Sliding a client on a sheet causes friction and is to be avoided. Friction injures skin and predisposes to pressure ulcer formation. Rolling the client is an acceptable method to use when changing positions as long as the client is maintained in anatomically neutral positions and her limbs are properly supported. The client may be lifted as long as the nurse has assistance and uses proper body mechanics to avoid injury to himself or herself or the client. Having the client help lift herself off the bed with a trapeze is an acceptable means to move a client without causing friction burns or skin breakdown.

Assign to LPN? 1. A client 2 days postop after abdominal hysterectomy asking to ambulate in the hall 2. A client with a colostomy requiring assistance with an irrigation 3. A client with a right-sided CVA requiring assistance with bathing 4. A client refusing medication for treatment of cancer of the colon

2. Stable client with an expected outcome; sigmoid colostomy may require irrigation 1. NAP; give clear directions and should report back to RN 3. NAP; standard unchanging; ADLs within UAP's scope 4. RN; requires assessment and judgment

4. The primary nurse informs the shift manager one of the unlicensed assistive personnel (UAPs) is falsifying vital signs. Which action should the shift manager implement first? 1. Notify the unit manager of the potential situation of falsifying vital signs. 2. Take the assigned client's vital signs and compare with the UAP's results. 3. Talk to the UAP about the primary nurse's allegation. 4. Complete a counseling record and place in the UAP's file.

2. Take the assigned client's vital signs and compare with the UAP's results.

7. Which task should the critical care nurse delegate to the unlicensed assistive personnel (UAP)? 1. Check the pulse oximeter reading for the client on a ventilator. 2. Take the client's sterile urine specimen to the laboratory. 3. Obtain the vital signs for the client in an Addisonian crisis. 4. Assist the HCP with performing a paracentesis at the bedside.

2. Take the client's sterile urine specimen to the laboratory.

1. The new graduate working on a medical unit night shift is concerned that the charge nurse is drinking alcohol on duty. On more than one occasion, the new graduate has smelled alcohol when the charge nurse returns from a break. Which action should the new graduate nurse implement first? 1. Confront the charge nurse with the suspicions. 2. Talk with the night supervisor about the concerns. 3. Ignore the situation unless the nurse cannot do her job. 4. Ask to speak to the nurse educator about the problem.

2. Talk with the night supervisor about the concerns.

31. The clinic nurse is caring for clients in a pediatric clinic. Which client should the nurse assess first? 1. The 4-year-old child who fell and is complaining of left leg pain. 2. The 3-year-old child who is drooling and does not want to swallow. 3. The 8-year-old child who has complained of a headache for 2 days. 4. The 10-year-old child who is thirsty all the time and has lost weight.

2. The 3-year-old child who is drooling and does not want to swallow.

82. The charge nurse on a 20-bed surgical unit has one RN, two licensed practical nurses (LPNs), and two unlicensed assistive personnel (UAPs) for a 12-hour shift. Which task would be an inappropriate delegation of assignments? 1. The RN will perform the shift assessments. 2. The LPN should administer all IVP medications. 3. The UAP will complete all a.m. care. 4. The RN will monitor laboratory values.

2. The LPN should administer all IVP medications.

15. The unlicensed assistive personnel (UAP) is preparing to provide postmortem care to a client with a questionable diagnosis of anthrax. Which instruction is priority for the nurse to provide to the UAP? 1. The UAP is not at risk for contracting an illness. 2. The UAP should wear a mask, gown, and gloves. 3. The UAP may skip performing postmortem care. 4. Ask whether the UAP is pregnant before she enters the client's room.

2. The UAP should wear a mask, gown, and gloves.

120. Which data indicates therapy has been effective for the client diagnosed with bipolar disorder? 1. The client only has four episodes of mania in 6 months. 2. The client goes to work every day for 9 months. 3. The client wears a nightgown to the day room for therapy. 4. The client has had three motor vehicle accidents.

2. The client goes to work every day for 9 months.

65. Which client should the nurse in the post-anesthesia care unit (PACU) assess first? 1. The client who received general anesthesia who is complaining of a sore throat. 2. The client who had right knee surgery and has a pulse oximeter reading of 90%. 3. The client who received epidural surgery and has a palpable 2+ dorsalis pedal pulse. 4. The client who had abdominal surgery and has green bile draining from the N/G tube.

2. The client who had right knee surgery and has a pulse oximeter reading of 90%.

64. The night shift nurse is caring for clients on the surgical unit. Which client situation would warrant immediate notification of the surgeon? 1. The client who is 2 days postoperative for bowel resection and who refuses to turn, cough, and deep breathe. 2. The client who is 5 hours postoperative for abdominal hysterectomy who reported feeling a "pop" and then her pain went away. 3. The client who is 2 hours postoperative for TKR and who has 400 mL in the cell-saver collection device. 4. The client who is 1 day postoperative for bilateral thyroidectomy and who has a negative Chvostek sign.

2. The client who is 5 hours postoperative for abdominal hysterectomy who reported feeling a "pop" and then her pain went away.

105. The community health nurse is triaging victims at a bus accident. Which client would the nurse categorize as red, priority 1? 1. The client with head trauma whose pupils are fixed and dilated. 2. The client with compound fractures of the tibia and fibula. 3. The client with a sprained right wrist with a 1-inch laceration. 4. The client with a piece of metal embedded in the right eye.

2. The client with compound fractures of the tibia and fibula.

113. The psychiatric clinic nurse is returning telephone calls. Which telephone call should the nurse return first? 1. The female client who reports being slapped by her husband when he got drunk last night. 2. The male client who reports he is tired of living, since his wife just left him because he lost his job. 3. The female client diagnosed with anorexia who reports she does not think she can stand to eat today. 4. The male client diagnosed with Parkinson's disease who reports his hands are shaking more than yesterday.

2. The male client who reports he is tired of living, since his wife just left him because he lost his job.

32. Which statement is an example of community-oriented, population-focused nursing? 1. The nurse cares for an older adult client who had a kidney transplant and who lives in the community. 2. The nurse develops an educational program for the type 2 diabetics in the community. 3. The nurse refers a client with Cushing's syndrome to the registered dietician. 4. The nurse provides the client chronic renal disease with pamphlets.

2. The nurse develops an educational program for the type 2 diabetics in the community.

16. The client on a medical unit died of a communicable disease. Which information should the nurse provide to the mortuary workers? 1. No information can be released to the mortuary service. 2. The nurse should tell the funeral home the client's diagnosis. 3. Ask the family for permission to talk with the mortician. 4. Refer the funeral home to the HCP for information.

2. The nurse should tell the funeral home the client's diagnosis.

24. The surgical unit has a low census and is overstaffed. Which staff member should the house supervisor notify first and request to stay home? 1. The nurse who has the most vacation time. 2. The nurse who requested to be off. 3. The nurse who has the least experience on the unit. 4. The nurse who has called in sick the previous 2 days.

2. The nurse who requested to be off.

109. The HH aide calls the HH nurse to report that the client has a reddened area on the sacral area. Which intervention should the nurse implement first? 1. Notify the client's healthcare provider. 2. Visit the client to assess the reddened area. 3. Document the finding in the client's chart. 4. Refer the client to the wound care nurse.

2. Visit the client to assess the reddened area.

Psych unit admission, seen first? 2. A police officer with PTSD history who was admitted with agoraphobia after two of his co-officers were shot and killed in a drug raid 4. A college student admitted for depression and anxiety after his younger sibling committed suicide. His mother was recently diagnosed with lung cancer.

2. high potential for violence to self &/or others; male; easy access to weapons, and has knowledge of how to use them; needs assessment orientation to the physical surroundings, staff, unit schedules and expectations, rules and procedures for asking for help; any visitors would need to be particularly monitored for potential weapons, especially if they are other police officers and accustomed to carrying their guns. 4. Should be the 2nd patient seen; siblings of a person who committed suicide often feel despair and survivor guilt, putting themselves at risk for suicide; this patient has experienced 2 serious losses, 1 actual and 1 potential.

reassigned RN? 1. a client diagnosed with spinal cord injury requiring assistance with meals. 2. a client diagnosed with MI complaining of burning on urination 3. a client diagnosed with terminal cancer exhibiting Cheyne-stokes 4. a client diagnosed with a head injury with a glasgow coma score of 7

2. like an LPN, assign to stable client with expected outcome; burning on urination is indicative of UTI 1. assign to CNA 3. RN; periodic breathing characterized by rhythmic waxing and waning of the depth of respirations; client may be dying 4. 8 or less indicates severe brain damage

Assign to RN? 1. A child recovering from surgical repair of a hypospadias. 2. A client recovering from excisionof a malignant melanoma 3. A client diagnosed with a MI requiring assistance to the bathroom 4. A client diagnosed with urolithiasis recovering from lithotripsy

2. may require a wide excision that requires nurse to anticipate the need for analgesic medications; psychological support is also necessary because of diagnosis of cancer; requires assessment, teaching and nursing judgment. 1. ensure patency of urinary diversin after surgery; assign to LPN 3. standard unchanging procedure, assign to NAP 4. observe for obstruction and infection, strain urine; assign to LPN.

First action? Nurse notes many has flu but accompanied client to the clinic. 1. Inform the family members they should stay home if they have a cough 2. Instruct the coughing family members to sit at least 3 feet from each other

2. the Flu spreads by droplet; nurse should offer masks to people who are coughing as well as enforce separation 1. family shouldn't have gone out but they are in the clinic therefore nurse's priority is to prevent spread of the flu.

20. A client with mania will be placed in seclusion after overturning two tables and throwing a chair against the wall. Before placing the client in seclusion, the nurse would first: a) inspect the client for injuries resulting from the incident and initiate appropriate treatment b) document the behavior leading to seclusion c) document the time and the client is placed in seclusion d) make sure that there is a written order by the physician allowing for the seclusion

20) A - The primary concern of the nurse should be to ascertain that the client is injury free or to attend to any injuries that may have resulted. Options B, C, and D are all important tasks for the nurse, but they do not refer to assessment of the client and would not be the nurse's first action.

21. A nurse in a postanesthesia care unit (PACU) receives a client transferred from the operating room. The PACU nurse assesses the client for which of the following first? a) active bowel sounds b) adequate urine output c) orientation to the surroundings d) a patent airway

21) D - After a transfer from the operating room, the PACU nurse performs an assessment of the client. The ABCs'airway, breathing, and circulation'must be assessed first. Urine output and orientation to the surroundings might also be assessed, but these are not the first actions. The client might not have active bowel sounds at this time because of the effects of anesthesia.

22. A nurse manager is planning the client assignments for the day. Which of the following clients would the nurse assign to the nursing assistant? a) a 2-day postoperative client who had a below-the-knee amputation b) a client on a 24-hour urine collection who is on strict bedrest c) a cleint scheduled to be discharged after coronary artery bypass surgery d) a client scheduled for a cardiac catheterization

22) B - The registered nurse is legally responsible for client assignments and must assign tasks on the basis of the guidelines of nurse practice acts and the job description of the employing agency. A 2-day postoperative client who had a below-the-knee amputation will require both physiological and psychosocial care. A client scheduled to be discharged after coronary artery bypass surgery will require reinforcement of home care management. A client scheduled for a cardiac catheterization requires physiological needs and frequent nursing assessments. The nursing assistant has been trained to care for a client on bedrest and on urine collections. The nurse manager would provide instructions to the nursing assistant regarding the tasks, but the tasks required for this client are within the role description of a nursing assistant.

23. A registered nurse (RN) must determine how best to assign coworkers (another RN and one licensed practical nurse LPN) to provide care to a group of clients. Which of the following is the appropriate assignment? a) the RN is assigned to care for an unemployed 26-year old woman, newly diagnosed with acquired immunodeficiency syndrome (AIDS), who has four school-age children b) the LPN is assigned to care for a 41-year old male, postresection of an acoustic neuroma 2 days ago, transferred from the intensive care unit (ICU) this morning c) the LPN is assigned to provide discharge teaching about medications and maintenance of nephrostomy tube to a 35-year old man d) the RN is assigned to care for a 65-year old woman hospitalized because of chest pain, being discharged today to home with no medication

23) A - In order to determine what can and cannot be delegated to a co-worker, several factors need to be considered. The nurse must carefully consider what level of care each client requires immediately and potentially in the future, what competencies are possessed by co-workers, and what legal limitations there are on the practice of those co-workers. In option 2, the client has undergone a serious neurosurgical procedure that can impair swallowing and gag reflexes, and there is significant risk of increased intracranial pressure in the first few days postoperatively. This and the fact that the client has been transferred from the ICU this morning make this an inappropriate assignment for an LPN. The LPN is also not able to provide discharge teaching on medications and treatments to a client. Teaching is a professional responsibility, which the RN cannot delegate to anyone except another RN, making option 3 incorrect. Although under some circumstances the RN might care for a client being discharged following chest pain, the question tells you that there is an LPN available. The RN would be best used to care for the client with more critical or complicated needs. Option 4 is therefore incorrect. The woman newly diagnosed with AIDS, who is unemployed and with small children, is likely to be in need of the skills of an RN in terms of both physiological and psychosocial needs, making option 1 an appropriate assignment.

24. A nurse manager of a medical-surgical unit returns to work after being on vacation for a week. It is the beginning of the shift, and the nurse manager is faced with several activities that need attention. Which activity will the nurse manager attend to first? a) a crash cart needs checking b) client assignments for the day c) a phone message that indicates that the charge nurse of the next shift is ill and will not be reporting to work d) a stack of mail from the education department and administrative services

24) B - The nurse manager needs to attend to the client assignments first. Client care is the priority. In addition, the nursing staff needs assignments so that they can begin client assessments and begin delivering client care. The nurse manager should next check the crash cart (which is normally done every shift) to ensure that needed equipment is available in the event of an emergency. The nurse manager could also delegate this task to another registered nurse while client assignments are being planned. The nurse manager would next begin the problem-solving process related to finding a charge nurse for the next shift. Because this activity directly affects client care, this would be done before reading the stack of mail.

25. A nurse responds to an external disaster that occurred in a large city when a building collapsed. Numerous victims require treatment. Which victim will the nurse attend to first? a) an alert victim who has numerous bruises on the arms and legs b) a victim with a partial amputation of a leg who is bleeding profusely c) a hysterical victim who received a head injury d) a victim who sustained multiple serious injuries and is deceased

25) B - The nurse determines which victim will be attended to first on the basis of the acuity level of the victims involved in the disaster. The priority victim is the one who must be treated immediately or life, limb, or vision will be threatened. This victim is categorized as emergent (option 2). The victim who requires treatment, but life, limb, or vision is not threatened if care can be provided within 1 to 2 hours is considered urgent and is the second priority (option 3). The victim who requires evaluation and possible treatment but for whom time is not a critical factor is categorized as nonurgent and is the third priority (option 1).

An older adult client has been brought to the emergency department (ED) with a suspected stroke. An IV fluid bolus was initiated prior to arriving in the ED, and the second liter of fluid is finishing infusing at this time. Initial vital signs are BP 150/100, pulse 90, and respirations 20. The client was alert and orientated on admission. After 30 minutes, vital signs have changed to BP 200/110, pulse 78, and respirations 28. The client is now lethargic and difficult to arouse. What should the nurse initiate next? 1.Turn the client on the left side. 2.Check the client's phenytoin (Dilantin) level. 3.Get an order to decrease IV fluids. 4.Prepare the client for a lumbar puncture.

3. A nurse is formulating a plan of care for a client receiving enteral feedings. The nurse identifies which nursing diagnosis as the highest priority for this client? a) diarrhea b) risk for aspiration c) risk for deficient flid volume d) imbalanced nutrition, less than body requirements

3) B - Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places a client at risk for aspiration. Although options 1, 3, and 4 may be a concern, these are not the priority.

90. The critical care unit is having problems with staff members clocking in late and clocking out early from the shift. Which statement by the charge nurse indicates he has a democratic leadership style? 1. "You cannot clock out 1 minute before your shift is complete." 2. "As long as your work is done you can clock out any time you want." 3. "We are going to have a meeting to discuss the clocking in procedure." 4. "The clinical manager will take care of anyone who clocks out early."

3. "We are going to have a meeting to discuss the clocking in procedure."

94. The newly admitted client in a long-term care facility stays in the room and refuses to participate in client activities. Which statement is a priority for the nurse to discuss with the client? 1. "You have to get out of this room or you will never make friends here at the home." 2. "It is not so bad living here; you are lucky that we care about what happens to you." 3. "You seem sad; would you like to talk about how you are feeling about being here?" 4. "The activities director can arrange for someone to come and visit you in your room."

3. "You seem sad; would you like to talk about how you are feeling about being here?"

A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? 1. Sit quietly with the client until the episode is over. 2. Ignore the behavior. 3. Attempt to divert the client's attention. 4. Tell the client that this behavior is unacceptable.

3. A client who has brain damage may be emotionally labile and may cry or laugh for no explainable reason. Crying is best dealt with by attempting to divert the client's attention. Ignoring the behavior will not affect the mood swing or the crying and may increase the client's sense of isolation. Telling the client to stop is inappropriate.

3. After undergoing a modified radical mastectomy, a client is transferred to the postanesthesia care unit (PACU). Which nursing action is best to delegate to an experienced LPN/ LVN? 1. Monitoring the client's dressing for any signs of bleeding 2. Documenting the initial assessment on the client's chart 3. Communicating the client's status report to the charge nurse on the surgical unit 4. Teaching the client about the importance of using pain medication as needed

3. Ans: 1 An LPN/ LVN working in a PACU would be expected to check dressings for bleeding and alert RN staff members if bleeding occurs. The other tasks are more appropriate for nursing staff with RN-level education and licensure. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 196). Elsevier Health Sciences. Kindle Edition.

3. A client with diabetic neuropathy reports a burning, electrical-type pain in the lower extremities that is worse at night and not responding to nonsteroidal anti-inflammatory drugs. Which medication will you advocate for first? 1. Gabapentin (Neurontin) 2. Corticosteroids 3. Hydromorphone (Dilaudid) 4. Lorazepam (Ativan)

3. Ans: 1 Gabapentin is an antiepileptic drug, but it is also used to treat diabetic neuropathy. Corticosteroids are for pain associated with inflammation. Hydromorphone is a stronger opioid, and it is not the first choice for chronic pain that can be managed with other drugs. Lorazepam is an anxiolytic that may be ordered as an adjuvant nedication. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 3). Elsevier Health Sciences. Kindle Edition.

3. Which patient is at greatest risk for pancreatic cancer? 1. An elderly African-American man who smokes 2. A young white obese woman with gallbladder disease 3. A young African-American man with type 1 diabetes 4. An elderly white woman who has pancreatitis

3. Ans: 1 Pancreatic cancer is more common in African-Americans, males, and smokers. Other associated factors include alcohol use, diabetes, obesity, history of pancreatitis, exposure to organic chemicals, consumption of a high-fat diet, and previous abdominal irradiation. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 168). Elsevier Health Sciences. Kindle Edition.

3. As charge nurse, you would assign the nursing care of which patient to an LPN/ LVN, working under the supervision of an RN? 1. 48-year-old with cystitis who is taking oral antibiotics 2. 64-year-old with kidney stones who has a new order for lithotripsy 3. 72-year-old with urinary incontinence who needs bladder training 4. 52-year-old with pyelonephritis who has severe acute flank pain

3. Ans: 1 The patient with cystitis who is taking oral antibiotics is in stable condition with predictable outcomes, and caring for this patient is therefore appropriate to the scope of practice of an LPN/ LVN under the supervision of an RN. The patient with a new order for lithotripsy will need teaching about the procedure, which should be accomplished by the RN. The patient in need of bladder training will need the RN to plan this intervention. The patient with flank pain needs careful and skilled assessment by the RN. Focus: Assignment LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 195). Elsevier Health Sciences. Kindle Edition.

3. The UAP tells you that a patient who is receiving oxygen at a flow rate of 6 L/ min by nasal cannula is reporting nasal passage discomfort. What intervention should you suggest to improve the patient's comfort for this problem? 1. Humidify the patient's oxygen. 2. Use a simple face mask instead of a nasal cannula. 3. Provide the patient with an extra pillow. 4. Have the patient sit up in a chair at the bedside.

3. Ans: 1 When the oxygen flow rate is higher than 4 L/ min, the mucous membranes can be dried out. The best treatment is to add humidification to the oxygen delivery system. Applying water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options will treat the problem. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 175). Elsevier Health Sciences. Kindle Edition.

3. The nursing care plan for the client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/ LVN being supervised by a nurse? (Select all that apply.) 1. Reminding the client to avoid commercial mouthwashes 2. Encouraging mouth rinsing with warm saline 3. Observing the lips, tongue, and mucous membranes 4. Providing mouth care every 2 hours while the client is awake 5. Seeking a dietary consult to increase fluids on meal trays

3. Ans: 1, 2, 3, 4 The LPN/ LVN scope of practice and educational preparation includes oral care and routine observation. State practice acts vary as to whether LPNs/ LVNs are permitted to perform assessment. The client should be reminded to avoid most commercial mouthwashes, which contain alcohol, a drying agent. Initiating a dietary consult is within the purview of the RN or physician. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 172). Elsevier Health Sciences. Kindle Edition.

3. A nursing diagnosis for a patient with newly-diagnosed diabetes is Risk for Injury related to sensory alterations. Which key points should you include in the teaching plan for this patient? (Select all that apply.) 1. " Clean and inspect your feet every day." 2. " Be sure that your shoes fit properly." 3. " Nylon socks are best to prevent friction on your toes from shoes." 4. " Only a podiatrist should trim your toenails." 5. " Report any nonhealing skin breaks to your health care provider."

3. Ans: 1, 2, 5 Sensory alterations are the major cause of foot complications in diabetic patients, and patients should be taught to examine their feet on a daily basis. Properly-fitted shoes protect the patient from foot complications. Broken skin increases the risk of infection. Cotton socks are recommended to absorb moisture. Patients, family, or health care providers may trim toenails. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (pp. 189-190). Elsevier Health Sciences. Kindle Edition.

3. Which clients would be best to assign to the most experienced nurse in an ambulatory care center that specializes in vision problems and eye surgery? (Select all that apply.) 1. Client who requires postoperative instructions after cataract surgery 2. Client who needs an eye pad and a metal shield applied 3. Client who requests a home health referral for dressing changes and eyedrop instillation 4. Client who needs teaching about self-administration of eyedrops 5. Client who requires an assessment for recent and sudden loss of sight 6. Client who requires preoperative teaching for laser trabeculoplasty

3. Ans: 1, 3, 5, 6 Providing postoperative and preoperative instructions, making home health referrals, and assessing for needs related to loss of vision should be done by an experienced nurse who can give specific details and specialized information about follow-up eye care and adjustment to loss. The principles of applying an eye pad and shield and teaching the administration of eyedrops are basic procedures that should be familiar to all nurses. Focus: Assignment LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 185). Elsevier Health Sciences. Kindle Edition.

3. The health care provider prescribes these actions for a client who was admitted with acute substernal chest pain. Which actions are appropriate to delegate to an experienced LPN/ LVN who is working with you in the ED? (Select all that apply.) 1. Attaching cardiac monitor leads 2. Giving heparin 5000 units IV push 3. Administering morphine sulfate 4 mg IV 4. Obtaining a 12-lead electrocardiogram (ECG) 5. Asking the client about pertinent medical history 6. Having the client chew and swallow aspirin 162 mg

3. Ans: 1, 4, 6 Attaching cardiac monitor leads, obtaining an ECG, and administering oral medications are within the scope of practice for LPN/ LVNs. An experienced ED LPN/ LVN would be familiar with these activities. Although anticoagulants and narcotics may be administered by LPNs/ LVNs to stable clients, these are high-alert medications that should be given by the RN to this unstable client. Obtaining a pertinent medical history requires RN-level education and scope of practice. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 178). Elsevier Health Sciences. Kindle Edition.

3. You are working in the obstetric triage area, and several patients have just come in. Which patient should you assess first? 1. A 17-year-old gravida 1, para 0 (G1P0) woman at 40 weeks' gestation with contractions every 6 minutes who is crying loudly and is surrounded by anxious family members 2. A 22-year-old G3P2 woman at 38 weeks' gestation with contractions every 3 minutes who is requesting to go to the bathroom to have a bowel movement 3. A 32-year-old G4P3 woman at 27 weeks' gestation who noted vaginal bleeding today following intercourse 4. A 27-year-old G2P1 woman at 37 weeks' gestation who experienced spontaneous rupture of membranes 30 minutes ago but feels no contractions

3. Ans: 2 A multiparous patient in active labor with an urge to have a bowel movement will probably give birth imminently. She needs to be the first assessed, the provider must be notified immediately, and she must be moved to a safe location for the birth. She should not be allowed up to the bathroom at this time. The other patients all have needs requiring prompt assessment, but the imminent birth takes priority. Vaginal bleeding after intercourse could be due to cervical irritation or a vaginal infection, or could have a more serious cause such as placenta previa. This patient should be the second one assessed. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 199). Elsevier Health Sciences. Kindle Edition.

3. You have just received a change-of-shift report for the burn unit. Which client should you assess first? 1. Client with deep partial-thickness burns on both legs who reports severe and continuous leg pain 2. Client who has just arrived from the emergency department with facial burns sustained in a house fire 3. Client who has just been transferred from the postanesthesia care unit after having skin grafts applied to the anterior chest 4. Client admitted 3 weeks ago with full-thickness leg and buttock burns who has been waiting for 3 hours to receive discharge teaching

3. Ans: 2 Facial burns are frequently associated with airway inflammation and swelling, so this client requires the most immediate assessment. The other clients also require rapid assessment or interventions, but not as urgently as the client with facial burns. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 193). Elsevier Health Sciences. Kindle Edition.

3. A 32-year-old patient with sickle cell anemia is admitted to the hospital during a sickle cell crisis. Which action prescribed by the health care provider will you implement first? 1. Give morphine sulfate 4 to 8 mg IV every hour as needed. 2. Administer 100% oxygen using a nonrebreather mask. 3. Start a 14-gauge IV line and infuse normal saline at 200 mL/ hr. 4. Give pneumococcal (Pneumovax) and Haemophilus influenzae (ActHIB) vaccines.

3. Ans: 2 Hypoxia and deoxygenation of the RBCs are the most common cause of sickling, so administration of oxygen is the priority intervention here. Pain control and hydration are also important interventions for this patient and should be accomplished rapidly. Vaccination may help prevent future sickling episodes by decreasing the risk of infection, but it will not help with the current sickling crisis. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 181). Elsevier Health Sciences. Kindle Edition.

3. For a patient with hyperthyroidism, which task will you delegate to an experienced UAP? 1. Instructing the patient to report any occurrence of palpitations, dyspnea, vertigo, or chest pain 2. Monitoring the apical pulse, blood pressure, and temperature every 4 hours 3. Drawing blood to measure levels of thyroid-stimulating hormone, triiodothyronine, and thyroxine 4. Teaching the patient about side effects of the drug propylthiouracil

3. Ans: 2 Monitoring vital signs and recording their values are within the education and scope of practice of UAPs. An experienced UAP should have been taught how to monitor the apical pulse. However, a nurse should observe the UAP to be sure that the UAP has mastered this skill. Instructing and teaching patients, as well as performing venipuncture to obtain laboratory samples, are more suited to the education and scope of practice of licensed nurses. In some facilities, an experienced UAP may perform venipuncture, but only after special training. Focus: Delegation, supervision, assignment LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 191). Elsevier Health Sciences. Kindle Edition.

3. You are working with a student nurse to care for an HIV-positive patient with severe esophagitis caused by Candida albicans. Which action by the student indicates that you need to intervene most quickly? 1. Putting on a mask and gown before entering the patient's room 2. Giving the patient a glass of water after administering the ordered oral nystatin (Mycostatin) suspension 3. Suggesting that the patient should order chile con carne or chicken soup for the next meal 4. Placing a "No Visitors" sign on the door of the patient's room

3. Ans: 2 Nystatin should be in contact with the oral and esophageal tissues as long as possible for maximum effect. The other actions are also inappropriate and should be discussed with the student but do not require action as quickly. HIV-positive patients do not require droplet/ contact precautions or visitor restrictions to prevent opportunistic infections. Hot or spicy foods are not usually well tolerated by patients with oral or esophageal fungal infections. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 171). Elsevier Health Sciences. Kindle Edition.

3. Your assessment reveals all of these data when you are admitting a patient with Paget disease. Which finding should you notify the physician about first? 1. There is a bowing of both legs and the knees are asymmetrical. 2. The base of the skull is invaginated (platybasia). 3. The patient is only 5 feet tall and weighs 120 lb. 4. The skull is soft, thick, and larger than normal.

3. Ans: 2 Platybasia (basilar skull invagination) causes brainstem manifestations that threaten life. Patients with Paget disease are usually short and often have bowing of the long bones that results in asymmetrical knees or elbow deformities. The skull is typically soft, thick, and enlarged. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 186). Elsevier Health Sciences. Kindle Edition.

3. As the charge nurse, you are reviewing the assignment sheet for an acute psychiatric unit. Which experienced team member should be reassigned? 1. Male LVN assigned to a male patient with chronic depression and excessive rumination 2. Young male mental health assistant assigned to a female adolescent with anorexia nervosa 3. Female RN assigned to a newly admitted female patient who has command hallucinations and delusions of persecution 4. Older female RN with medical-surgical experience assigned to a male patient with Alzheimer disease

3. Ans: 2 Teenagers, in general, are self-conscious in the presence of members of the opposite sex, and teens with anorexia are overly concerned with their appearance; therefore, it would be better to assign this patient to a mature female staff member. An experienced LVN, regardless of gender pairing, is able to set boundaries and to assist patients with chronic health problems. An experienced RN should be assigned to new admissions, particularly if there are acute safety issues. An RN with medical-surgical experience would be well acquainted with care issues related to dementia. Focus: Assignment LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 207). Elsevier Health Sciences. Kindle Edition.

3. When a primary survey of a trauma client is conducted, what is considered one of the priority actions? 1. Obtain a complete set of vital sign measurements. 2. Palpate and auscultate the abdomen. 3. Perform a brief neurologic assessment. 4. Check the pulse oximetry reading.

3. Ans: 3 A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Measuring vital signs, assessing the abdomen, and checking pulse oximetry readings are considered part of the secondary survey. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 204). Elsevier Health Sciences. Kindle Edition.

3. After a client has a seizure, which action can you delegate to the UAP? 1. Documenting the seizure 2. Performing neurologic checks 3. Taking the client's vital signs 4. Restraining the client for protection

3. Ans: 3 Measurement of vital signs is within the education and scope of practice of UAPs. The nurse should perform neurologic checks and document the seizure. Clients with seizures should not be restrained; however, the nurse may guide the client's movements if necessary. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 182). Elsevier Health Sciences. Kindle Edition.

3. You are caring for several children with cancer and are reviewing morning laboratory results for all of your patients. Which of these patient conditions combined with the indicated laboratory result causes you the greatest immediate concern? 1. Nausea and vomiting with a potassium level of 3.3 mEq/ L 2. A nosebleed with a platelet count of 100,000/ mm3 3. Fever with an absolute neutrophil count of 450/ mm3 4. Fatigue with a hemoglobin level of 8 g/ dL

3. Ans: 3 National guidelines indicate that rapid treatment of infection in neutropenic patients is essential to prevent complications such as overwhelming sepsis and secondary infections; therefore, the child with fever and a low neutrophil count is the priority. A potassium level of 3.3 mEq/ L is borderline low and should be monitored. Nosebleeds are common, and the patient and parents should be taught to apply direct pressure to the nose, have the child sit upright, and not disturb the clot. Severe spontaneous hemorrhage is not expected until the platelet count drops below 20,000 mm3. Children can withstand low hemoglobin levels. The nurse should help the patient and parents regulate activity to prevent excessive fatigue. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 201). Elsevier Health Sciences. Kindle Edition.

3. You are preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order will you perform the following actions? 1. Remove N95 respirator. 2. Take off goggles. 3. Remove gloves. 4. Take off gown. 5. Perform hand hygiene. _____, _____, _____, _____,

3. Ans: 3, 2, 4, 1, 5 This sequence will prevent contact of the contaminated gloves and gown with areas (such as your hair) that cannot be easily cleaned after client contact and stop transmission of microorganisms to you and your other clients. The correct method for donning and removal of personal protective equipment (PPE) has been standardized by agencies such as the CDC and the Occupational Safety and Health Administration. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 173). Elsevier Health Sciences. Kindle Edition.

3. You are preparing to administer TPN through a central line. Place the following steps for administration in the correct order. 1. Use aseptic technique when handling the injection cap. 2. Thread the IV tubing through an infusion pump. 3. Check the solution for cloudiness or turbidity. 4. Connect the tubing to the central line. 5. Select and flush the correct tubing and filter. 6. Set the infusion pump at the prescribed rate. 7. Confirm the order for TPN prior to administration. _____, _____, _____, _____, _____, _____, _____

3. Ans: 7, 3, 5, 2, 1, 4, 6 Always check the order before administering TPN; generally, each bag is individually prepared by the pharmacist. The solution should not be cloudy or turbid. Prepare the equipment by priming the tubing and threading the pump. To prevent infection, scrub the hub and use aseptic technique when inserting the connector into the injection cap and connecting the tubing to the central line. Set the pump at the prescribed rate. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 187). Elsevier Health Sciences. Kindle Edition.

118. The nurse on the psychiatric unit observes one client shove another client. Which intervention should the nurse implement first? 1. Discuss the aggressive behavior with the client. 2. Document the occurrence in the client's chart. 3. Approach the client with another staff member. 4. Instruct the client to go to the unit's quiet room.

3. Approach the client with another staff member.

52. The physical therapist has notified the unit secretary that the client will be ambulated in 45 minutes. After receiving notification from the unit secretary, which task should the charge nurse delegate to the unlicensed assistive personnel (UAP)? 1. Administer a pain medication 30 minutes before therapy. 2. Give the client a washcloth to wash his or her face before walking. 3. Check to make sure the client has been offered the use of the bathroom. 4. Find a walker that is the correct height for the client to use.

3. Check to make sure the client has been offered the use of the bathroom.

72. The unlicensed assistive personnel (UAP) tells the nurse the client who is 5 hours postoperative for an L-3/L-4 laminectomy is complaining of feeling numbness in both feet. Which intervention should the nurse implement? 1. Ask the UAP to take the client's vital signs. 2. Request the UAP to log roll the client to the right side. 3. Complete the neurovascular assessment on the client's legs. 4. Contact the physical therapist to check the client.

3. Complete the neurovascular assessment on the client's legs.

During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's: 1. Pulse. 2. Respirations. 3. Blood pressure. 4. Temperature.

3. Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored, and blood pressure is maintained as identified by the physician and specific to the client's ischemic tissue needs and risk of bleeding from treatment. The other vital signs are important, but the priority is to monitor blood pressure.

3. A nursing graduate is attending an agency orientation regarding the nursing model of practice implanted in the health care facility. The nurse is told that the model is a team nursing approach. The nurse understands that planning care delivery will be based on which characteristic of this type of nursing model of practice. a. A task approach method is used to provide care to clients b. Managed care concepts and tools are used in providing client care. c. A single registered nurse is responsible for providing care to a group of clients d. A registered nurse leads nursing personnel in providing care to a group of clients.

3. D- In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 3 identifies primary nursing (relationship-based practice).

25. The nurse and the unlicensed assistive personnel (UAP) are caring for residents in a long-term care facility. Which task should the nurse delegate to the UAP? 1. Apply a sterile dressing to a Stage IV pressure wound. 2. Check the blood glucose level of a resident who is weak and shaky. 3. Document the amount of food the residents ate after a meal. 4. Teach the residents how to play different types of bingo.

3. Document the amount of food the residents ate after a meal.

See First? 1. A client post CABG having the AV wires removed later in the day 2. A client with type 1 diabetes scheduled for a cardiac cath later today 3. A client 1 day postop with an epidural cath in place 4. A client diagnosed with cardiomyopathy being evaluated for a heart transplant

3. Epidural used fro pain relief, monitor for urinary incontinence, hypotension, respiratory depression and nausea and vomiting 1. Although client requires a high level of nursing, no indication that the client is unstable. 2. Client requires preop assessment and teaching, no indication that the client is unstable. 4. requires monitoring but client with epidural takes priority

13. The female client with osteoarthritis is 6 weeks postoperative for open reduction and internal fixation of the right hip. The home health (HH) aide tells the HH nurse the client will not get in the shower in the morning because she "hurts all over." Which action would be most appropriate by the HH nurse? 1. Tell the HH aide to allow the client to stay in bed until the pain goes away. 2. Instruct the HH aide to get the client up to a chair and give her a bath. 3. Explain to the HH aide the client should get up and take a warm shower. 4. Arrange an appointment for the client to visit her healthcare provider.

3. Explain to the HH aide the client should get up and take a warm shower.

17. The new graduate nurse is assigned to work with an unlicensed assistive personnel (UAP) to provide care for a group of clients. Which action by the nurse is the best method to evaluate whether delegated care is being provided? 1. Check with the clients to see whether they are satisfied. 2. Ask the charge nurse whether the UAP is qualitied. 3. Make rounds to see that the clients are being turned. 4. Watch the UAP perform all the delegated tasks.

3. Make rounds to see that the clients are being turned.

89. The nurse in the critical care unit of a medical center answers the phone and the person says, "There is a bomb in the hospital kitchen." Which action should the nurse take? 1. Notify the kitchen that there is a bomb. 2. Call the operator to trace the phone call. 3. Notify the hospital security department. 4. Call the local police department.

3. Notify the hospital security department.

107. The community health nurse is triaging victims at the scene of a building collapse. Which intervention should the nurse implement first? 1. Discuss the disaster situation with the media. 2. Write the client's name clearly in the disaster log. 3. Place disaster tags securely on the victims. 4. Identify an area for family members to wait.

3. Place disaster tags securely on the victims.

71. The unlicensed assistive personnel (UAP) is changing a full sharps container in the client's room. Which action should the nurse implement? 1. Tell the UAP she cannot change the sharps container. 2. Explain the housekeeping department changes the sharps containers. 3. Praise the UAP for taking the initiative to change the sharps container. 4. Report the behavior to the clinical manager on the unit.

3. Praise the UAP for taking the initiative to change the sharps container.

Room accommodations? 1. A semiprivate with an infant diagnosed with the flu 2. A semiprivate room with an infant diagnosed with kawasaki syndrome 3. A private room with sleeping accommodations 4. a private room without sleeping accommodations

3. RSV causes bronchiolitis and requires contact precautions; parents are best providers of care for their children, sleeping accommodations are appropriate 1. requires droplet 2. acute systemic vasculitis of unknown cause; treated with IV immune globulin and aslicylate therapy; requires standard precautions 4. provide sleeping accommodations

77. The charge nurse on the 30-bed surgical unit has been told to send one staff member to the medical unit. The surgical unit is full, with multiple clients who require custodial care. Which staff member would be most appropriate to send to the medical unit? 1. Send the unlicensed assistive personnel (UAP) who has worked on the surgical unit for 5 years. 2. Send the RN who has worked in the hospital for 8 years in a variety of areas. 3. Send the licensed practical nurse (LPN) who has 3 years of experience, which includes 6 months on the medical unit. 4. Send the new graduate nurse who is orienting to the surgical unit.

3. Send the licensed practical nurse (LPN) who has 3 years of experience, which includes 6 months on the medical unit.

A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. The nurse should first: 1. Ask what medications the client is taking. 2. Complete a history and health assessment. 3. Identify the time of onset of the stroke. 4. Determine if the client is scheduled for any surgical procedures.

3. Studies show that clients who receive recombinant t-PA treatment within 3 hours after the onset of a stroke have better outcomes. The time from the onset of a stroke to t-PA treatment is critical. A complete health assessment and history is not possible when a client is receiving emergency care. Upcoming surgical procedures may need to be delayed because of the administration of t-PA, which is a priority in the immediate treatment of the current stroke. While the nurse should identify which medications the client is taking, it is more important to know the time of the onset of the stroke to determine the course of action for administering t-PA.

23. The 75-year-old client has undergone an open cholecystectomy for cholelithiasis 2 days ago and has a t-tube drain in place. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Explain the procedure for using the patient-controlled analgesia (PCA) pump. 2. Check the client's abdominal dressing for drainage. 3. Take and record the client's vital signs. 4. Empty the client's indwelling catheter bag at the end of the shift. 5. Assist the client to ambulate in the hallway three to four times a day.

3. Take and record the client's vital signs. 4. Empty the client's indwelling catheter bag at the end of the shift. 5. Assist the client to ambulate in the hallway three to four times a day.

34. The home health (HH) nurse along with an HH aide is caring for a client who is 3 weeks postoperative for open reduction and internal fixation of a right hip fracture. Which task would be appropriate for the nurse to delegate to the aide? 1. Instruct the HH aide to palpate the right pedal pulse. 2. Ask the HH aide to change the right hip dressing. 3. Tell the HH aide to elevate the right leg on two pillows. 4. Request the HH aide to mop the client's bedroom floor.

3. Tell the HH aide to elevate the right leg on two pillows.

101. The charge nurse must notify a staff member to stay home because of low census. The unit currently has 35 clients who all have at least one IV and multiple IV medications. The unit is staffed with two RNs, three licensed practical nurses (LPNs), and three unlicensed assistive personnel (UAPs). Which nurse should be notified to stay home? 1. The least experienced RN. 2. The most experienced LPN. 3. The UAP who asked to be requested off. 4. The UAP who was hired 4 weeks ago.

3. The UAP who asked to be requested off.

73. The ED nurse is requesting a bed in the intensive care unit (ICU). The ICU charge nurse must request a transfer of one client from the ICU to the surgical unit to make room for the client coming into the ICU from the ED. Which client should the ICU charge nurse request to transfer to the surgical unit? 1. The client diagnosed with fail chest who has just come from the operating room with a right-sided chest tube. 2. The client diagnosed with acute diverticulitis who is 1 day postoperative for creation of a sigmoid colostomy. 3. The client who is 1 day postoperative for total hip replacement (THR) whose incisional dressing is dry and intact. 4. The client who is 2 days postoperative for repair of a fractured femur and who has had a fat embolism.

3. The client who is 1 day postoperative for total hip replacement (THR) whose incisional dressing is dry and intact.

92. Which client should the charge nurse of a long-term care facility see first after receiving shift report? 1. The client who is unhappy about being placed in a long-term care facility. 2. The client who wants to have the HCP to order a nightly glass of wine. 3. The client who is upset because the call light was not answered for 30 minutes. 4. The client whose son is being discharged from the hospital after heart surgery.

3. The client who is upset because the call light was not answered for 30 minutes.

59. A major disaster has been called, and the charge nurse on a medical unit must recom- mend to the medical discharge officer on rounds which clients to discharge. Which client should not be discharged? 1. The client diagnosed with chronic angina pectoris who has been on new medication for 2 days. 2. The client diagnosed with deep vein thrombosis (DVT) who has had heparin discontinued and has been on warfarin (Coumadin) for 4 days. 3. The client with an infected leg wound who is receiving vancomycin IVPB every 24 hours for methicillin-resistant Staphylococcus aureus (MRSA) infection. 4. The client diagnosed with COPD who has the following arterial blood gas (ABG) levels: pH, 7.34; PCO2, 55; HCO3, 28; PaO2, 89.

3. The client with an infected leg wound who is receiving vancomycin IVPB every 24 hours for methicillin-resistant Staphylococcus aureus (MRSA) infection.

19. The nurse is caring for the following clients on a medical unit. Which client should the nurse assess first? 1. The client with disseminated intravascular coagulation (DIC) who has blood oozing from the intravenous site. 2. The client with benign prostatic hypertrophy (BPH) who is complaining of terminal dribbling and inability to empty bladder. 3. The client with renal calculi who is complaining of severe flank pain and has hematuria. 4. The client with Addison's disease who has bronze skin pigmentation and hypoglycemia.

3. The client with renal calculi who is complaining of severe flank pain and has hematuria.

43. Which assessment data warrants immediate intervention by the nurse for the client diagnosed with chronic kidney disease (CKD) who is on peritoneal dialysis? 1. The client's serum creatinine level is 2.4 mg/dL. 2. The client's abdomen is soft to touch and nontender. 3. The dialysate being removed from the abdomen is cloudy. 4. The dialysate instilled was 1,500 mL and removed was 2,100 mL.

3. The dialysate being removed from the abdomen is cloudy.

104. Which action by the nurse is a violation of the Joint Commission's Patient Safety Goals? 1. The surgery nurse calls a time-out when a discrepancy is noted on the surgical permit. 2. The unit nurse asks the client for his or her date of birth before administering medications. 3. The nurse educator gives the orientee the answers to the quiz covering the IV pumps. 4. The admitting nurse initiates the facility's fall prevention program on an older adult

3. The nurse educator gives the orientee the answers to the quiz covering the IV pumps.

Which nursing intervention has been found to be the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis? 1. Place the client's feet against a firm footboard. 2. Reposition the client every 2 hours. 3. Have the client wear ankle-high tennis shoes at intervals throughout the day. 4. Massage the client's feet and ankles regularly.

3. The use of ankle-high tennis shoes has been found to be most effective in preventing plantar flexion (footdrop) because they add support to the foot and keep it in the correct anatomic position. Footboards stimulate spasms and are not routinely recommended. Regular repositioning and range-of-motion exercises are important interventions, but the client's foot needs to be in the correct anatomic position to prevent overextension of the muscle and tendon. Massaging does not prevent plantar flexion and, if rigorous, could release emboli.

What is the expected outcome of thrombolytic drug therapy for stroke? 1. Increased vascular permeability. 2. Vasoconstriction. 3. Dissolved emboli. 4. Prevention of hemorrhage.

3. Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, thus reestablishing cerebral perfusion. They do not increase vascular permeability, cause vasoconstriction, or prevent further hemorrhage.

84. The nurse is discharging the 72-year-old client who is 5 days postoperative for repair of a fractured hip with comorbid medical conditions. At this time, which referral would be the most appropriate for the nurse to make for this client? 1. To a home healthcare agency. 2. To a senior citizen center. 3. To a rehabilitation facility. 4. To an outpatient physical therapist.

3. To a rehabilitation facility.

See first? 1. 29 year old undergoing peritoneal dialysis. the outflow appear bloody. 2. 35 year man diagnosed with acute postinfectious glomerulonephritis. The client's blood pressure 150/90 3. A 45 yr old woman diagnosed with P. jiroveci pneumonia. The client complains of a persistent dry cough. 4. A 56 yr old diagnosed with angina. The client is scheduled for discharge today.

3. opportunistic infection associated with AIDs; causes progressive hypoxemia and cyanosis 1. not unusual that because of tonicity of dialysate; in the beginning of dialysis, there might be some serosanguinous drainage 2. hypertension caused by volume overload; give antihypertensives and diuretics, restrict salt

First action? Lab tech draws blood and drops blood on the floor 2. Contact nurse manager to report incident 3. Call housekeeping to clean and disinfect area

3. priority is to clean up the contaminated area 2. 2nd action nurse's responsibility to communicate to the nurse manager.

4. A client arrives at the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. The priority nursing action is to: a) obtain vital signs b) ask the client about the precipitating events c) complete an abdominal physical assessment d) insert a nasogastric (NG) tube and Hematest the emesis

4) A - The priority action is to obtain vital signs to determine whether the client is in shock from blood loss and to obtain a baseline by which to monitor the progress of treatment. The client may not be able to provide subjective data until the immediate physical needs are met. Insertion of an NG tube may be prescribed but is not the priority action. A complete abdominal physical assessment needs to be performed but is not the priority.

The client who has had a stroke with residual physical handicaps becomes discouraged by his physical appearance. What approach to the client is best for the nurse to use to help the client overcome his negative self-concept? Select all that apply. 1. Helpfulness. 2. Charity. 3. Firmness. 4. Encouragement. 5. Patience.

4, 5. When offering emotional support to a client who is discouraged and has a negative self-concept because of physical handicaps, the nurse should approach the client with encouragement and patience. The client should be praised when he or she shows progress in efforts to overcome handicaps. An attitude of helpfulness and sympathy allows the client to assume a role of someone not ordinary, someone who is not like others. Regardless of the handicap, the client still feels the same on the inside and has the same innate needs for his or her growth and developmental age-group. An attitude of charity tends to make the client feel like a "charity case" or like someone who is given something free because of his "condition." The client feels unequal to his peers or unable to fulfill the role relationships that were obtained before the stroke. An approach using firmness is inappropriate because it implies that the client can do better if he just tries harder and leaves no room for softness in the approach to overcoming a negative self-concept.

80. The older adult client fell and fractured her left femur. The nurse finds the client crying, and she tells the nurse, "I don't want to go to the nursing home but my son says I have to." Which response would be most appropriate by the nurse? 1. "Let me call a meeting of the healthcare team and your son." 2. "Has the social worker talked to you about this already?" 3. "Why are you so upset about going to the nursing home?" 4. "I can see you are upset. Would you like to talk about it?"

4. "I can see you are upset. Would you like to talk about it?"

3. The graduate nurse is working with an unlicensed assistive personnel (UAP) who has been an employee of the hospital for 12 years. However, tasks delegated to the UAP by the graduate nurse are frequently not completed. Which action should the graduate nurse take first? 1. Tell the charge nurse the UAP will not do tasks as delegated by the nurse. 2. Write up a counseling record with objective data and give it to the manager. 3. Complete the delegated tasks and do nothing about the insubordination. 4. Address the UAP to discuss why the tasks are not being done as requested.

4. Address the UAP to discuss why the tasks are not being done as requested.

4. These activities are included in the care plan for a 78-year-old patient admitted to the hospital with anemia caused by possible gastrointestinal bleeding. Which activity can you delegate to an experienced UAP? 1. Obtaining stool specimens for fecal blood test (Hemoccult) slides 2. Having the patient sign a colonoscopy consent form 3. Giving the prescribed polyethylene glycol electrolyte solution (GoLYTELY) 4. Checking for allergies to contrast dye or shellfish

4. Ans: 1 An experienced UAP will have been taught how to obtain a stool specimen for the Hemoccult slide test, because this is a common screening test for hospitalized patients. Having the patient sign an informed consent form should be done by the physician who will be performing the colonoscopy. Administering medications and checking for allergies are within the scope of practice of licensed nursing staff. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 181). Elsevier Health Sciences. Kindle Edition.

4. A 19-year-old G1P0 patient at 40 weeks' gestation who is in labor is being treated with magnesium sulfate for seizure prophylaxis in preeclampsia. Which are priority assessments with this medication? (Select all that apply.) 1. Check deep tendon reflexes. 2. Observe for vaginal bleeding. 3. Check the respiratory rate. 4. Note the urine output. 5. Monitor for calf pain.

4. Ans: 1, 3, 4 Magnesium sulfate toxicity can cause fatal cardiovascular events and/ or respiratory depression or arrest, so monitoring of respiratory rate is of utmost importance. The drug is excreted by the kidneys, and therefore monitoring for adequate urine output is essential. Deep tendon reflexes disappear when serum magnesium is reaching a toxic level. Vaginal bleeding is not associated with magnesium sulfate use. Calf pain can be a sign of a deep vein thrombosis, but is not associated with magnesium sulfate therapy. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 199). Elsevier Health Sciences. Kindle Edition.

4. You are working with a UAP to care for a client who has had a right breast lumpectomy and axillary lymph node dissection. Which nursing action can you delegate to the UAP? 1. Teaching the client why blood pressure measurements are taken on the left arm 2. Elevating the client's arm on two pillows to promote lymphatic drainage 3. Assessing the client's right arm for lymphedema 4. Reinforcing the dressing if it becomes saturated

4. Ans: 2 Positioning the client's arm is a task within the scope of practice for UAP working on a surgical unit. Client teaching and assessment are RN-level skills. The RN should reinforce dressings as necessary, because this requires assessment of the surgical site and possible communication with the surgeon. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 196). Elsevier Health Sciences. Kindle Edition.

4. You are admitting a 66-year-old male patient suspected of having a urinary tract infection (UTI). Which piece of the patient's medical history supports this diagnosis? 1. Patient's wife had a UTI 1 month ago 2. Followed for prostate disease for 2 years 3. Intermittent catheterization 6 months ago 4. Kidney stone removal 1 year ago

4. Ans: 2 Prostate disease increases the risk of UTIs in men because of urinary retention. The wife's UTI should not affect the patient. The times of the catheter usage and kidney stone removal are too distant to cause this UTI. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 195). Elsevier Health Sciences. Kindle Edition.

4. You are preparing to admit a client with a seizure disorder. Which actions can you delegate to an LPN/ LVN? 1. Completing the admission assessment 2. Setting up oxygen and suction equipment 3. Placing a padded tongue blade at the bedside 4. Padding the side rails before the client arrives

4. Ans: 2 The LPN/ LVN can set up the equipment for oxygen and suctioning. The RN should perform the complete initial assessment. Controversy exists as to whether padded side rails actually provide safety, and their use may embarrass the client and family. Tongue blades should not be at the bedside and should never be inserted into the client's mouth after a seizure begins. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 182). Elsevier Health Sciences. Kindle Edition.

4. A client has been diagnosed with disseminated herpes zoster. Which personal protective equipment (PPE) will you need to put on when preparing to assess the client? (Select all that apply.) 1. Surgical face mask 2. N95 respirator 3. Gown 4. Gloves 5. Goggles 6. Shoe covers

4. Ans: 2, 3, 4 Because herpes zoster (shingles) is spread through airborne means and by direct contact with the lesions, you should wear an N95 respirator or high-efficiency particulate air filter respirator, a gown, and gloves. Surgical face masks filter only large particles and will not provide protection from herpes zoster. Goggles and shoe covers are not needed for airborne or contact precautions. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 173). Elsevier Health Sciences. Kindle Edition.

4. Patients receiving chemotherapy are at risk for thrombocytopenia related to chemotherapy or disease processes. Which actions are needed for patients who must be placed on bleeding precautions? (Select all that apply.) 1. Provide mouthwash with alcohol for oral rinsing. 2. Use paper tape on fragile skin. 3. Provide a soft toothbrush or oral sponge. 4. Gently insert rectal suppositories. 5. Avoid aspirin or aspirin-containing products. 6. Avoid overinflation of blood pressure cuffs. 7. Pad sharp corners of furniture.

4. Ans: 2, 3, 5, 6, 7 Mouthwash should not include alcohol, because it has a drying action that leaves mucous membranes more vulnerable. Insertion of suppositories, probes, or tampons into the rectal or vaginal cavity is not recommended. All other options are appropriate. Focus: Prioritization, knowledge LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 168). Elsevier Health Sciences. Kindle Edition.

4. As the shift begins, you are assigned to care for the following patients. Which patient should you assess first? 1. 38-year-old with Graves disease and a heart rate of 94 beats/ min 2. 63-year-old with type 2 diabetes and fingerstick glucose level of 137 mg/ dL 3. 58-year-old with hypothyroidism and a heart rate of 48 beats/ min 4. 49-year-old with Cushing disease and dependent edema rated as 1 +

4. Ans: 3 Although patients with hypothyroidism often have cardiac problems that include bradycardia, a heart rate of 48 beats/ min may have significant implications for cardiac output and hemodynamic stability. Patients with Graves disease usually have a rapid heart rate, but 94 beats/ min is within normal limits. The diabetic patient may need sliding-scale insulin dosing. This is important but not urgent. Patients with Cushing disease frequently have dependent edema. Focus: Prioritization 5. Ans: 1 Patients with hypofunction of the adrenal gland often have hypotension and should be instructed to change positions slowly. Once a patient has been so instructed, it is appropriate for the UAP to remind the patient of those instructions. Assessing, teaching, and planning nursing care require more education and should be done by licensed nurses. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 191). Elsevier Health Sciences. Kindle Edition.

4. The charge nurse observes an LPN/ LVN providing all of these interventions for a patient with Paget disease. Which action requires that the charge nurse intervene? 1. Administering 600 mg of ibuprofen (Advil) to the patient 2. Encouraging the patient to perform PT-recommended exercises 3. Applying ice and gentle massage to the patient's lower extremities 4. Reminding the patient to drink milk and eat cottage cheese

4. Ans: 3 Applying heat, not ice, is the appropriate measure to help reduce the patient's pain. Ibuprofen is useful to manage mild to moderate pain. Exercise prescribed by the PT would be nonimpact in nature and provide strengthening for the patient. A diet rich in calcium promotes bone health. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 186). Elsevier Health Sciences. Kindle Edition.

4. Which client is most likely to receive opioids for extended periods of time? 1. A client with fibromyalgia 2. A client with phantom limb pain in the leg 3. A client with progressive pancreatic cancer 4. A client with trigeminal neuralgia

4. Ans: 3 Cancer pain generally worsens with disease progression, and the use of opioids is more generous. Fibromyalgia is more likely to be treated with nonopioid and adjuvant medications. Trigeminal neuralgia is treated with antiseizure medications such as carbamazepine (Tegretol). Phantom limb pain usually subsides after ambulation begins. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 3). Elsevier Health Sciences. Kindle Edition.

4. You arrive home and find that the house of your neighbor (Jane) is on fire. A fireman is physically restraining her from running back into the house. What is the best response? 1. " Jane, come and sit in my house until this is over with." 2. " Jane, calm down and let the fireman do his job." 3. " Jane, look at me and hold my hand." 4. " Jane, tell me why you are struggling so hard."

4. Ans: 3 Jane is experiencing a panic level of anxiety and initially she needs very simple and direct instructions. Instruct her to look at you first, to make a connection and to get her attention, then you can continue with your instructions. Telling her to calm down is not useful at this point, and she may or may not be able to articulate why she is trying to go back into the house. Regardless of her reason, she cannot be allowed to run back into the house. Directing her to go to your house is kind and therapeutic, but it may be difficult to remove her from the scene until her anxiety is more under control. Focus: Prioritization 5. Ans: 3 This patient has trouble LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 207). Elsevier Health Sciences. Kindle Edition.

4. An LPN/ LVN's assessment of two diabetic patients reveals all of these findings. Which would you instruct the LPN/ LVN to report immediately? 1. Fingerstick glucose reading of 185 mg/ dL 2. Numbness and tingling in both feet 3. Profuse perspiration 4. Bunion on the left great toe

4. Ans: 3 Profuse perspiration is a symptom of hypoglycemia, a complication of diabetes that requires urgent treatment. A glucose level of 185 mg/ dL will need coverage with sliding-scale insulin, but this is not urgent. Numbness and tingling, as well as bunions, are related to the chronic nature of diabetes and are not urgent problems. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 190). Elsevier Health Sciences. Kindle Edition.

4. A 56-year-old client comes to the triage area with left-sided chest pain, diaphoresis, and dizziness. What is the priority action? 1. Initiate continuous electrocardiographic monitoring. 2. Notify the ED physician. 3. Administer oxygen via nasal cannula. 4. Establish IV access.

4. Ans: 3 The priority goal is to increase myocardial oxygenation. The other actions are also appropriate and should be performed immediately after administering oxygen. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 205). Elsevier Health Sciences. Kindle Edition.

4. You are supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause you to intervene? 1. Suctioning the tracheostomy tube before performing tracheostomy care 2. Removing old dressings and cleaning off excess secretions 3. Removing the inner cannula and cleaning using standard precautions 4. Replacing the inner cannula and cleaning the stoma site

4. Ans: 3 When tracheostomy care is performed, a sterile field is set up and sterile technique is used. Standard precautions such as washing hands must also be maintained but are not enough when performing tracheostomy care. The presence of a tracheostomy tube provides direct access to the lungs for organisms, so sterile technique is used to prevent infection. All of the other steps are correct and appropriate. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 175). Elsevier Health Sciences. Kindle Edition.

4. You are performing a sterile dressing change for a client with infected deep partial-thickness burns of the chest and abdomen. List the steps of the care plan in the order in which each should be accomplished. 1. Apply silver sulfadiazine (Silvadene) ointment. 2. Obtain specimens for aerobic and anaerobic wound cultures. 3. Administer morphine sulfate 10 mg IV. 4. DÃ © bride the wound of eschar using gauze sponges. 5. Cover the wound with a sterile gauze dressing. _____, _____, _____, _____, _____

4. Ans: 3, 4, 2, 1, 5 Pain medication should be administered before changing the dressing, because changing dressings for partial-thickness burns is painful, especially if the dressing change involves removal of eschar. The wound should be dÃ © brided before obtaining wound specimens for culture to avoid including bacteria that are skin contaminants rather than causes of the wound infection. Culture specimens should be obtained prior to the application of antibacterial creams. The antibacterial cream should then be applied to the area after dÃ © bridement to gain the maximum effect. Finally, the wound should be covered with a sterile dressing. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 193). Elsevier Health Sciences. Kindle Edition.

4. You are caring for a client with peptic ulcer disease. Which assessment finding is the most serious? 1. Projectile vomiting 2. Burning sensation 2 hours after eating 3. Coffee-ground emesis 4. Boardlike abdomen with shoulder pain

4. Ans: 4 A boardlike abdomen with shoulder pain is a symptom of a perforation, which is the most lethal complication of peptic ulcer disease. A burning sensation is a typical complaint and can be controlled with medications. Projectile vomiting can signal an obstruction. Coffee-ground emesis is typical of slower bleeding, and the client will require diagnostic testing. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 187). Elsevier Health Sciences. Kindle Edition.

4. The health care provider has written all of these orders for a client with a diagnosis of Excess Fluid Volume. The client's morning assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time? 1. Weigh the client every morning. 2. Maintain accurate intake and output records. 3. Restrict fluids to 1500 mL/ day. 4. Administer furosemide (Lasix) 40 mg IV push.

4. Ans: 4 Bilateral moist crackles indicate fluid-filled alveoli, which interferes with gas exchange. Furosemide is a potent loop diuretic that will help mobilize the fluid in the lungs. The other orders are important, but are not urgent. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 172). Elsevier Health Sciences. Kindle Edition.

4. A 6-year-old who received chemotherapy and had anorexia is now cheerfully eating peanut butter, yogurt, and applesauce. When the mother arrives, the child refuses to eat and throws the dish on the floor. What is your best response to this behavior? 1. Remind the child that foods tasted good today and will help the body to get strong. 2. Allow the mother and child time alone to review and control the behavior. 3. Ask the mother to leave until the child can finish eating and then invite her back. 4. Explain to the mother that the behavior could be a normal expression of anger.

4. Ans: 4 Help the mother to understand that the child may be angry about being left in the hospital or about her inability to prevent the illness and protect the child. Reminding the child about the food and the purpose of the food does not address the strong emotions underlying the outburst. Allowing the mother and child time alone is a possibility, but the assumption would be that the mother understands the child's behavior and is prepared to deal with the behavior in a constructive manner. Asking the mother to leave the child suggests that the mother is a source of stress. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 201). Elsevier Health Sciences. Kindle Edition.

4. You are evaluating an HIV-positive patient who is receiving IV pentamidine (Pentam) as a treatment for Pneumocystis jiroveci (PCP) pneumonia. Which information is most important to communicate to the physician? 1. The patient is reporting pain at the site of the infusion. 2. The patient is not taking in an adequate amount of oral fluids. 3. Blood pressure is 104/ 76 mm Hg after pentamidine administration. 4. Blood glucose level is 55 mg/ dL after medication administration.

4. Ans: 4 Pentamidine can cause fatal hypoglycemia, so the low blood glucose level indicates a need for a change in therapy. The low blood pressure suggests that the pentamidine infusion rate may need to be slowed. The other responses indicate a need for independent nursing actions (such as establishing a new IV site and encouraging oral intake) but are not associated with pentamidine infusion. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 171). Elsevier Health Sciences. Kindle Edition.

4. Place the following steps for eyedrop administration in the correct order. 1. Gently press on the lacrimal duct for 1 minute 2. Gently pull the tissue underneath the eye downward to expose the lower conjunctival sac. 3. Have the client gently close the eye and move it around. 4. Have the client look up while you instill the number of prescribed drops. 5. Hold the dropper and stabilize your hand on the client's forehead. 6. Have the client sit down and tilt his or her head slightly backward. _____, _____, _____, _____, _____, _____

4. Ans: 6, 2, 5, 4, 3, 1 Have the client sit with the head tilted back. Pulling down the lower conjunctival sac creates a small pocket for the drops. Stabilizing the hand prevents accidentally poking the client's eye. Having the client look up prevents the drops from falling on the cornea and stimulating the blink reflex. When the client gently moves the eye, the medication is distributed. Pressing on the lacrimal duct prevents systemic absorption. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 185). Elsevier Health Sciences. Kindle Edition.

4. A nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? a. A client who is ambulatory b. A client scheduled for physical therapy at 1 pm c. A client with a fever who is diaphoretic and restless d. A postoperative client who has just received pain medication

4. C- The nurse should plan to care for the client who has a fever and is diaphoretic and restless first because this client's needs are the priority. The client who is ambulatory and the client scheduled for physical therapy later in the day do not have priority needs related to care. Waiting for pain medication to take effect before providing care to the postoperative client is best.

37. The home health (HH) nurse notes the 88-year-old female client is unable to cook for herself and mainly eats frozen foods and sandwiches. Which intervention should the nurse implement? 1. Discuss the situation with the client's family. 2. Refer the client to the HH occupational therapist. 3. Request the HH aide to cook all the client's meals. 4. Contact the community's Meals on Wheels.

4. Contact the community's Meals on Wheels.

58. At 0830, the day shift nurse is preparing to administer medications to the client. Which action should the nurse take first? 1. Check the client's armband against the medication administration record (MAR). 2. Assess the client's IV site for redness and patency. 3. Ask for the client's date of birth. 4. Determine the client's last K+ level.

4. Determine the client's last K+ level.

53. The volunteer on a medical unit tells the nurse that one of the clients on the unit is her neighbor and asks about the client's condition. Which information should the nurse discuss with the volunteer? 1. Determine how well she knows the client before talking with the volunteer. 2. Tell the volunteer the client's condition in layperson's terms. 3. Ask the client if it is all right to talk with the volunteer. 4. Explain that client information is on a need-to-know basis only.

4. Explain that client information is on a need-to-know basis only.

119. The client in the operating room states, "I don't think I will have this surgery after all." Which intervention should the nurse implement first? 1. Have the surgeon speak with the client. 2. Ask the client to discuss the concerns. 3. Continue to prep the client for surgery. 4. Immediately stop the surgical procedure.

4. Immediately stop the surgical procedure.

67. The client who had surgery on the right elbow has no right radial pulse and the fingers are cold, the client complains of tingling, and she cannot move the fingers of the right hand. Which intervention should the nurse implement first? 1. Document the findings in the client's chart. 2. Elevate the client's right hand. 3. Assess the radial pulse with the Doppler. 4. Notify the client's healthcare provider.

4. Notify the client's healthcare provider.

111. The labor and delivery nurse has assisted in the delivery of a 37-week fetal demise. Which intervention should the nurse implement? 1. Remove the baby from the delivery area quickly. 2. Tell the father to arrange to take the infant home. 3. Wrap the infant in a towel and place it aside. 4. Obtain a lock of the infant's hair for the parents.

4. Obtain a lock of the infant's hair for the parents.

70. The licensed practical nurse (LPN) is working in a surgical rehabilitation unit. Which nursing task would be most appropriate for the LPN to implement? 1. Bathe the client who is incontinent of urine. 2. Document the amount of food the client eats. 3. Conduct the afternoon bingo game in the lobby. 4. Perform routine dressing changes on assigned clients.

4. Perform routine dressing changes on assigned clients.

12. The female home health (HH) aide calls the office and reports pain after feeling a pulling in her back when she was transferring the client from the bed to the wheel- chair. Which priority action should the HH nurse tell the HH aide? 1. Explain how to perform isometric exercises. 2. Instruct her to go to the local emergency room. 3. Tell her to complete an occurrence report. 4. Recommend that she apply an ice pack to the back.

4. Recommend that she apply an ice pack to the back.

6. The nurse, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) are caring for clients in a critical care unit. Which task would be most appropriate for the nurse to assign/delegate? 1. Instruct the UAP to obtain the client's serum glucose level. 2. Request the LPN to change the central line dressing. 3. Ask the LPN to bathe the client and change the bed linens. 4. Tell the UAP to obtain urine output for the 12-hour shift.

4. Tell the UAP to obtain urine output for the 12-hour shift.

18. The charge nurse is making assignments on a pediatric unit. Which client should be assigned to the licensed practical nurse (LPN)? 1. The 6-year-old client diagnosed with sickle cell crisis. 2. The 8-year-old client diagnosed with biliary atresia. 3. The 10-year-old client diagnosed with anaphylaxis. 4. The 11-year-old client diagnosed with pneumonia.

4. The 11-year-old client diagnosed with pneumonia.

83. The head nurse is completing the yearly performance evaluation on a nurse. Which data regarding the nurse's performance should be included in the evaluation? 1. The number of times the nurse has been tardy. 2. The attitude of the nurse at the client's bedside. 3. The thank you notes the nurse received from clients. 4. The chart audits of the clients for whom the nurse cared.

4. The chart audits of the clients for whom the nurse cared.

33. The home health (HH) agency director of nursing is making assignments for the nurses. Which client should be assigned to the HH nurse new to HH nursing? 1. The client diagnosed with AIDS who is dyspneic and confused. 2. The client who does not have the money to get prescriptions filled. 3. The client with full-thickness burns on the arm who needs a dressing change. 4. The client complaining of pain who is diagnosed with diabetic neuropathy.

4. The client complaining of pain who is diagnosed with diabetic neuropathy.

35. The charge nurse has received laboratory data for clients in the medical department. Which client would require intervention by the charge nurse? 1. The client diagnosed with a myocardial infarction (MI) who has an elevated troponin level. 2. The client receiving the IV anticoagulant heparin who has a partial thromboplastin time (PTT) of 68 seconds. 3. The client diagnosed with end-stage liver failure who has an elevated ammonia level. 4. The client receiving the anticonvulsant phenytoin (Dilantin) who has levels of 24 mg/dL.

4. The client receiving the anticonvulsant phenytoin (Dilantin) who has levels of 24 mg/dL.

87. The nurse is caring for clients on a surgical intensive care unit. Which client should the nurse assess first? 1. The client who is 4 hours postoperative for abdominal surgery who is complaining of abdominal pain and has hypoactive bowel sounds. 2. The client who is 1 day postoperative for total hip replacement (THR) who has voided 550 mL of clear amber urine in the last 8 hours. 3. The client who is 8 hours postoperative for open cholecystectomy who has a T-tube draining green bile. 4. The client who is 12 hours postoperative for total knee replacement (TKR) who is complaining of numbness and tingling in the foot.

4. The client who is 12 hours postoperative for total knee replacement (TKR) who is complaining of numbness and tingling in the foot.

106. The clinic nurse is reviewing the laboratory data of clients seen in the clinic the previous day. Which client requires immediate intervention by the nurse? 1. The client whose white blood cell (WBC) count is 9.5 mm3. 2. The client whose cholesterol level is 230 mg/dL. 3. The client whose calcium level is 10.4 mg/dL. 4. The client whose International Normalized Ratio (INR) is 3.8.

4. The client whose International Normalized Ratio (INR) is 3.8.

42. Which client warrants immediate intervention from the nurse on the medical unit? 1. The client diagnosed with an abdominal aortic aneurysm who has an audible bruit. 2. The client with adult respiratory distress syndrome (ARDS) who has bilateral crackles. 3. The client diagnosed with bacterial meningitis who has nucal rigidity and neck pain. 4. The client with Crohn's disease who has right lower abdominal pain and has diarrhea.

4. The client with Crohn's disease who has right lower abdominal pain and has diarrhea.

100. The admitting nurse is subpoenaed to give testimony in a case in which the client fell from the bed and fractured the left hip. The nurse initiated fall precautions on ad- mission but was not on duty when the client fell. Which issue should the nurse be prepared to testify about the incident? 1. What preceded the client's fall from the bed. 2. The extent of injuries the client sustained. 3. The client's mental status before the incident. 4. The facility's policy covering falls prevention.

4. The facility's policy covering falls prevention.

A nurse is teaching a client who had a stroke about ways to adapt to a visual disability. Which does the nurse identify as the primary safety precaution to use? 1. Wear a patch over one eye. 2. Place personal items on the sighted side. 3. Lie in bed with the unaffected side toward the door. 4. Turn the head from side to side when walking.

4. To expand the visual field, the partially sighted client should be taught to turn the head from side to side when walking. Neglecting to do so may result in accidents. This technique helps maximize the use of remaining sight. Covering an eye with a patch will limit the field of vision. Personal items can be placed within sight and reach, but most accidents occur from tripping over items that cannot be seen. It may help the client to see the door, but walking presents the primary safety hazard.

See first? 1. A 22 yr old admitted with viral gastroenteritis complaining of nausea, vomiting and diarrhea 2. 42 year old 24 hours post thyroidectomy who is complaining of headache and pain at the incision site 3. 50 year old admitted 72 hours ago for ckd with uop of 220mL in 8 hours and hands and feet are edematous 4. A 64 year old admitted yesterday for hypertension, hf, digitalis toxicity with frequent PVCs (premature ventricular complexes)

4. indicated potassium imbalance; hypokalemia, dysrhythmias can rapidly deteriorate to ventricular tachycardia or sudden death. 1. potential E-lyte imbalance; monitor 2. expected outcome; headache needs further investigation but is not most concerning 3. indicates sodium retention=expected finding in CKD; output needs to be evaluated but is not most concerning

See First? 1. multigravida at 12 weeks experiencing white vaginal discharge 2. Primigravida at 17 weeks has not felt baby move 3. primigravida at 22 weeks complains of feeling dizzy and clammy when lying on her back 4. multigravida at 32 weeks experiencing malaise and bilateral dependent and facial edema

4. symptoms of pre-eclampsia that require evaluation 1. leukorrhea caused by hyperplasia of vaginal mucosa, normal finding 2. normal 3. vena cava syndrome-obstruction or compression of blood flow; instruct client to lie on side

See first? 1. A client who is breastfeeding 2 day old 2. discharged client with IV hep therapy for DVT 3. Elderly client discharged 3 days ago with pneumonia 4. elderly client who used all the diuretic medication and is expectorating pink-tinged mucous

4. symptoms of pulmonary edema; requires immediate attention 1. stable 2. assess for bleeding gums and hematuria; not a priority 3. assess for breath sounds, encourage fluids, cough and deep breathe

Calculate the CPP for the patient with an ICP of 34 mm Hg and a systemic BP of 108/64 mm Hg. mm Hg

45 mm Hg MAP = DBP + 1 ⁄3 (SBP − DBP) = 64 + 15 = 79 CPP = MAP − ICP = 79 − 34 = 45

A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time? a) 5:30 p.m. b) 3:00 p.m. c) 4:00 p.m. d) 2:30 p.m.

4:00 p.m. Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset. Therefore, since symptom onset was 1:00 pm, the window of opportunity ends at 4:00 pm.

5. A client with a history of suicide attempts is admitted to the mental health unit with the diagnosis of depression. Upon the client's arrival, the client's therapist reports to the nurse that the clients telephoned the therapist earlier in the evening and reported having a overwhelming suicidal thoughts. Keeping this information in mind, the priority of the nurse is to assess for: a) interaction with peers b) the presence of suicidal thoughts c) the amount of food intake for the past 24 hours d) information regarding the past medication regimen

5) B The critical information from the therapist is that the client is having thoughts of self-harm; therefore, the nurse needs further information about present thoughts of suicide so that the treatment plan may be as appropriate as possible. The nurse must make sure the client is safe. The items in options A, C, and D should be assessed; however, evaluation for suicide potential is most important

5. The plan of care for a diabetic patient includes all of these interventions. Which intervention should you delegate to a UAP? 1. Checking to make sure that the patient's bath water is not too hot 2. Discussing community resources for diabetic outpatient care 3. Teaching the patient to perform daily foot inspection 4. Assessing the patient's technique for drawing insulin into a syringe

5. Ans: 1 Checking the bath water temperature is part of assisting with activities of daily living and is within the education and scope of practice of the UAP. Discussing community resources, teaching, and assessing require a higher level of education and are appropriate to the scope of practice of licensed nurses. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 190). Elsevier Health Sciences. Kindle Edition.

5. A patient is hospitalized with adrenocortical insufficiency. Which nursing activity should you delegate to a UAP? 1. Reminding the patient to change positions slowly 2. Assessing the patient for muscle weakness 3. Teaching the patient how to collect a 24-hour urine sample 4. Revising the patient's nursing plan of care

5. Ans: 1 Patients with hypofunction of the adrenal gland often have hypotension and should be instructed to change positions slowly. Once a patient has been so instructed, it is appropriate for the UAP to remind the patient of those instructions. Assessing, teaching, and planning nursing care require more education and should be done by licensed nurses. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 191). Elsevier Health Sciences. Kindle Edition.

5. A client is admitted through the ED for treatment of a strangulated intestinal obstruction with perforation. What interventions do you anticipate for this emergency condition? (Select all that apply.) 1. Preparation for surgery 2. Barium enema examination 3. Nasogastric (NG) tube insertion 4. Abdominal radiography 5. IV fluid administration 6. IV administration of broad-spectrum antibiotics 7. Morphine via a client-controlled analgesia device

5. Ans: 1, 3, 4, 5, 6 Strangulated intestinal obstruction is a surgical emergency. The NG tube is for decompression of the intestine. Abdominal radiography is the most useful diagnostic aid. IV fluids are needed to maintain fluid and electrolyte balance and allow IV delivery of medication. IV broad-spectrum antibiotics are usually ordered. Pain medications are likely to be withheld during the initial period to prevent masking of peritonitis or perforation. In addition, morphine slows gastric motility. A barium enema examination is not ordered if perforation is suspected. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 205). Elsevier Health Sciences. Kindle Edition.

5. When care assignments are being made for patients with alterations related to gastrointestinal (GI) cancer, which patient would be the most appropriate to assign to an LPN/ LVN under the supervision of a team leader RN? 1. A patient with severe anemia secondary to GI bleeding 2. A patient who needs enemas and antibiotics to control GI bacteria 3. A patient who needs preoperative teaching for bowel resection surgery 4. A patient who needs central line insertion for chemotherapy

5. Ans: 2 Administering enemas and antibiotics is within the scope of practice of LPNs/ LVNs. Although some states an facilities may allow the LPN/ LVN to administer blood, in general, administering blood, providing preoperative teaching, and assisting with central line insertion are the responsibilities of the RN. Focus: Assignment LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 168). Elsevier Health Sciences. Kindle Edition.

5. You are taking an initial history for a client seeking surgical treatment for obesity. Which finding should be called to the attention of the surgeon before proceeding with additional history taking or physical assessment? 1. Obesity for approximately 5 years 2. History of counseling for body dysmorphic disorder 3. Failure to reduce weight with other forms of therapy 4. Body weight 100% above the ideal for age, gender, and height

5. Ans: 2 Body dysmorphic disorder is a preoccupation with an imagined physical defect. Corrective surgery can exacerbate this disorder when the client continues to feel dissatisfied with the results. The other findings are criterion indicators for this treatment. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 187). Elsevier Health Sciences. Kindle Edition.

5. After interviewing an HIV-positive patient who is considering starting highly active antiretroviral therapy (HAART), which patient information concerns you the most? 1. The patient has been HIV positive for 8 years and has never taken any drug therapy for the HIV infection. 2. The patient tells you, "I have never been very consistent about taking medications." 3. The patient is sexually active with multiple partners and says "I always use a condom." 4. The patient has many questions and concerns regarding the effectiveness and safety of the medications.

5. Ans: 2 Drug therapy for HIV infection requires taking medications very consistently. Failure to take the medications daily can lead to mutations and the emergence of more virulent forms of the virus. Although the other data indicate the need for further assessments or interventions, they will not affect the decision to initiate antiretroviral therapy for this patient. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 171). Elsevier Health Sciences. Kindle Edition.

5. Which action would best demonstrate evidence-based nursing practice in the care of a patient who is 1 day postpartum and reporting nipple soreness while breast-feeding? 1. Give the baby a bottle after 5 minutes of nursing to allow soreness to resolve. 2. Assess the mother-baby couplet for nursing position and latch, and correct as indicated. 3. Advise the use of a breast pump until nipple soreness resolves. 4. Advise alternating breast and bottle feedings to avoid excess sucking at the nipple.

5. Ans: 2 It is recommended to avoid artificial nipples and pacifiers while establishing breast feeding unless medically indicated. Improper latch and position are common causes of nipple soreness and can be corrected with assessment and assistance to the mother. This practice supports the Perinatal Core Measure of increasing the percentage of newborns who are fed breast milk only. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 199). Elsevier Health Sciences. Kindle Edition.

5. You have been floated to the telemetry unit for the day. The monitor watcher informs you that the client has developed prominent U waves. Which laboratory value should you check immediately? 1. Sodium 2. Potassium 3. Magnesium 4. Calcium

5. Ans: 2 Suspect hypokalemia and check the client's potassium level. Common ECG changes with hypokalemia include ST-segment depression, inverted T waves, and prominent U waves. Clients with hypokalemia may also develop heart block. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 172). Elsevier Health Sciences. Kindle Edition.

5. You are working as the triage nurse in the ED when the following four clients arrive. Which client requires the most rapid action to protect other clients in the ED from infection? 1. 3-year-old who has paroxysmal coughing and whose sibling has pertussis 2. 5-year-old who has a new pruritic rash and a possible chickenpox infection 3. 62-year-old who has a history of a methicillin-resistant Staphylococcus aureus (MRSA) abdominal wound infection 4. 74-year-old who needs tuberculosis (TB) testing after being exposed to TB during a recent international airplane flight

5. Ans: 2 Varicella (chickenpox) is spread by airborne means and could be rapidly transmitted to other clients in the ED. The child with the rash should be quickly isolated from the other ED clients through placement in a negative-pressure room. Droplet and/ or contact precautions should be instituted for the clients with possible pertussis and MRSA infection, but this can be done after isolating the child with possible chickenpox. The client who has been exposed to TB does not place other clients at risk for infection because there are no symptoms of active TB. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 173). Elsevier Health Sciences. Kindle Edition.

5. You are supervising an RN who floated from the medical-surgical unit to the emergency department. The nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which directions would you clearly provide to the RN? (Select all that apply.) 1. Position the patient supine and turned on his side. 2. Apply direct lateral pressure to the nose for 5 minutes. 3. Maintain standard body substance precautions. 4. Apply ice or cool compresses to the nose. 5. Instruct the patient not to blow the nose for several hours.

5. Ans: 2, 3, 4, 5 The correct position for a patient with an anterior nosebleed is upright and leaning forward to prevent blood from entering the stomach and to avoid aspiration. All of the other instructions are appropriate according to best practice for emergency care of a patient with an anterior nosebleed. Focus: Delegation, supervision, assignment LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 175). Elsevier Health Sciences. Kindle Edition.

5. Which tasks are appropriate to delegate to an LPN/ LVN who is functioning under the supervision of an RN? (Select all that apply.) 1. Assessing the sexual implications for a client with oculogenital-type Chlamydia trachomatis infection 2. Administering sulfacetamide sodium 10% (Sulf-10 Ophthalmic) to a child with conjunctivitis 3. Reviewing hand-washing and hygiene practices with clients who have eye infections 4. Showing clients how to gently cleanse eyelid margins to remove crusting 5. Assessing nutritional factors for a client with age-related macular degeneration 6. Reviewing the health history of a client to identify risk for ocular manifestations 7. Performing a routine check of a client's visual acuity using the Snellen eye chart

5. Ans: 2, 3, 4, 7 Administering medications, reviewing and demonstrating standard procedures, and performing standardized assessments with predictable outcomes in noncomplex cases are within the scope of the LPN/ LVN. Assessing for systemic manifestations and behaviors, risk factors, and nutritional factors is the responsibility of the RN. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 185). Elsevier Health Sciences. Kindle Edition.

5. You are the nurse manager in the burn unit. Which client is best to assign to an RN who has floated from the oncology unit? 1. 23-year-old who has just been admitted with burns over 30% of the body after a warehouse fire 2. 36-year-old who requires discharge teaching about nutrition and wound care after having skin grafts 3. 45-year-old with infected partial-thickness back and chest burns who has a dressing change scheduled 4. 57-year-old with full-thickness burns on both arms who needs assistance in positioning hand splints

5. Ans: 3 A nurse from the oncology unit would be familiar with dressing changes and sterile technique. The charge RN in the burn unit would work closely with the float RN to provide partners to assist in providing care and to answer any questions. Admission assessment and development of the initial care plan, discharge teaching, and splint positioning in burn clients all require expertise in caring for clients with burns. These clients should be assigned to RNs who regularly work on the burn unit. Focus: Assignment LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 193). Elsevier Health Sciences. Kindle Edition.

5. As charge nurse, you are making the daily assignments on the medical-surgical unit. Which patient is best assigned to a float nurse who has come from the postanesthesia care unit (PACU)? 1. 30-year-old patient with thalassemia major who has an order for subcutaneous infusion of deferoxamine (Desferal) 2. 43-year-old patient with multiple myeloma who requires discharge teaching 3. 52-year-old patient with chronic gastrointestinal bleeding who has returned to the unit after a colonoscopy 4. 65-year-old patient with pernicious anemia who has just been admitted to the unit

5. Ans: 3 A nurse who works in the PACU will be familiar with the monitoring needed for a patient who has just returned from a procedure such as a colonoscopy, which requires conscious sedation. Care of the other patients requires staff with more experience with various types of hematologic disorders and would be better to assign to nursing personnel who regularly work on the medical-surgical unit. Focus: Assignment 6. Ans: 1 Patients with pancytopenia are at higher risk for infection. The patient with digoxin toxicity presents the least risk of infecting the new patient. Viral pneumonia, shingles, and cellulitis are infectious processes. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 181). Elsevier Health Sciences. Kindle Edition.

5. You make a home visit to evaluate a hypertensive client who has been taking enalapril (Vasotec). Which finding indicates that you need to contact the health care provider about a change in the drug therapy? 1. Client reports frequent urination. 2. Client's blood pressure is 138/ 86 mm Hg. 3. Client coughs often during the visit. 4. Client says, "I get dizzy sometimes."

5. Ans: 3 A persistent and irritating cough (caused by accumulation of bradykinin) is a possible adverse effect of angiotensin-converting enzyme (ACE) inhibitors such as enalapril and is a common reason for changing to another medication category such as the angiotensin II receptor blockers. The other assessment data indicate a need for more client teaching and ongoing monitoring but would not require a change in therapy. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 178). Elsevier Health Sciences. Kindle Edition.

5. There is a patient on the medical-surgical unit who has been there for several months. He is hostile, rude, and belligerent, and no one likes to interact with him. How should you handle the assignment? 1. Rotate the assignment schedule so that no one has to care for him more than once or twice a week. 2. Pair a float nurse and a nursing student and assign the patient to that team because they will have a fresh perspective toward the patient. 3. Identify two or three experienced nurses as primary caregivers and develop a plan that includes psychosocial interventions. 4. Assign yourself as primary caregiver so that you can role-model how patients should be treated.

5. Ans: 3 This patient has trouble with interpersonal interactions, so consistent caregivers who use psychosocial interventions have the best chance of being able to develop a relationship with this difficult individual. Rotating the assignment sheet to give the staff a break and using float staff are frequent strategies that are employed, but these are not necessarily the best for the patient. Taking the patient yourself may seem like the easiest solution, but in the long run strengthening and supporting the staff are better strategies than trying to do all of the hard tasks yourself. Focus: Assignment LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 207). Elsevier Health Sciences. Kindle Edition.

5. A nursing student is teaching a client and family about epilepsy before the client's discharge. For which statement should you intervene? 1. " You should avoid consumption of all forms of alcohol." 2. " Wear your medical alert bracelet at all times." 3. " Protect your loved one's airway during a seizure." 4. " It's OK to take over-the-counter medications."

5. Ans: 4 A client with a seizure disorder should not take over-the-counter medications without consulting with the health care provider first. The other three statements are appropriate teaching points for clients with seizure disorders and their families. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 182). Elsevier Health Sciences. Kindle Edition.

5. A patient is being admitted to rule out interstitial cystitis. What should your plan of care for this patient include? 1. Take daily urine samples for urinalysis. 2. Maintain accurate intake and output records. 3. Obtain an admission urine sample to determine electrolyte levels. 4. Teach the patient about the cystoscopy procedure.

5. Ans: 4 A cystoscopy is needed to accurately diagnose interstitial cystitis. Urinalysis may show WBCs and RBCs, but no bacteria. The patient will probably need a urinalysis upon admission, but daily samples do not need to be obtained. Intake and output may be assessed, but results will not contribute to the diagnosis. Cystitis does not usually affect urine electrolyte levels. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 195). Elsevier Health Sciences. Kindle Edition.

5. An 8-year-old child has stomatitis secondary to chemotherapy. Which task would be best to delegate to the UAP? 1. Reporting evidence of severe mucosal ulceration 2. Assisting the child in swishing and spitting an anesthetic mouthwash 3. Assessing the child's ability and willingness to drink through a straw 4. Helping the patient to eat a bland, moist, soft diet

5. Ans: 4 Helping the patient to eat is within the scope of responsibilities for a UAP. Assessing ability and willingness to drink and checking for extent of mucosal ulceration is the responsibility of an RN. Plain water or saline rinses are preferable if the child cannot gargle or spit out fluids. The RN should assess and administer oral preparations as needed. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 201). Elsevier Health Sciences. Kindle Edition.

5. As the charge nurse, you are reviewing the charts of clients who were assigned to the care of a newly graduated RN. The RN has correctly charted dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should you take first? 1. Make a note in the nurse's file and continue to observe clinical performance. 2. Refer the new nurse to the in-service education department. 3. Quiz the nurse about knowledge of pain management and pharmacology. 4. Give praise for correctly charting the dose and time and discuss the deficits in charting.

5. Ans: 4 In supervision of the new RN, good performance should be reinforced first and then areas of improvement can be addressed. Asking the nurse about knowledge of pain management is also an option; however, it would be a more indirect and time-consuming approach. Making a note and watching do not help the nurse to correct the immediate problem. In-service training might be considered if the problem persists. Focus: Supervision, delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 3). Elsevier Health Sciences. Kindle Edition.

5. As charge nurse, you are making assignments for the day shift. Which patient would you assign to the nurse who was floated from the postanesthesia care unit (PACU) for the day? 1. 35-year-old with osteomyelitis who needs teaching before hyperbaric oxygen therapy 2. 62-year-old with osteomalacia who is being discharged to a long-term care facility 3. 68-year-old with osteoporosis given a new orthotic device whose knowledge of its use must be assessed 4. 72-year-old with Paget disease who has just returned from surgery for total knee replacement

5. Ans: 4 The PACU nurse is very familiar with the assessment skills necessary to monitor a patient who just underwent surgery. For the other patients, nurses familiar with musculoskeletal system- related nursing care are needed to provide teaching and assessment, and prepare a report to the long-term care facility. Focus: Assignment LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 186). Elsevier Health Sciences. Kindle Edition.

5. You obtain the following assessment data about your client who has had a transurethral resection of the prostate (TURP) and has continuous bladder irrigation. Which finding indicates the most immediate need for nursing intervention? 1. The client states that he feels a continuous urge to void. 2. The catheter drainage is light pink with occasional clots. 3. The catheter is taped to the client's thigh. 4. The client reports painful bladder spasms.

5. Ans: 4 The bladder spasms may indicate that blood clots are obstructing the catheter, which would indicate the need for irrigation of the catheter with 30 to 50 mL of normal saline using a piston syringe. The other data would all be normal after a TURP, but the client may need some teaching about the usual post-TURP symptoms and care. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 197). Elsevier Health Sciences. Kindle Edition.

5. The nurse is giving a bed bath to an assigned client when an unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? a. Finish the bed bath and then administer the pain medication to the other client b. Ask the UAP to find out when the last pain medication was given to the client c. Ask the UAP to tell the client in pain that medication will be administered as soon as the bed bath is complete. d. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

5. D- The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not responsibility of the UAP.

47. The 24-month-old toddler is admitted to the pediatric unit with vomiting and diarrhea. Which interventions should the nurse implement? Rank in order of performance. 1. Teach the parent about weighing diapers to determine output status. 2. Show the parent the call light and explain safety regimens. 3. Assess the toddler's tissue turgor. 4. Place the appropriate size diapers in the room. 5. Take the toddler's vital signs.

5. Take the toddler's vital signs. 3. Assess the toddler's tissue turgor. 2. Show the parent the call light and explain safety regimens 4. Place the appropriate size diapers in the room. 1. Teach the parent about weighing diapers to determine output status.

The cerebral perfusion pressure (CPP) is the pressure needed to ensure blood flow to the brain. Normal CPP is 60 to 100 mm Hg. Calculate the CPP of a patient whose blood pressure (BP) is 106/52 mm Hg and ICP is 14 mm Hg. mm Hg

56 mm Hg Mean arterial pressure (MAP) = diastolic blood pressure (DBP) + 1 ⁄3 (systolic blood pressure [SBP] - DBP) = 52 + 18 = 70 Cerebral per

6. A group of health nurse is caring for a group of homeless people. When planning for the potential needs of this group, what is the most immediate concern? a) peer support through structured groups b) finding affordable housing for the group c) setting up a 24-hour crisis center and hotline d) meeting the basic needs to ensure that adequate food, shelter, and clothing are available

6) D - The question asks about the immediate concern. The ABCs of community health are always attending to people's basic needs of food, shelter, and clothing. Options A, B, and C are other activities that may be completed at a later time.

6. While admitting a client, you obtain this information about her cardiovascular risk factors: Her mother and two siblings have had myocardial infarctions (MIs). The client smokes and has a 20 pack-year history of cigarette use. Her work as a mail carrier involves a lot of walking. She takes metoprolol (Lopressor) for hypertension, and her blood pressure has been in the range of 130/ 60 to 138/ 85 mm Hg. Which interventions will be important to include in the discharge plan for this client? (Select all that apply.) 1. Referral to community programs that assist in smoking cessation 2. Teaching about the impact of family history on cardiovascular risk 3. Education about the need for a change in antihypertensive therapy 4. Assistance in reducing the stress associated with her cardiovascular risk 5. Discussion of the risks associated with having a sedentary lifestyle

6. Ans: 1, 2 The client's major modifiable risk factor is her ongoing smoking. The family history is significant, and she should be aware that this increases her cardiovascular risk. The goal when treating hypertension with medications is reduction of blood pressure to under 140/ 90 mm Hg. There is no indication that stress is a risk factor for this client. The client's work involves moderate physical activity; although leisure exercise may further decrease her cardiac risk, this is not an immediate need for this client. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 178). Elsevier Health Sciences. Kindle Edition.

6. The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An unlicensed assistive personnel (UAP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the UAP? a. Ignore the resistance b. Exert coercion on the UAP c. Provide a positive reward system for the UAP d. Confront the UAP to encourage verbalization of feelings regarding the change

6. D- Confrontation is an important strategy to meet resistance head on. Face-to face meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem. Option 1 will not address the problem. Option 2 may produce additional resistance. Option 3 may provide a temporary solution to the resistance, but will not address the concern specifically

7. A community health nurse is working with older residents who were involved in a recent flood. Many of the residents are emotionally despondent, and they refused to leave their homes for days. When planning forth rescue and relocation of these older residents, what is the first item that the nurse needs to consider? a) contacting the older resident's families b) attending to the emotional needs of the older residents c) arranging for ambulance transportation for the oldest residents d) attending to the nutritional status and basic needs of the older residents

7) D - The question asks about the first thing that the nurse needs to consider. The ABCs of community health are always attending to people's basic needs of food, shelter, and clothing. Options A, B, and C are other activities that may or may not be needed at a later date.

7. The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an unlicensed assistive personnel (UAP)? a. A client requiring a colostomy irrigation b. A client receiving continuous feedings c. A client who requires urine specimen collections d. A client with difficulty swallowing food and fluids

7. C- The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the UAP would be to care for the client who requires urine specimen collections. The UAP is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by unlicensed personnel. The client with difficulty swallowing food and fluids is at risk for aspiration

8. A client is scheduled for an arteriogram using a radiopaque dye. The nurse assesses which most critical item before the procedure? a) vital signs b) intake and output c) height and weight d) allergy to iodine or shellfish

8) D - Allergy to iodine or seafood is associated with allergy to the radiopaque dye that is used for medical imaging examinations. Informed consent is necessary, because an arteriogram requires the injection of a radiopaque dye into the blood vessel. Although options A, B, and C are components of the preprocedure assessment, the risks of allergic reaction and possible anaphylaxis are the most critical.

8. A new unit nurse manager is holding her first staff meeting. The manager greets the staff and comments that she has been employed to bring about quality improvement. The manager provides a plan that she developed and a list of tasks and activities for which each staff member must volunteer to perform. In addition, she instructs staff members to report any problems directly to her. What type of leader and manager approach do the new manager's characteristics suggest? a. Autocratic b. Situational c. Democratic d. Laissez-faire

8. A- The autocratic leader is focused, maintains strong control, makes decisions, and addresses all problems. The autocrat dominates the group and commands rather than seeks suggestions or input. In this situation, the manager addresses a problem (quality improvement) with the staff, designs a plan without input, and wants all problems reported directly back to her. A situational leader will use a combination of styles, depending on the needs of the group and the tasks to be achieved. The situational leader would work with the group to validate that the information that the leader gained as a new employee was accurate and that a problem existed then the leader would take the time to get to know the group determine which approach to change (if needed) would work best according to the needs of the group and the nature and substance of the change that was required. A democratic leader is participative and would likely meet with each staff person individually to determine the staff member's perception of the problem. The democratic leader would also speak with the staff about any issues and ask the staff for input with developing a plan. A laissez-faire leader is passive and nondirective. The laissez-faire leader would state what the problem was and inform the staff that the staff needed to come up with a plan to "fix it."

9. A client in a long-term care facility has had a series of gastrointestinal (GI) diagnostic tests, including an upper GI series and endoscopies. Upon return to the long-term care facility, the priority nursing assessment should focus on: a) the comfort level b) activity tolerance c) the level of consciousness d) the hydration and nutrition status

9) D- Many of the diagnostic studies to identify GI disorders require that the GI tract be cleaned (usually with laxatives and enemas) before testing. In addition, the client most often takes nothing by mouth before and during the testing period. Because the studies may be done over a period that exceeds 24 hours, the client may become dehydrated and/or malnourished. Although options A, B, and C may be components of the assessment, option D is the priority.

9. The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical (vocational) nurse and three unlicensed assistive personnel (UAP) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical (vocational) nurse? a. A client who requires a bed bath b. An older client requiring frequent ambulation c. A client who requires hourly vital sign measurements d. A client requiring abdominal wound irrigations and dressing changes every 3 hours

9. D- When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Giving a bed bath, assisting with frequent ambulation, and taking vital signs can be provided most appropriately by the unlicensed assistive personnel (UAP). The licensed practical (vocational) nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? a. Left-sided cerebrovascular accident (CVA) b. Right-sided cerebrovascular accident (CVA) c. Transient ischemic attack (TIA) d. Completed Stroke

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. Monitoring is needed as rapid neurologic deterioration may occur. b. Symptoms will evolve over a period of 1 week. c. The crash cart with defibrillator is kept nearby. d. Bleeding continues into the intracerebral area.

During a 6-month well-baby check up, the mother mentions to the nurse that her infant seems to be sleeping just as much as she did as a newborn, and she seems to do everything with her left hand. The nurse recognizes that these are warning signs of stroke that occurred early in life. What other question should the nurse ask to assess for signs of stroke? A) "Have you noticed your baby jerking any muscles of the face, arms, or legs?" B) "Have you noticed your baby having trouble forming words?" C) "Does your baby vomit frequently after feeding?" D) "Does your baby frequently seem to lose her balance?"

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? a. Seizure was 1 minute in duration including tonic-clonic activity. b. Sleeping quietly after the seizure c. The client cried out before the seizure began. d. Seizure began at 1300 hours.

The medication clopidogrel (Plavix) is most commonly given during which stage of treatment for a stroke? A) Stroke prevention B) Acute care immediately after a stroke C) Recovery care after a stroke D) Rehabilitation after a stroke

When providing teaching to a client who reports tension headaches, which of the following instructions would be most beneficial to prevent onset of symptoms? a. Perform stretching exercises and frequent position change. b. Apply cool or warm cloth to head or eyes. c. Eliminate use of bright lights when working. d. Avoid certain foods.

Which of the following is contraindicated in a patient with increased ICP? A. Lumbar puncture B. Midline position of the head C. Hyperosmotic diuretics D. Barbiturates medications

While completing a health history with an older adult client, the nurse learns that the client experienced a transient ischemic attack (TIA) several months ago. The nurse should recognize that: A) the client is at risk for an ischemic thrombotic stroke. B) the client will have minimal symptoms should a stroke occur. C) the client will not experience a stroke in the future. D) the client is at high risk for a hemorrhagic stroke.

While teaching a wellness class on the warning signs of stroke, a participant asks the nurse, "What's the most important thing for me to remember?" What is an appropriate response by the nurse? A) "Be alert for sudden weakness or numbness." B) "Know your family history." C) "Keep a list of your medications." D) "Call 911 if you notice a gradual onset of paralysis or confusion."

You're collecting vital signs on a patient with ICP. The patient has a Glascoma Scale rating of 4. How will you assess the patient's temperature? A. Rectal B. Oral C. Axillary

You're maintaining an external ventricular drain. The ICP readings should be? A. 5 to 15 mmHg B. 20 to 35 mmHg C. 60 to 100 mmHg D. 5 to 25 mmHg

The patient had an acute ischemic stroke 4 hours ago and has an elevated blood pressure. What action should you take? A. Document the findings because the increased pressure is needed to perfuse the brain. B. Administer an antihypertensive medication to prevent additional damage. C. Hyperventilate the patient to cause vasodilatation. D. Teach patient about a low sodium diet.

A After a stroke, temporary hypertension is needed to perfuse the area of swelling. No treatment is done unless the pressure is above 220/110 mm Hg in the first few hours. Aggressive lowering of blood pressure is not done, because if the pressure drops, it can prevent regional perfusion and lead to local tissue damage. Hyperventilation is done if hypercapnia is identified, but it is not prophylactic.

During admission of a patient with a severe head injury to the emergency department, you place the highest priority on assessment of A. patency of airway. B. presence of a neck injury. C. neurologic status with the Glasgow Coma Scale. D. cerebrospinal fluid leakage from the ears or nose.

A An initial priority in the emergency management of a patient with a severe head injury is for you to ensure that the patient has a patent airway.

When assessing a patient with a traumatic brain injury, you notice uncoordinated movement of the extremities. How would you document this? A. Ataxia B. Apraxia C. Anisocoria D. Anosognosia

A Ataxia is a lack of coordination of movement, possibly caused by lesions of sensory or motor pathways, cerebellar disorders, or certain medications.

The patient reports falling when he his foot got "stuck" on a crack in the sidewalk, hitting his head when he fell, and "passing out". The paramedics found the patient walking at the scene and talking before transporting the patient to the hospital. In the emergency department, the patient starts to lose consciousness. This is a classic scenario for which complication? A. Epidural hematoma B. Subdural hematoma C. Subarachnoid bleed D. Diffuse axial inju

A Epidural hematoma often results from a linear fracture crossing a major artery in the dura. The classic sign is an initial period of unconsciousness at the scene and a brief lucid interval followed by a decrease in LOC. A subdural hematoma often results from injury to the brain and veins and develops more slowly. The classic sign or symptom of subarachnoid hemorrhage is a patient describing "the worst headache of my life." Diffuse axonal injury is widespread axonal damage occurring after a traumatic brain injury.

Which nursing action should be implemented in the care of a patient who is experiencing increased ICP? A. Monitor fluid and electrolyte status astutely. B. Position the patient in a high-Fowler's position. C. Administer vasoconstrictors to maintain cerebral perfusion. D. Maintain physical restraints to prevent episodes of agitation.

A Fluid and electrolyte disturbances can have an adverse effect on ICP and must be vigilantly monitored. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically administered in the treatment of ICP.

Computed tomography of a 68-year-old patient's head reveals that he has experienced a hemorrhagic stroke. Which option is a nursing priority intervention in the emergency department? A. Maintenance of the patient's airway B. Positioning to promote cerebral perfusion C. Control of fluid and electrolyte imbalances D. Administration of tissue plasminogen activator (tPA)

A Maintenance of a patent airway is the priority in the acute care of a patient with a hemorrhagic stroke, and it supersedes the importance of fluid and electrolyte imbalance and positioning. Use of tPA is contraindicated in hemorrhagic stroke.

Why are the data regarding mobility, strength, coordination, and activity tolerance important for you to obtain? A. Many neurologic diseases affect one or more of these areas. B. Patients are less able to identify other neurologic impairments. C. These are the first functions to be affected by neurologic disease. D. Aspects of movement are the most important function of the nervous system.

A Many neurologic disorders can cause problems in the patient's mobility, strength, and coordination. These problems can result in changes in the patient's usual activity and exercise patterns.

The home care nurse is planning the order of clients for the day. Which client should the nurse prioritize as needing to be seen first? A.A newly diagnosed diabetic client who is administering morning insulin independently for the first time B.A client requiring indwelling catheter change due to leakage C.A client being seen poststroke for rehabilitation and education about poststroke care D.A client with daily dressing change, normally done at 0800 per client preference

A Rationale: A newly diagnosed client who is administering insulin independently for the first time creates a time constraint. The nurse would see this client first to ensure that the insulin is being administered properly. While client preferences are an important consideration, the time constraint of the insulin would be a higher priority. A client being seen poststroke for rehabilitation and education as well as a client with a leaking indwelling catheter would also be lower priorities when planning the order of clients for the day.

The nurse administered blood pressure medications to the wrong client. Upon realizing the error, the nurse notes that the last blood pressure assessment of the client who received the wrong medication was 82/50 mmHg. Which level of urgency would be required to address this situation? A.Critical B.Acute C.Nonacute D.Imminent death

A Rationale: In this situation, a blood pressure medication was administered to the wrong client who has low blood pressure, creating a critical situation to which the nurse needs to respond quickly since the client's condition could become life threatening. This would not be an acute or nonacute situation, as it is a medium-high priority. It is not likely that this error would result in death of the client, so the choice of imminent death would not be appropriate.

Which client should the nurse assess first after receiving the change-of-shift report? A.A client with heart failure who is complaining of shortness of breath B.A client with type 1 diabetes mellitus with blood glucose of 82 mg/dL C.A client with a bowel obstruction who is complaining of nausea D.A client with hypertension with a blood pressure of 168/88 mmHg

A Rationale: Using the ABCs (airway, breathing, and circulation) as a guide, the nurse should first assess the client with shortness of breath. This would take priority over a client complaining of nausea, a client with an elevated (but not critically elevated) blood pressure, and a client with a normal blood glucose reading.

The patient is diagnosed with a brain tumor. Which option is the correct understanding of the preferred treatment? A. Surgical removal is preferred, even if the tumor is not malignant. B. Chemotherapy is a common and effective treatment. C. Stereotactic radiosurgery is the preferred treatment. D. A large dose of intravenous steroid therapy is preferred.

A Surgical removal is the preferred treatment. It can reduce tumor mass (decreasing intracranial pressure [ICP]), provides relief of symptoms, and extend survival time. Even a benign mass has a malignant effect by taking up space. Traditional chemotherapy effectiveness is limited because of the blood-brain barrier, tumor cell heterogeneity, and tumor cell drug resistance. Stereotactic radiosurgery delivers a high, concentrated dose of radiation precisely directed and is used when conventional surgery has failed or is not an option. Corticosteroids are not an integral part of therapy, but are used to control complications of radiation therapy.

What is the standard to evaluate the degree of impaired consciousness for a patient with an acute head trauma? A. Best eye opening, verbal response, and motor response B. National Institutes of Health (NIH) Stroke Scale C. Romberg test D. Widening pulse pressure, bradycardia, and respirations

A The Glasgow Coma Scale (GCS) is a standardized tool used to assess the degree of impaired consciousness, and it consists of three components. The NIH stroke scale is used for a suspected stroke and includes other components of cranial nerve assessment, motor testing, and sensory testing. The Romberg test measures balance and is used for suspected cerebellar dysfunction. The components in the last option are Cushing's triad and an indication of increased ICP, not LOC.

A patient with a suspected closed head injury has bloody nasal drainage. You suspect that this patient has a cerebrospinal fluid (CSF) leak when observing which of the following? A. A halo sign on the nasal drip pad B. Decreased blood pressure and urinary output C. A positive reading for glucose on a Test-tape strip D. Clear nasal drainage along with the bloody discharge

A When drainage containing CSF and blood is allowed to drip onto a white pad, the blood coalesces into the center within a few minutes, and a yellowish ring of CSF encircles the blood, giving a halo effect. The presence of glucose is unreliable for determining the presence of CSF because blood also contains glucose.

The nurse working in a community clinic is reviewing the clients to be seen for the day. Which client should require more time in the schedule? A.A 75-year-old with recent cognitive decline B.A 32-year-old with newly diagnosed diabetes who is returning for a blood glucose recheck C.A 50-year-old who is being seen for blood pressure recheck D.A 20-year-old who is being seen for evaluation of insulin pump management

A Rationale: An older client with cognitive issues may require more time than do other clients due to both developmental and cognitive issues. Blood pressure rechecks, insulin pump follow-up, and blood glucose rechecks of young and middle-aged adults would not necessarily require more time.

The nurse working on a busy medical-surgical unit is caring for five clients. As the nurse is preparing to administer routine medications to the assigned clients, she is informed that a new admission will be arriving to the unit shortly. Which type of situation challenges the nurse's time management and organizational skills? A.Pop-up B.Pitfall C.Emergent D.Urgent

A Rationale: Events such as new admissions that are unexpected and require that nurses take time and attention away from their plan for the day are referred to as pop-ups. Pitfalls are unforeseen situations that harbor consequences for nurses and can result in client harm. Urgent and nonurgent events are methods of triaging and setting priorities for care.

The nurse is caring for a client with increased intracranial pressure secondary to a brain tumor. Which position should the nurse place the client in to help decrease intracranial pressure? A.Semi-Fowler B.High Fowler C.Left lateral recumbent D.Fowler

A Rationale: The client with increased intracranial pressure should be placed in the semi-Fowler position (30 degrees elevation) to decrease pressure.

Which action should the nurse take to best involve hospitalized clients in their care and avoid pitfalls related to not involving clients in their own care? A.Observing client behaviors for cues about preferences B.Orienting the client and family to the hospital facility and routines C.Asking the client's family about usual patterns of behavior D.Informing clients of the daily schedule of care

A Rationale: To avoid pitfalls related to not involving clients in their own care, the nurse should observe client behaviors for cues about preferences. Informing clients about the daily schedule of care and orienting clients and families to the hospital routine do not provide information about client preferences. While a family may be able to provide information concerning client preferences, it is best to ask or observe the client to determine preferences.

A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing? A. Coughing B. Sneezing C. Talking D. Valsalva maneuver E. Vomiting F. Keeping the head of the bed between 30- 35 degrees

A B D E

Select the main structures below that play a role with altering intracranial pressure: A. Brain B. Neurons C. Cerebrospinal Fluid D. Blood E. Periosteum F. Dura mater

A C D

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

A blood clot lodges in a cerebral vessel and blocks blood flow.

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.

The nurse is teaching a patient about a carotid endarterectomy. Which explanation should the nurse use to describe the procedure? A carotid endarterectomy reroutes blood flow through cerebral tissue. A carotid endarterectomy uses a stent to enlarge the diameter of the carotid artery. A carotid endarterectomy removes atherosclerotic plaque from the carotid arteries. A carotid endarterectomy shoots pulses of water through the artery to widen the blood vessel.

A carotid endarterectomy removes atherosclerotic plaque from the carotid arteries

The nurse is teaching a patient about a carotid endarterectomy. Which explanation should the nurse use to describe the procedure? A carotid endarterectomy reroutes blood flow through cerebral tissue. A carotid endarterectomy shoots pulses of water through the artery to widen the blood vessel. A carotid endarterectomy removes atherosclerotic plaque from the carotid arteries. A carotid endarterectomy uses a stent to enlarge the diameter of the carotid artery.

A carotid endarterectomy removes atherosclerotic plaque from the carotid arteries. A carotid endarterectomy is a surgical procedure that improves blood flow to affected areas of the brain and decreases the incidence of a stroke by removing plaque from the carotid arteries. A carotid endarterectomy does not change the direction of blood flow, nor does it use a stent to widen the diameter of the artery to improve blood flow. Stent placement in the carotid artery is completed in a carotid angioplasty with stenting. Pulses of water are not shot through the carotid artery during carotid endarterectomy.

A client is admitted to the intensive care unit (ICU) with a diagnosis of cerebrovascular accident (CVA). Which assessment by the nurse provides the most significant finding in differentiating between ischemic and hemorrhagic strokes? a) Oropharyngeal suctioning as needed. b) Kepprais ordered for treatment of focal seizures. c) A unit of fresh frozen plasma is infusing. d) Neurological checks are ordered every 2 hours.

A unit of fresh frozen plasma is infusing. FFP is usedin the treatment of clotting deficiencies as seen with over dose of anticoagulants and would indicate a hemorrhagic stroke. Neuro checks ordered every 2 hours does not differentiate between types of strokes. Focal seizures can occur with any stroke and would not differentiate. Suctioning is a nursing action taken to maintain airway and does not indicate a specific type of stroke.

A patient with a traumatic brain injury is in need of fluid replacement therapy to maintain a systole blood pressure of at least 90 mm Hg. The nurse realizes that the best fluid replacement for this patient would be: a.) Normal saline. b.) D5W c.) D5 1/2 0.9% NS d.) 0.45% NS

A ~ A systolic blood pressure less than 90 mm Hg in a patient with a traumatic brain injury is a predictor of a poor outcome. Initial management usually involves assuring that the patient is hydrated. Isotonic crystalloids such as 0.9% saline or Ringer's solution are most commonly used. Normal Saline is preferred because it is inexpensive, iso-osmolar and has no free water. #2 and #4 are not correct. In general, the use of hypotonic crystalloids, such as D5W or 0.45% normal saline is avoided because of the potential for worsening cerebral edema. #3 is not correct. D51/2 NS is hypertonic and will draw fluid from the cells & interstial tissue into the vascular space. This could worsen cerebral edema.

Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation (DIC)? a.) Hemorrhagic skin rash b.) Edema c.) Cyanosis d.) Dyspnea on exertion

A ~ DIC is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the condition.

A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions? a.) Laceration of the middle meningeal artery b.) Rupture of the carotid artery c.) Thromboembolism from a carotid artery d.) Venous bleeding from the arachnoid space

A ~ Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. An embolic stroke is a thromboembolism from a carotid artery that ruptures. Venous bleeding from the arachnoid space is usually observed with subdural hematoma

The nurse is caring for a client with a closed head injury. Which of the following would contribute to intracrainal hypertension? a.) hypoventilation b.) elevating the head of the bed c.) hypernatremia d.) quiet darkened environnent

A ~ Hypoventilation leads to vasodilation and increased intracranial pressure.

A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mmHG and the ICP is 18 mmHg; therefore his cerebral perfusion pressure (CPP) is: a.) 52 mm Hg b.) 88 mm Hg c.) 48 mm Hg d.) 68 mm Hg

A ~ MAP=Systolic+Diastolic(x2)/3 90+60(2)=210 90+120=210 210/3=70 MAP=70 CCP=MAP-ICP 70-18=52 CCP=52

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: a.) A positive Brudzinski's sign b.) A negative Kernig's sign c.) Absence of nuchal rigidity d.) A Glascow Coma Scale score of 15

A ~ Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is fixed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the knee and thigh are extended from a flexed-right angle position. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glascow Coma Scale of 15 is a perfect score and indicates the client is awake and alert with no neurological deficits.

A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Apply intermittent pneumatic compression stockings. b. Assist to dangle on edge of bed and assess for dizziness. c. Encourage patient to cough and deep breathe every 4 hours. d. Insert an oropharyngeal airway to prevent airway obstruction.

A ~ The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.

A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? a.) Evaluate urine specific gravity b.) Anticipate treatment for renal failure c.) Provide emollients to the skin to prevent breakdown d.) Slow down the IV fluids and notify the physician

A ~ Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce anti-diuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. There's no evidence that the client is experiencing renal failure. Providing emollients to prevent skin breakdown is important, but doesn't need to be performed immediately. Slowing the rate of IV fluid would contribute to dehydration when polyuria is present.

After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed b. A 50-year-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A 40-year-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due d. A 30-year-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled

A ~ tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications should also be given as quickly as possible, but timing of the medications is not as critical.

What part of the body controls reflexes and regulates activities such as vomiting, hiccupping, coughing, and sneezing? A) Brainstem B) Hypothalamus C) Spinal cord D) Thalamus

A) Brainstem

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

A) Cardiac and respiratory status

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) Evidence of hemorrhagic stroke

A newly admitted adult client with increased intracranial pressure caused from a head injury has a Glasgow Coma Scale (GCS) score of 6. Which of the following assessment findings is most likely in this client? A) Extension to painful stimuli B) Spontaneous eye opening C) Oriented to time, place, and person D) Withdraws to touch

A) Extension to painful stimuli

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) Facial droop

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) Frustration around changes in function and communication

The nurse is determining ways to decrease environmental stimuli for a client with increased intracranial pressure. Which actions should the nurse take to support this client's care need? Select all that apply. A) Limit the client's visitors. B) Teach family to speak softly and minimize touching. C) Elevate the head of the bed. D) Raise pads and bedrails. E) Keep the room dark and quiet.

A) Limit the client's visitors. B) Teach family to speak softly and minimize touching. E) Keep the room dark and quiet.

A client with a head injury is demonstrating signs of increased intracranial pressure (IICP). Which classifications of medications should the nurse anticipate administering to this client? Select all that apply. A) Loop diuretics B) Antibiotics C) Antiseizure drugs D) Histamine H2 antagonists E) Antipyretics

A) Loop diuretics C) Antiseizure drugs D) Histamine H2 antagonists E) Antipyretics

While caring for a client with increased intracranial pressure (IICP), a family member asks to assist. Which interventions are appropriate for the nurse to teach the family member regarding this client's care? Select all that apply. A) Maintain head of the bed elevated to 30 degrees. B) Position client in a supine position. C) Decrease stimuli. D) Keep bedrails raised. E) Keep the client in a stationary position.

A) Maintain head of the bed elevated to 30 degrees. C) Decrease stimuli. D) Keep bedrails raised.

During a patient's 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) National Institutes of Health Stroke Scale (NIHSS) score C) LOC at time of admission E) Age

You are caring for a semiconscious man with left-sided paralysis. His airway is patent and his respirations are 14 breaths/min with adequate tidal volume. Treatment for this patient should include: A) Oxygen via a nonrebreathing mask, left lateral recumbent position, and transport. B) An oral airway, assisted ventilation with a bag-mask device, Fowler's position, and transport. C) Assisted ventilation with a bag-mask device, right lateral recumbent position, and transport. D) Oxygen via a nonrebreathing mask, supine position with legs elevated 6² to 12², and transport.

A) Oxygen via a nonrebreathing mask, left lateral recumbent position, and transport.

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) Positioning to avoid hypoxia

The patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the patient's 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) Provide a board of commonly used needs and phrases.

The patient with diabetes mellitus has had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient related to expected manifestations of this stroke? A) Safety measures B) Patience with communication C) Mobility assistance on the right side D) Place food in the left side of patient's mouth.

A) Safety measures Rationale: A patient with a right-sided stroke has spatial-perceptual deficits, tends to minimize problems, has a short attention span, is impulsive, and may have impaired judgment. Safety is the biggest concern for this patient. Hemiplegia occurs on the left side of this patient's body. The patient with a left-sided stroke has hemiplegia on the right, is more likely to have communication problems, and needs mobility assistance on the right side with food placed on the left side if the patient needs to be fed after a swallow evaluation has taken place.

Following diagnostic testing, a patient has been admitted to the ICU and placed on cerebral aneurysm precautions. What nursing action should be included in patient's plan of care? A) Supervise the patient's 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 patient's hygiene and feeding.

A) Supervise the patient's activities of daily living closely.

The nurse makes a visit to the home of an adolescent recently discharged from the hospital following treatment for a tonic-clonic seizure disorder. Which observations indicate that outcomes for care have been achieved? Select all that apply. A) The client is not driving. B) The client has not had a seizure for 1 month. C) The client is participating in the school basketball team. D) The client has bruises on both arms. E) The client is complaining of constipation.

A) The client is not driving. B) The client has not had a seizure for 1 month. C) The client is participating in the school basketball team.

The nurse is caring for a pregnant client with a history of idiopathic intracranial hypertension (IIH) and optic neuritis. What should the nurse least assume regarding this client? A) The client will deliver her baby via cesarean birth. B) Pregnancy-related weight gain should be kept to no more than 9 kg. C) The client has been prescribed a medication to treat the IIH. D) The second stage of labor should not be prolonged.

A) The client will deliver her baby via cesarean birth.

A transient ischemic attack (TIA) occurs when: A) The normal body processes destroy a clot in a cerebral artery. B) Signs and symptoms resolve spontaneously within 48 hours. C) Medications are given to dissolve a cerebral blood clot. D) A small cerebral artery ruptures and causes minimal damage.

A) The normal body processes destroy a clot in a cerebral artery.

A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's 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) The patient should be approached on the side where visual perception is intact.

A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patient's family in adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurse's 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 patient's risk of stroke recurrence.

A) The patient should mobilize as soon as she is physically able.

The nurse identifies the diagnosis Risk for Injury as appropriate for a client with a seizure disorder. Based on this diagnosis, which nursing interventions are appropriate when this client experiences a seizure? Select all that apply. A) Turn the client to a lateral position, if possible. B) Stay with the client. C) Insert a tongue blade into the client's mouth. D) Call for help. E) Restrain the client.

A) Turn the client to a lateral position, if possible. B) Stay with the client. D) Call for help.

The anterior aspect of the cerebrum controls: A) Vision. B) Touch Correct Answer C) Emotion. D) Movement.

A) Vision.

The nurse is assessing a client with a traumatic head injury and suspects increased intracranial pressure (IICP). Which assessment finding supports this suspicion? (Select all that apply.) A. Double vision B. Drowsiness C. Blurred vision D. Increased heart rate E. Hemiparesis

A, B, C, D Rationale: Hemiparesis or hemiplegia of the contralateral side may be an early sign of IICP. Drowsiness can occur with IICP. Double vision and blurred vision can occur with IICP. Headache is common with IICP. The client may also report other generalized manifestations such as dizziness. The heart rate generally decreases with IICP.

A client is demonstrating signs of increasing intracranial pressure. Which intervention should the nurse implement? (Select all that apply.) A. Assessing vital signs B. Reducing environmental stimuli C. Monitoring pupillary response D. Assessing cranial nerve function E. Providing hypotonic fluids

A, B, C, D Rationale: Nursing actions for the client demonstrating signs of increasing intracranial pressure include assessing vital signs, monitoring pupillary response, assessing cranial nerve function, and reducing environmental stimuli. Intravenous fluids administered at this time would be isotonic or hypertonic.

Which client is most at risk for increased intracranial pressure? (Select all that apply.) A. School-aged child B. Older adult C. Newborn infant D. Adolescent E. Pregnant obese woman

A, B, C, D, E Rationale: Falls continue to be the major cause of traumatic brain injury leading to increased intracranial pressure (IICP). Older adults are more prone to falls due to sensory and motor losses, as well as medication use. Adolescents are at risk for motor vehicle crashes and trauma resulting from violence. Premature newborn infants are at an increased risk of IICP. School-aged children are prone to falling. School-aged children are at risk for bicycle, swimming, or activity-related accidents that cause IICP. Obese women of childbearing age often have idiopathic intracranial hypertension. During pregnancy, these women must be closely monitored for increased intracranial pressure.

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. Monitor vital signs b. Intake and output c. Neurovascular assessment of the lower extremity d. Dressing assessment e. PEARLA f. Social History g. Coughing and deep breathing

A, B, C, D, G

A family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when a client experiences a stroke on the right side of the brain, common deficits include what? Select all that apply. a. Neglect of objects and people on the left side b. Left-sided hemiplegia c. Hyperaware of deficits d. Tendency to distractibility e. Impairment of long-term memory

A, B, D

The nurse is assessing a client's ability to detect sensation in the upper extremity. Which nursing actions would be appropriate? Select all that apply. a. Touch the client with the pads of the finger. b. A gentle pinch using the fingers. c. A light prick using a needle. d. Place a warm cotton ball on the arm. e. Drag the alcohol pad over the skin.

A, B, D, E

The nurse is caring for a client who has increased intracranial pressure from a traumatic brain injury. Which diagnostic test should the nurse anticipate being ordered? (Select all that apply.) A. Cardiac monitoring B. Arterial blood gas C. Electromyogram D. Intracranial pressure monitor E. Computerized tomography (CT) scan of the head

A, B, D, E

The nurse assessing a client who presents with an altered level of consciousness (LOC) should suspect which condition? (Select all that apply.) A. Traumatic brain injury B. Seizure activity C. Sciatica D. Cerebral infarction E. Hematoma

A, B, D, E Rationale: Localized and systemic disorders can alter LOC. Processes occurring in the brain that may directly destroy or compress the neurologic structures are numerous but include increased intracranial pressure, cerebral infarction, hematoma, hydrocephalus, intracranial hemorrhage, tumors, infections, traumatic brain injury, seizure activity, and recovery. Sciatica, although painful, does not cause an alteration of LOC.

The nurse is monitoring a patient for increased ICP following a head injury. Which of the following manifestations indicate an increased ICP (select all that apply) a. fever b. oriented to name only c. narrowing pulse pressure d. dilated right pupil > left pupil e. decorticate posturing to painful stimulus

A, B, D, E- The first sign of increased ICP is a change in LOC. Other manifestations are dilated ipsilateral pupil, changes in motor response such as posturing, and fever, which may indicate pressure on the hypothalamus. Changes in vital signs would be an increased systolic BP with widened pulse pressure and bradycardia

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

A, B, E Rationale: 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.

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. Limited range of motion b. Weight bearing c. Bone demineralization d. Spasticity e. Contractures

A, C, D, E

The nurse is caring for a client with increased intracranial pressure (IICP) who is supported with mechanical ventilation. Which intervention should the nurse implement to ensure adequate oxygenation for this client? (Select all that apply.) A. Performing suctioning as needed B. Initiating hyperventilation C. Maintaining partial pressure of arterial carbon dioxide of 35 mmHg D. Maintaining partial pressure of arterial oxygen of 100 mmHg E. Implementing measures to prevent atelectasis and fluid accumulation

A, C, D, E Rationale: Maintaining an appropriate arterial oxygen and carbon dioxide assists in oxygenation and prevents respiratory distress. Performing suctioning ensures a patent airway, and preventing atelectasis and fluid accumulation allows for gas exchange in the alveoli. Judicious hyperventilation is only used as an emergency intervention for clients with IICP and impending herniation.

Which assessment finding for a client should the nurse attribute to increased intracranial pressure? (Select all that apply.) A. Altered level of consciousness B. Fluid intake for the past 24 hours C. Decreased heart rate D. Decreased motor status and strength E. Slowed pupillary responses to light

A, C, D, E Rationale: Neurologic assessments of a client with a head injury include assessment of the level of consciousness. Decreased level of consciousness will often be the first indication of an increase in intracranial pressure. Assessment of the vital signs will reveal a slowed heart and respiratory rate and increased blood pressure. The motor status and strength will decrease. The pupillary response to light will be slow. Previous oral fluid intake is not associated with a head injury, but ongoing fluid monitoring and limitation may be part of the treatment plan

The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions (select all that apply)? A. Clopidogrel (Plavix) B. Enoxaparin (Lovenox) C. Dipyridamole (Persantine) D. Enteric-coated aspirin (Ecotrin) E. Tissue plasminogen activator (tPA)

A, C, D. Aspirin is the most frequently used antiplatelet agent. Other drugs to prevent clot formation include clopidogrel (Plavix), dipyridamole (Persantine), ticlopidine (Ticlid), combined dipyridamole and aspirin (Aggrenox), and anticoagulant drugs, such as oral warfarin (Coumadin). Tissue plasminogen activator is a fibrinolytic medication used to treat ischemic stroke not prevent TIAs or strokes.

The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply. a. Unequal pupils b. Pupil reacts to light c. Absence of pupillary response d. Pupil reaction quick e. Pinpoint pupils

A, C, E

The nurse suspects that a newly admitted client is in spinal shock. What are the symptoms of spinal shock? Select all that apply. a. Poikilothermia b. Loss of hunger sensation c. Circulatory failure d. No perspiration below the level of the injury e. Bladder distention

A, D, E

An alert client presents at the urgent care center after a fall. Which assessment should the nurse perform? (Select all that apply.) A. Vital signs B. Anthropometric measurements C. Body mass index D. Pupillary size and reaction to light E. Level of consciousness (LOC)

A, D, E Rationale: Assessment of the neurologic status establishes the client's clinical condition and provides a baseline for measuring changes. Assessment areas include LOC, behavior, motor/sensory functions, pupillary size and reaction to light, and vital signs. Body mass index (BMI) and anthropometric measurements are commonly used during nutritional assessment.

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. Corticosteroids c. Antidepressants d. Loop diuretics e. Anticonvulsants f. Antibiotics

A, E, F

A client with a minor head injury has a Glasgow Coma Scale score of 15 out of 15. What does this score indicate to the nurse? (Select all that apply.) A.Client uses appropriate words and phrases. B.Client spontaneously opens the eyes. C.Client is oriented to person, place, and time. D.Client withdraws to touch. E.Client withdraws to pain.

A,B,C Rationale: The maximum Glasgow Coma Scale score is 15. This means that the client uses appropriate words and phrases, spontaneously opens the eyes, and is oriented to person, place, and time. Withdrawing to pain or touch would cause the Glasgow Coma Scale score to be less than 15.

Which intervention should the nurse initiate secondary to a change in level of consciousness (LOC) for a client experiencing increased intracranial pressure (IICP)? (Select all that apply.) A.Maintain the head of the bed at 30 degrees B.Assess LOC, pupillary response, and neurologic status C.Implement deep vein thrombosis prophylaxis D.Monitor ICP/cerebral perfusion pressure (CCP) as indicated E.Encourage family to visit and keep client engaged in normal activities as possible

A,B,C,D Rationale: For the client with IICP, the nurse should monitor ICP/CCP as indicated, implement precautions for seizures, maintain the head of the bed at 30 degrees, and assess LOC, pupillary response, and neurologic status.

The nurse is preparing to conduct a neurologic assessment interview with a client. Which general question should the nurse ask when conducting this assessment? (Select all that apply.) A."Are you having any problems with your memory?" B."Do you have a history of seizures or fainting?" C."Do you have any problems with balance or coordination?" D."How many fingers am I holding up at this time?" E."Are you experiencing any pain?"

A,B,C,E Rationale: General questions to include in a neurologic assessment interview include asking about pain, history of seizures or fainting, and problems with memory and coordination or balance. Asking to identify the number of fingers would focus on the client's vision.

Which action by the nurse can help to avoid pitfalls that can result in client harm? (Select all that apply.) A.Following ethical care practices B.Prioritizing client care appropriately C.Incorporating client preferences as possible when prioritizing care D.Delegating care only when absolutely necessary E.Knowing client healthcare concerns

A,B,C,E Rationale: To avoid common pitfalls when providing care, the nurse should follow ethical care practices, know client healthcare concerns, prioritize care appropriately, and incorporate client preferences as possible when prioritizing client care. Appropriate delegation can be helpful to the nurse when prioritizing care, so it should not be avoided but used appropriately.

The nurse is caring for a client with an altered level of consciousness. To assess the level of consciousness, the nurse administers the Glasgow Coma Scale. Which response does this scale measure? (Select all that apply.) A.Eye opening B.Motor response C.Cerebellar function D.Verbal response E.Corneal reflex

A,B,D Rationale: The Glasgow Coma Scale measures eye opening and motor and verbal responses. This assessment tool does not measure the corneal reflex or cerebellar function.

You are providing care for a patient who has been admitted to the hospital with a head injury who requires regular neurologic vital signs. Which assessments are components of the patient's score on the Glasgow Coma Scale (select all that apply)? A. Eye opening B. Abstract reasoning C. Best verbal response D. Best motor response E. Cranial nerve function

A,C,D The three dimensions of the Glasgow Coma Scale are eye opening, best verbal response, and best motor response.

The nurse notes that a client has muscle fasciculations of both bicep muscles. Which additional information should the nurse assess? (Select all that apply.) A.List of medications taken B.Last solid food intake C.Body temperature D.Blood pressure and pulse E.Urine output

A,C,E Rationale: Fasciculations occur in clients with disease or trauma to the lower motor neurons, as a side effect of medications, in fever, in sodium deficiency, and in uremia. Fasciculations are not associated with food intake or blood pressure and pulse measurements.

What are the common psychosocial reactions of the patient to the stroke (select all that apply)? A. Depression B. Disassociation C. Intellectualization D. Sleep disturbances E. Denial of the severity of the stroke

A,D,E The patient with a stroke may experience many losses, including sensory, intellectual, communicative, functional, role behavior, emotional, social, and vocational losses. Some patients experience long-term depression and symptoms such as anxiety, weight loss, fatigue, poor appetite, and sleep disturbances. The time and energy required to perform previously simple tasks can result in anger and frustration. Frustration and depression are common in the first year after a stroke. A stroke is usually a sudden, extremely stressful event for the patient, caregiver, family, and significant others. The family is often affected emotionally, socially, and financially, as well as changing roles and responsibilities. Reactions vary considerably but may involve fear, apprehension, denial of the severity of the stroke, depression, anger, and sorrow.

The nurse is prioritizing client care as low, medium, or high priority for the current assignment. Which client should the nurse identify as having a high-priority circumstance? (Select all that apply.) A. A client with emphysema and a pulse oximeter reading of 88 B. A client who is receiving warfarin (Coumadin) C. A client who is experiencing extreme bouts of diarrhea D. An extremely confused older client E. A client with congestive heart failure and shortness of breath

A. A client with emphysema and a pulse oximeter reading of 88 B. A client who is receiving warfarin (Coumadin) E. A client with congestive heart failure and shortness of breath Rationale: High-priority circumstances include clients with a risk for bleeding, such as a client receiving warfarin (Coumadin), clients with ineffective breathing patterns, and clients with impaired gas exchange. A confused client and a client with diarrhea would have medium-priority circumstances.

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

A. Brief period of a neurologic deficit Rationale: 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.

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

A. Encouraging active range-of-motion exercises Rationale: 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? A. Encouraging active range-of-motion exercises B. Turning the client every 2 hours C. Monitoring lower extremities for symptoms of thrombophlebitis D. Elevating the head of the bed 30 degrees

A. Encouraging active range-of-motion exercises Rationale: 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 planning the day on a general medical unit. Which activity should the nurse prioritize as "must do" and not advisable to be delegated to unlicensed assistive personnel (UAP)? A. Health teaching for a client being discharged poststroke B. Ambulating a stable client to the bathroom C. Assisting clients with hygienic care activities D. Collecting vital signs on assigned clients

A. Health teaching for a client being discharged poststroke Rationale: "Must do" activities carry the highest priority for completion and should not be delegated. Health teaching and discharge teaching must be done by the nurse. Collecting vital signs, ambulating a stable client to the bathroom, and assisting clients with hygienic activities can all be safely delegated to unlicensed assistive personnel (UAPs).

Which action should the nurse take to best involve hospitalized clients in their care and avoid pitfalls related to not involving clients in their own care? A. Observing client behaviors for cues about preferences B. Informing clients of the daily schedule of care C. Orienting the client and family to the hospital facility and routines D. Asking the client's family about usual patterns of behavior

A. Observing client behaviors for cues about preferences Rationale: To avoid pitfalls related to not involving clients in their own care, the nurse should observe client behaviors for cues about preferences. Informing clients about the daily schedule of care and orienting clients and families to the hospital routine do not provide information about client preferences. While a family may be able to provide information concerning client preferences, it is best to ask or observe the client to determine preferences.

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? A. Providing reassurance and support B. Providing behavioral and cognitive therapy when the condition stabilizes C. Maintaining fluid, oxygen, and nutritional status D. Developing an alternate means of communicating

A. Providing reassurance and support Rationale: 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.

The nurse caring for a client with diabetes mellitus receives a report from another nurse that the client is experiencing a hypoglycemic episode. The nurse immediately prepares to administer 50 mL of D50 IVP. Upon entering the room, the nurse notes that the client seems alert and does not have any current complaints and decides not to administer the D50. Which pitfall was avoided by the nurse in this situation? A. Relying solely on another's assessment B. Poor time management C. Incomplete assessment D. Failure to do periodic assessments

A. Relying solely on another's assessment Rationale: In this situation, the nurse prepared to administer D50 IVP based on the other nurse's assessment. Using this information to set priorities could have resulted in a negative client outcome. The potential pitfall in this situation was not created by an incomplete assessment, poor time management, or failure to do periodic assessments.

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? A. The client will participate in therapies to prevent contractures. B. The client will maintain bedrest. C. The client's blood pressure will remain within 40% of normal. D. The client will improve communication techniques.

A. The client will participate in therapies to prevent contractures. Rationale: 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.

A client with increased intracranial pressure is prescribed mannitol. The family asks, "What is the purpose of this medication?" The nurse's response should be based on which action of the drug? A. To draw fluid from the brain tissue B. To create a sodium and potassium balance C. To enhance renal excretion of retained protein D. To prevent tiny stress hemorrhages in the brain

A. To draw fluid from the brain tissue Rationale: Mannitol is used in the treatment of increased intracranial pressure to draw fluid out of the brain, thereby reducing intracranial pressure. Mannitol does not establish a sodium and potassium balance. Mannitol does not enhance excretion of serum protein, which is not an intended outcome. The medication does not prevent hemorrhages within the brain.

The nurse is requesting collaborative therapy from physical therapy for a client with increased intracranial pressure. Which reason supports this request? A. To recommend interventions for resulting hemiparesis or hemiplegia B. To assess the living accommodations before the client's discharge to home C. To determine if transfer to a skilled nursing facility is required D. To work with the nutritionist to determine effective methods to meet nutritional needs

A. To recommend interventions for resulting hemiparesis or hemiplegia Rationale: The purpose of a physical therapy consult for a client with an alteration in intracranial pressure is to address the client's motor skills and strength in performing daily activities requiring mobility. This is especially necessary if any hemiparesis or hemiplegia has resulted. A nurse or social worker involved in home care would most likely assess the client's home environment. The nutritionist would address the client's nutritional needs; the physical or occupational therapist may be included in the plan to recommend effective accommodations for the motor skills that are involved in the eating process. Many factors and individuals are involved in the decision to transfer a client to a skilled nursing facility. This decision would most likely be directed through a social service consult.

The nurse is caring for a client with increased intracranial pressure (IICP) from a cervical injury. Which statement by the nurse indicates an understanding of how to position the client? A. "I will ask another nurse to help me lift the client toward the head of the bed." B. "The head of the bed should be kept flat to make it easier to move the client." C. "I will ask the client to assist by pushing on the bed with their feet and hands." D. "The head of the bed should be kept at 90 degrees to assist with venous drainage from the brain."

A. "I will ask another nurse to help me lift the client toward the head of the bed." Rationale: To prevent a further increase in intracranial pressure (ICP), the nurse should ask for assistance from another staff member. This prevents the client from pushing with their hands or feet against the bed, both of which can increase ICP. The prone, or flat, position should be avoided; the head of the bed should be kept at 30 degrees to assist with venous drainage from the brain. It is not necessary to sit the client up at a 90-degree angle.

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? A. "When getting dressed, first put clothing on the left side." B. "The occupational therapist will teach you how to promote upper extremity strength." C. "Use the left arm to bathe, brush teeth, comb hair, and eat." D. "The occupational therapist will assist you in learning to walk using a walker."

A. "When getting dressed, first put clothing on the left side." Rationale: 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.

4. Practice Question •Which patients are at increased risk for stroke? Select all that Apply. •A. 66-year old man with diabetes mellitus. •B. 35-year old healthy woman who uses oral contraceptives. •C. 40-year old man with a history of multiple TIAs. •D. 25-year old woman with Bell's palsy. •E. 53-year old man with chronic alcoholism.

A. 66-year old man with diabetes mellitus. B. 35-year old healthy woman who uses oral contraceptives. C. 40-year old man with a history of multiple TIAs. E. 53-year old man with chronic alcoholism.

14. You need to obtain informed consent from a patient for a procedure. The patient experienced a stroke three months ago. The patient is unable to sign the consent form because he can't write. This is known as what:* A. Agraphia B. Alexia C. Hemianopia D. Apraxia

A. Agraphia

8. You're educating a group of nursing students about left side brain damage. Select all the signs and symptoms noted with this type of stroke:* A. Aphasia B. Denial about limitations C. Impaired math skills D. Issues with seeing on the right side E. Disoriented F. Depression and anger G. Impulsive H. Agraphia

A. Aphasia C. Impaired math skills D. Issues with seeing on the right side F. Depression and anger H. Agraphia The answers are A, C, D, F, and H. Patients who have left side brain damage will have aphasia, be AWARE of their limitations, impaired math skills, issues with seeing on the right side, no deficit in memory, depression/anger, cautious, and agraphia. All the other options are found in right side brain injury.

A patient has ICP monitoring with an intraventricular catheter. A priority nursing intervention for the patient is a. aseptic technique to prevent infection b. constant monitoring of ICP waveforms c. removal of CSF to maintain normal ICP d. sampling CSF to determine abnormalities

A. Aseptic technique to prevent infection An intraventricular catheter is a fluid coupled system that can provide direct access for microorganisms to enter the ventricles of the brain, and aseptic technique is a very high nursing priority to decrease the risk for infection. Constant monitoring of ICP waveforms is not usually necessary, and removal of CSF for sampling or to maintain normal ICP is done only when specifically ordered

A. Aseptic technique to prevent infection- An intraventricular catheter is a fluid coupled system that can provide direct access for microorganisms to enter the ventricles of the brain, and aseptic technique is a very high nursing priority to decrease the risk for infection. Constant monitoring of ICP waveforms is not usually necessary, and removal of CSF for sampling or to maintain normal ICP is done only when specifically ordered

A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema. An appropriate nursing intervention for the patient is a. avoiding positioning the patient with neck and hip flexion b. maintaining hyperventilation to a PaCO2 of 15 to 20 mm Hg c. clustering nursing activities to provide periods of uninterrupted rest d. routine suctioning to prevent accumulation of respiratory secretions

A. Avoiding positioning the patient with neck and hip flexion- Nursing care activities that increase ICP include hip and neck flexion, suctioning, clustering care activities, and noxious stimuli; they should be avoided or performed as little as possible in the patient with increased ICP. Lowering the PaCO2 below 20 mm Hg can cause ischemia and worsening of ICP; the PaCO2 should be maintained at 30 to 35 mm Hg.

A. Clopidogrel (Plavix) C. Dipyridamole (Persantine) D. Enteric-coated aspirin (Ecotrin) Aspirin is the most frequently used antiplatelet agent. Other drugs to prevent clot formation include clopidogrel (Plavix), dipyridamole (Persantine), ticlopidine (Ticlid), combined dipyridamole and aspirin (Aggrenox), and anticoagulant drugs, such as oral warfarin (Coumadin). Tissue plasminogen activator is a fibrinolytic medication used to treat ischemic stroke not prevent TIAs or strokes.

A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the patient communicate is to a. ask questions that the patient can answer with "yes" or "no." b. develop a list of words that the patient can read and practice reciting. c. have the patient practice her facial and tongue exercises with a mirror. d. prevent embarrassing the patient by answering for her if she does not respond.

A. Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.

12. Practice Question •The nurse is performing a neurologic assessment on a patient with a suspected stroke. In addition to the level of consciousness, what is assessed to evaluate cognitive changes that may be occurring? Select all that Apply. •A. Denial of illness. •B. Proprioceptive dysfunction. •C. Presence of flaccid paralysis. •D. Impairment of memory. •E. Decreased ability to concentrate

A. Denial of illness. B. Proprioceptive dysfunction. D. Impairment of memory. E. Decreased ability to concentrate

The ED nurse is completing the admission assessment. Nancy is alert but struggles to answer questions. When she attempts to talk, she slurs her speech and appears very frightened. Which additional clinical manifestations should the nurse expect to find if Nancy's symptoms have been caused by a brain attack (stroke)? A. Difficulty swallowing B. Decreased bowel sounds C. A carotid bruit D. Elevated blood pressure E. Hyperreflexic deep tendon reflexes

A. Difficulty swallowing - Difficulty swallowing can accompany a brain attack, placing the client at risk for aspiration. C. A carotid bruit - The carotid artery (artery to the brain) is narrowed in clients with a brain attack (stroke). A bruit is an abnormal sound heard on auscultation resulting from interference with normal blood flow. D. Elevated blood pressure - When a client has a brain attack (stroke), the blood pressure will often respond by going up. Increased BP is a sign of increased intracranial pressure.

The neurologist writes a diagnosis of "Suspected brain attack" and prescribes a non contrast computed tomography (CT) scan STAT. Which nursing intervention should the nurse implement when preparing Nancy and her daughter for this procedure? A. Explain to the daughter that her mother will have to remain still throughout the CT scan B. Determine if the client has any allergies to iodine C. Provide an explanation of relaxation exercises prior to the procedure D. Premedicate the client to decrease pain prior to having the procedure

A. Explain to the daughter that her mother will have to remain still throughout the CT scan. -Because head motion will distort the images, Nancy will have to remain still throughout the procedure. Since Nancy has decreased LOC, she may require head support to accomplish this.

Which modifiable risk factors for stroke would be most important for the nurse to include when planning a community education program? A. Hypertension B. Hyerlipidemia C. Alcohol consumption D. Oral contraceptive use

A. Hypertension Hypertension is the single most important modifiable risk factor, but it is still often undetected and inadequately treated. The public is often more aware of hyperlipidemia and oral contraceptive use as risk factors for stroke. Alcohol is also a modifiable risk factor.

A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? a. "The obstructing plaque is surgically removed from an artery in the neck." b. "The diseased portion of the artery in the brain is replaced with a synthetic graft." c. "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed." d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque."

A. In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, "The diseased portion of the artery in the brain is replaced" describes an arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The final response beginning, "A wire is threaded through the artery" describes the mechanical embolus removal in cerebral ischemia (MERCI) procedure.

When a patient is admitted to the emergency department following a head injury, the nurse's first priority in management of the patient once a patent airway is confirmed is a. maintaining cervical spine precautions b. determining the presence of increased ICP c. monitoring for changes in neurologic status d. establishing IV access with a large-bore catheter

A. In addition to monitoring for a patent airway during emergency care of the patient with a head injury, the nurse must always assume that a patient with a head injury may have a cervical spine injury. Maintaining cervical spine precautions in all assessment and treatment activities with the patient is essential to prevent additional neurologic damage.

Computed tomography (CT) of a 68-year-old male patient's head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? A. Maintenance of patient's airway. B. Positioning to promote cerebral perfusion. C. Control of fluid and electrolyte imbalances. D. Administration of tissue plasminogen activator (tPA)

A. Maintenance of patient's airway. Maintenance of a patent airway is the priority in the acute care of a patient with a hemorrhagic stroke. It supersedes the importance of fluid and electrolyte imbalance and positioning. tPA is contraindicated in hemorrhagic stroke.

Though Nancy's SaO2 potassium level, and telemetry readings are within normal limits for her age, her cardiac output is low. Which nursing interventions would be priority at this time? A. Monitor capillary refill every 2-4 hours B. Monitor level of consciousness C. Monitor vital signs every shift D. Strict intake and output E. Contact physician

A. Monitor capillary refill every 2-4 hours - Decreased cardiac output would affect tissue perfusion, reflected in a capillary refill of greater than 3 seconds. B. Monitor level of consciousness - With a decreased cardiac output, cerebral perfusion will be affected. This can be reflected in a further decreased level of consciousness. D. Strict intake and output - The kidneys use 25% of cardiac output, so when cardiac output is decreased, the kidneys may start failing. Close monitoring is essential. E. Contact physician - The physician needs to be notified regarding decreased cardiac output to decide whether to initiate IV fluids if hypovolemia is an issue and to determine other medical interventions.

3. Practice Question •The nurse is talking to the family of a stoke patient about home care measures. Which topics does the nurse include in this discussion? Select all that Apply. •A. Need for caregivers to plan for routine respite care and protection of own health. •B. Evaluation for potential safety risk such as throw rugs or slippery floors. •C. Awareness of potential patient frustration associated with communication. •D. Avoidance of independent transfers by the patient because of safety issues. •E. Referral to hospice and encouragement of family discussion of advance directives.

A. Need for caregivers to plan for routine respite care and protection of own health. B. Evaluation for potential safety risk such as throw rugs or slippery floors. C. Awareness of potential patient frustration associated with communication.

Which written documentation should the nurse put in the client's record? A. PT reported that client became dizzy and was lowered back to the bed with the assistance of a gait belt B. PT notified the primary nurse that the client could not ambulate at this time because of dizziness C. Client had difficulty ambulating from the bed to the chair when accompanied by the PT, variance report completed D. Client experienced orthostatic hypotension when getting out of bed

A. PT reported that client became dizzy and was lowered back to the bed with the assistance of a gait belt - This documentation provides the factual data of the events that occurred.

During admission of a patient with a severe head injury to the ED, the nurse places highest priority on assessment for a. patency of of airway b. presence of a neck injury c. neurologic status with Glascow Coma Scale d. CSF leakage from ears and nose

A. Patency of airway is the #1 priority with all head injuries

10. Practice Question •A patient with a stroke is having some trouble swallowing. Which interventions does the nurse anticipate the speech therapist to suggest after the swallowing evaluation is completed? Select all that Apply. •A. Position the patient upright while eating. •B. Administer orange juice with a straw. •C. Give small spoonful's of custard. •D. Position the head and neck slightly forward and flexed. •E. maintain the patient in an upright position 30 minutes after eating.

A. Position the patient upright while eating. C. Give small spoonful's of custard. D. Position the head and neck slightly forward and flexed. E. maintain the patient in an upright position 30 minutes after eating.

21. A patient has experienced right side brain damage. You note the patient is experiencing neglect syndrome. What nursing intervention will you include in the patient's plan of care?* A. Remind the patient to use and touch both sides of the body daily. B. Offer the patient a soft mechanical diet with honey thick liquids. C. Ask direct questions that require one word responses. D. Offer the bedpan and bedside commode every 2 hours.

A. Remind the patient to use and touch both sides of the body daily. The answer is A. It is important to watch for neglect syndrome. This tends to happen in right side brain damage. The patient ignores the left side of the body in this condition. The nurse needs to remind the patient to use and touch both sides of the body daily and that the patient must make a conscious effort to do so.

The patient with diabetes mellitus has had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient related to expected manifestations of this stroke? A. Safety measures B. Patience with communication C. Mobility assistance on the right side D. Place food in the left side of patient's mouth

A. Safety measures A patient with a right-sided stroke has spatial-perceptual deficits, tends to minimize problems, has a short attention span, is impulsive, and may have impaired judgment. Safety is the biggest concern for this patient. Hemiplegia occurs on the left side of this patient's body. The patient with a left-sided stroke has hemiplegia on the right, is more likely to have communication problems, and needs mobility assistance on the right side with food placed on the left side if the patient needs to be fed after a swallow evaluation has taken place.

The patient with diabetes mellitus has had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient related to expected manifestations of this stroke? A. Safety measures B. Patience with communication C. Mobility assistance on the right side D. Place food in the left side of patient's mouth.

9. During discharge teaching for a patient who experienced a mild stroke, you are providing details on how to eliminate risk factors for experiencing another stroke. Which risk factors below for stroke are modifiable?* A. Smoking B. Family history C. Advanced age D. Obesity E. Sedentary lifestyle

A. Smoking D. Obesity E. Sedentary lifestyle The answers are A, D, and E. These risk factors are modifiable in that the patient can attempt to change them to prevent another stroke in the future. The other risk factors are NOT modifiable.

1. Practice Question •A patient sustained a stroke that affected the right hemisphere of the brain. The patient has visual spatial deficits and deficits of proprioception. After assessing the safety of the patient's home, the home health nurse identifies which environmental feature that represents a potential safety problem for this patient? •A. The handrail that borders the bathtub is on the left-hand side. •B. The patient's favorite chair faces the front door of the house. •C. The patient's bedside table is on the right-hand side of the bed. •D. Family has relocated the patient to a ground-floor bedroom.

A. The handrail that borders the bathtub is on the left-hand side.

A. The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.

For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of a. risk for injury related to denial of deficits and impulsiveness. b. impaired physical mobility related to right-sided hemiplegia. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability.

A. The patient with right-sided brain damage typically denies any deficits and has poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.

You are assessing a 49-year-old man who, according to his wife, experienced a sudden, severe headache and then passed out. He is unresponsive and has slow, irregular breathing. His blood pressure is 190/94 mm Hg and his pulse rate is 50 beats/min. His wife tells you that he has hypertension and diabetes. He has MOST likely experienced: A. a ruptured cerebral artery. B. acute hypoglycemia. C. an occluded cerebral artery. D. a complex partial seizure.

A. a ruptured cerebral artery.

6. Practice Question •The nurse is caring for a patient at risk for increased ICP. Which sign is most likely to be the first indication of increased ICP? •A. decline in LOC. •B. Increase in Systolic BP. •C. Change in pupil size and response. •D. Abnormal posturing of extremities.

A. decline in LOC.

The nurse observes a student nurse assigned to initiate oral feedings for a 68-year-old woman with an ischemic stroke. The nurse should intervene if she observes the student nurse: A. giving the patient 8 ounces of ice water to swallow. B. telling the patient to perform a chin tuck before swallowing. C. assisting the patient to sit in a chair before feeding the patient. D. assessing cranial nerves IX and X before the patient attempts to eat.

A. giving the patient 8 ounces of ice water to swallow. The majority of patients after a stroke have dysphagia. The gag reflex and swallowing ability (cranial nerves IX and X) should be assessed before the first oral feeding. To assess swallowing ability, the nurse should elevate the head of the bed to an upright position (unless contraindicated) and give the patient a very small amount (not 8 ounces) of crushed ice or ice water to swallow. The patient should remain in a high Fowler's position, preferably in a chair with the head flexed forward, for the feeding and for 30 minutes following.

A. tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications should also be given as quickly as possible, but timing of the medications is not as critical.

A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, the nurse anticipates that the health care provider will request a a. CT scan b. lumbar puncture c. cerebral arteriogram d. positron emission tomography (PET)

A: CT scan- A CT scan is the most commonly used diagnostic test to determine the size and location of the lesion and to differentiate a thrombotic stroke from a hemorrhagic stroke. Positron emission tomography (PET) will show the metabolic activity of the brain and provide a depiction of the extent of tissue damage after a stroke. Lumbar punctures are not performed routinely because of the chance of increased intracranial pressure causing herniation. Cerebral arteriograms are invasive and may dislodge an embolism or cause further hemorrhage; they are performed only when no other test can provide the needed information

A: Hypertension- The body responds to the vasopasm and a decreased circulation to the brain that occurs with a stroke by increasing the BP, frequently resulting in hypertension. The other options are important cardiovascular factors to assess, but they do not result from impaired cerebral blood flow.

A newly admitted patient who has suffered a right sided brain stroke has a nursing diagnosis of disturbed visual sensory perception related to homonymous hemianopsia. Early in the care of the patient, the nurse should a. place objects on the right side within the patient's field of vision b. approach the patient from the left side to encourage the patient to turn the head c. place objects on the patient's left side to assess the patient's ability to compensate d. patch the affected eye to encourage the patient to turn the head to scan the environment

A: Place objects on the right side within the patient's field of vision- the presence of homonymous hemianopia in a patient with right-hemisphere brain damage causes a loss of vision in the left field. Early in the care of the patient, objects should be placed on the right side of the patient in the field of vision, and the nurse should approach the patient from the right side. Later in treatment, patients should be taught to turn the head and scan the environment and should be approached from the affected side to encourage head turning. Eye patches are used if patients have diplopia (double vision).

Four days following a stroke, a patient is to start oral fluids and feedings. Before feeding the patient, the nurse should first a. check the patient's gag reflex b. order a soft diet for the patient c. raise the head of the bed to sitting position d. evaluate the patient's ability to swallow small sips of ice water

A: check the patient's gag reflex- the first step in providing oral feedings for a patient with a stroke is ensuring that the patient has an intact gag reflex because oral feedings will not be provided if gag reflex is impaired. The nurse should then evaluate the patient's ability to swallow ice chips or ice water after placing the patient in an upright position

A nurse is caring for a client with a history of hypertension who is treated with metoprolol (Lopressor), hydrochlorothiazide (HydroDIURIL), and captopril (Capoten). The client's current blood pressure is 120/80 with a heart rate of 56. The client's usual heart rate is 76-84 since hospitalization. Which is the best action by the nurse? 1. Administer the metoprolol and the hydrochlorothiazide, hold the captopril, and notify the physician. 2. Administer the captopril and the hydrochlorothiazide, hold the metoprolol, and notify the physician. 3. Administer all medications and notify the physician. 4. Withhold all medications and notify the physician.

Administer the captopril and the hydrochlorothiazide, hold the metoprolol, and notify the physician.

The nurse is planning discharge teaching for a patient who requires assistance with mobility and eating after experiencing a stroke. Which instruction should the nurse include? Telling the family that the patient will return to their original level of mobility within a year Informing the patient there is no need to continue the inpatient therapy plan of care Advising the family to install grab bars next to the toilet Having the family to encourage the patient to adhere to the existing family routine

Advising the family to install grab bars next to the toilet

The nurse is planning discharge teaching for a patient who requires assistance with mobility and eating after experiencing a stroke. Which instruction should the nurse include? Advising the family to install grab bars next to the toilet Having the family to encourage the patient to adhere to the existing family routine Informing the patient there is no need to continue the inpatient therapy plan of care Telling the family that the patient will return to their original level of mobility within a year

Advising the family to install grab bars next to the toilet Discharge instructions should focus on the care the patient will receive at home. Safety is assessed, and appropriate instructions are given based on the assessment. Installing a grab bar next to the toilet is an appropriate item to help ensure the patient's safety. The other instructions are inappropriate for this patient.

Which of the following terms refer to the failure to recognize familiar objects perceived by the senses? a) Agnosia b) Perseveration c) Apraxia d) Agraphia

Agnosia Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to disturbances in writing intelligible words. Apraxia refers to inability to perform previously learned purposeful motor acts on a voluntary basis. Perseveration is the continued and automatic repetition of an activity, word, or phrase that is no longer appropriate.

You are alerted to a possible acute subdural hematoma in the patient who A. has a linear skull fracture crossing a major artery. B. has focal symptoms of brain damage with no recollection of a head injury. C. develops decreasing LOC and a headache within 48 hours of a head injury. D. has an immediate loss of consciousness with a brief lucid interval followed by decreasing LOC.

An acute subdural hematoma manifests within 24 to 48 hours of the injury. The signs and symptoms are similar to those associated with brain tissue compression by increased intracranial pressure (ICP) and include decreasing LOC and headache.

Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene? A: Placing client on back with small pillow under the head B: Keeping portable suctioning equipment at the bedside C: Opening the client's mouth with a padded tongue blade D: Cleaning the clients mouth and teeth with toothbrush

Answer: A

The client diagnosed with A-fib, has experienced a TIA. Which medication would the nurse anticipate being ordered for the client on discharge? A: PO anticoagulant medication B: Beta-blocker medication C: Anti-hyperuricemic medication D: Thrombolytic medication

Answer: A

Answer: A Antiplatelet and anticoagulant drugs, including aspirin, clopidogrel, dipyridamole, and ticlopidine, are often used as preventive drugs in clients with a history of previous transient ischemic attacks or stroke. Recombinant tissue plasminogen activator alteplase is the gold standard for the treatment of acute ischemic stroke. The rehabilitation phase of treatment usually involves physical, occupational, and/or speech therapy rather than medication.

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

Answer: A Rationale: 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.

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? A. Physical therapy B. Speech and language therapy C. Occupational therapy D. Home health

Answer: A Rationale: 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.

Answer: A Rationale: 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.

Answer: A Stroke warning signs in infants include seizures, extreme sleepiness, and favoring the use of only one side of the body. Signs of seizure in neonates include repetitive facial movements, staring, apnea, and jerking of the muscles of the face, arms, or legs. Questions related to balance or forming words are not age appropriate, as most normal 6-month-old infants do not have steady balance or the ability to form words. The question related to vomiting is also not appropriate, as vomiting at this age is more frequently related to food intolerances/allergies or gastrointestinal problems rather than stroke.

Answer: A TIAs are often warning signs of an ischemic thrombotic stroke. There is no way to predict the symptoms the client will experience after a stroke. One or many TIAs may precede a stroke, with the time between the attack and the stroke ranging from hours to months. A hemorrhagic stroke is caused by the rupture of a cerebral blood vessel and is not related to a TIA.

Answer: A To address the client's alteration in sensory and motor statuses, the nurse should encourage the client to use the nonaffected arm to feed self, bathe, and dress. The nurse should not provide all care for the client. The nurse should not talk loudly to the client but should articulate slower and face the client when speaking. Speaking in normal conversational patterns and tones may not be adequate when communicating with the client.

Answer: A Warning signs of stroke include sudden weakness, numbness, paralysis, loss of speech, confusion, dizziness, unsteadiness, and loss of balance—the key word is sudden. Family history and past medical history can be indicators for risk, but they are not warning signs of stroke. Gradual onset of symptoms is not indicative of a stroke

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? A. Providing reassurance and support B. Developing an alternate means of communicating C. Providing behavioral and cognitive therapy when the condition stabilizes D. Maintaining fluid, oxygen, and nutritional status

Answer: A Rationale: 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.

The nurse is planning care for a client admitted with a stroke. Which intervention would support the client's sensorimotor needs? A) Encourage use of non-affected arm to feed self, bathe, and dress. B) Speak in normal conversational pattern and tones. C) Provide complete care. D) Talk loudly and distinctly.

Answer: A Explanation: A) To address the client's alteration in sensory and motor statuses, the nurse should encourage the client to use the non-affected arm to feed self, bathe, and dress. The nurse should not provide all care for the client. The nurse should not talk loudly to the client but should articulate slower and face the client when speaking. Speaking in normal conversational patterns and tones may not be adequate when communicating with the client.

While completing a health history with an older client, the nurse learns that the client experienced a transient ischemic attack several months ago. What does this information suggest to the nurse? A) The client is at risk for an ischemic thrombotic stroke. B) The client will have minimal symptoms should a stroke occur. C) The client will not experience a stroke in the future. D) The client is at high risk for a hemorrhagic stroke.

Answer: A Explanation: A) Transient ischemic attacks are often warning signs of an ischemic thrombotic stroke. One or many transient ischemic attacks may precede a stroke, with the time between the attack and the stroke ranging from hours to months. A hemorrhagic stroke is caused by the rupture of a cerebral blood vessel and is not related to a transient ischemic attack. There is no way to predict the symptoms the client will experience after a stroke.

Answer: A Explanation: A) Warning signs of stroke include sudden weakness, numbness, paralysis, loss of speech, confusion, dizziness, unsteadiness, and loss of balance-the key word is sudden. Family history and past medical history can be indicators for risk, but they are not warning signs of stroke. Gradual onset of symptoms is not indicative of a stroke.

Answer: A Rationale: 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.

An older client is diagnosed with a left cerebral hemorrhage. To meet the needs of the client and family, the nurse will provide teaching in which areas? Select all that apply. A) Time adjustment to complete activities B) How to use a sign board C) Nutrition support D) Transfer techniques E) Information about impulse control

Answer: A, B, D Explanation: A) The left cerebral hemisphere is responsible for the language center, calculation skills, and thinking/reasoning abilities. Reading and speaking could be compromised if there is left-sided brain damage. The client also might display over-cautious behavior and might be slow to respond or complete activities. Transfer techniques would apply regardless of the side involved. Impulse control problems can arise with right-sided involvement. Nutritional support may or may not be an issue with this client.

A nurse is caring to a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? A) Teach the client to scan to the right to see objects on the right side of the body. B) Place the bedside table on the right side of the bed. C) Orient the client to the food on her plate using the clock method. D) Place the wheelchair on the client's left side.

Answer: B

What is a priority nursing assessment in the first 24 hours after admission of client with a thrombotic stroke? A: Cholesterol level B: Pupil size and papillary response C: Vowel sounds D: Echo

Answer: B

The community nurse is teaching a class at the community center regarding the cultural and ethnic risk factors for stroke. Which statement should nurse include in this presentation? A) Caucasians have an increased incidence of intracerebral hemorrhage. B) African Americans have almost twice the number of first-ever strokes compared with Whites. C) Asian Americans are more likely to die following a stroke than Whites. D) The prevalence of hypertension among Hispanics is the highest in the world.

Answer: B African Americans have almost twice the number of first-ever strokes compared with Caucasians and have the highest rate of hypertension compared to other races/ethnicities. Hispanics have an increased incidence of intracerebral hemorrhage. Individuals living in the Southeastern United States have the highest stroke mortality rate.

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

Answer: B Rationale: 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.

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

Answer: B Rationale: 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.

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? A. Stool softener B. Antiplatelet C. Anticoagulant D. Beta blocker

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

Answer: B Rationale: 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 re-clotted 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.

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

Answer: B, C, D Rationale: 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.

A 78 year old client is admitted to the ED with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? A: Prepare to administer recombinant tissue plasminogen activator (rt-PA) B: Discuss the precipitating factors that caused the symptoms C: Schedule a STAT CT scan of head D: Notify speech pathologist for emergency consult

Answer: C

During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the clients: A: Pulse B: Respiration C: BP D: Temperature

Answer: C

What is expected outcome of thrombolytic drug therapy? A: Increased vascular permeability B: Vasoconstriction C: Dissolved emboli D: Prevention of hemorrhage

Answer: C

Which assessment data would indicate to nurse that the client would be at risk for hemorrhagic stroke? A: Blood glucose level of 480mg/dL B: Right sided carotid bruit C: BP of 220/120 mm Hg D: Presence of bronchogenic carcinoma

Answer: C

A client with a suspected transient ischemic attack (TIA) presents to the emergency department with aphasia. Based on this data, the nurse plans care based on ischemia to which portion of the brain? A) Anterior cerebral artery B) Vertebral artery C) Left hemisphere of the brain D) Right hemisphere of the brain

Answer: C Aphasia occurs due to ischemia of the left hemisphere. The other choices may be involved in a TIA, but are not the causative pathology of aphasia.

Answer: C Rationale: 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.

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? A. Thiazide diuretic B. Anticoagulant C. Beta blocker D. Antiplatelet

Answer: C Rationale: 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.

A nurse working in the Emergency Department is aware that there are various cultural and ethnic risk factors for stroke. The nurse understands that which of the following is an example of this? A) African-Americans have an increased incidence of intracerebral hemorrhage. B) Hispanics have almost twice the number of first-ever strokes compared with whites. C) African-Americans are more likely to die following a stroke than whites. D) The prevalence of hypertension among Hispanics is the highest in the world.

Answer: C Explanation: C) African-Americans are more likely to die following a stroke than whites. Also, African-Americans have the highest prevalence of hypertension in the world and almost twice the number of first-ever strokes compared with whites. Hispanics have an increased incidence of intracerebral hemorrhage.

A client with a suspected TIA presents to the Emergency Department with aphasia. Which is the pathophysiology causing aphasia? A) Middle cerebral artery involvement B) Posterior cerebral artery involvement C) Ischemia of the left hemisphere D) Ischemia of the right hemisphere

Answer: C Explanation: C) Aphasia occurs due to ischemia of the left hemisphere. The other choices may be involved in a TIA, but are not the causative pathology of aphasia.

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

Answer: D Rationale: 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.

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? A. Extracranial-intracranial bypass B. Cautious observation only C. Carotid endarterectomy D. Carotid angioplasty with stenting

Answer: D Rationale: 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.

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

Answer: D Rationale: 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 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? A. "Use the left arm to bathe, brush teeth, comb hair, and eat." B. "The occupational therapist will teach you how to promote upper extremity strength." C. "The occupational therapist will assist you in learning to walk using a walker." D. "When getting dressed, first put clothing on the left side."

Answer: D Rationale: 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.

What type of stroke occurs when the blood supply to a part of the brain is cut off by a thrombus, embolus, or stenosis? A) Intracerebral stroke B) Subarachnoid stroke C) Hemorrhagic stroke D) Ischemic stroke

Answer: D Strokes may be ischemic, occurring when the blood supply to a part of the brain is suddenly interrupted by a thrombus (blood clot), embolus (foreign matter traveling through the circulation), or stenosis (narrowing); or they may be hemorrhagic, occurring when a blood vessel breaks open and spills blood into spaces surrounding neurons. Intracerebral and subarachnoid are two types of hemorrhagic stroke.

The nurse is instructing the spouse of a client with a stroke on how to do passive range-of-motion exercises to the affected limbs. Which rationale for this intervention will the nurse include in the teaching session? A) Improve muscle strength B) Maintain cardiopulmonary function C) Improve endurance D) Maintain joint flexibility

Answer: D The nurse should instruct the spouse that the exercises will help with joint flexibility. Passive range-of-motion exercises help maintain joint flexibility. Active range-of-motion exercises improve muscle strength, can help maintain cardiopulmonary functioning. And improve endurance.

A client diagnosed with a stroke is going to receive treatment with fibrinolytic therapy using the recombinant tissue plasminogen activator alteplase (rt-PA). Which information should the nurse include when performing medication teaching for the client's family? A) Used to treat thrombotic and hemorrhagic strokes B) Not associated with serious complications C) Indicated if the stroke symptoms have occurred within the last 6 hours D) Administered to break up existing clots and increase cerebral blood flow

Answer: D Thrombolytic therapy using rt-PA is used to dissolve the clot formed with a thrombotic stroke. Dissolving the clot reestablishes cerebral circulation. The treatment is only used with ischemic strokes. Bleeding is a complication associated with the treatment, which may result in cerebral hemorrhage, causing extensive brain damage and disability. The treatment can be used if the symptoms have occurred within the last 3 hours

A client, diagnosed with Impaired Swallowing, complains of frequent heartburn. What should the nurse do? A) Teach the client the "chin tuck" technique when swallowing. B) Assist the client to a 90° sitting position, or as high as tolerated, during meals. C) Check the client's mouth for pocketing of food. D) Assist the client in maintaining a sitting position for 30 minutes after the meal.

Answer: D Explanation: D) Keeping the client upright for a time after the meal will help prevent food from being regurgitated back into the esophagus. The position of the client during the meals as well as teaching the "chin tuck" technique will assist with the swallowing mechanism but will not help with regurgitation. Pocketing food does not cause regurgitation.

The nurse is instructing the spouse of a client with a stroke on how to do passive range of motion to the affected limbs. What should the nurse explain regarding the purpose of these exercises? A) Improve muscle strength. B) Maintain cardiopulmonary function. C) Improve endurance. D) Maintain joint flexibility.

Answer: D Explanation: D) Passive range-of-motion exercises help to maintain joint flexibility. Active range-of-motion exercises improve muscle strength, improve endurance, and can help maintain cardiopulmonary functioning. The nurse should instruct the spouse that the exercises will help with joint flexibility.

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? Stool softener Anticoagulant Anti-platelet Beta blocker

Anti-platelet

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).

What is the drug classification of Clopidogrel and dipyridamole?

Antiplatelet- platelet inhibiting meds

Match each symptoms of stroke that affects the LEFT hemisphere

Aphasia, Unable to add numbers & Loss of hearing

Manifestations of left brain damage

Aphasia, inability to remember words

The nurse is caring for a client who has increased intracranial pressure from a traumatic brain injury. Which diagnostic test should the nurse anticipate being ordered? (Select all that apply.) Arterial blood gas Computerized tomography (CT) scan of the head Electromyogram Cardiac monitoring Intracranial pressure monitor

Arterial blood gas Computerized tomography (CT) scan of the head Cardiac monitoring Intracranial pressure monitor

A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first? a) Take the client's blood pressure. b) Ask the client if he has a headache. c) Ask the client if he has trouble breathing. d) Place antiembolism stockings on the client.

Ask the client if he has trouble breathing. The nurse should first assess the client's breathing. A complication of a carotid endarterectomy is an incisional hematoma, which could compress the trachea causing breathing difficulty for the client. Although the other measures are important actions, they aren't the nurse's top priority.

A client is to be discharged from the hospital first thing in the morning. However, overnight the client developed symptoms of "not being able to see well." The client also cannot move either the left arm or the left leg to get out of bed. What is the priority response by the nurse? Assess the client's vital signs Assist the client to dress for discharge Instruct the client on the use of assistive devices to assist in mobility Ask the client if he has a family history of strokes

Assess the client's vital signs Rationale The change in assessment should signal the nurse to follow the nursing process and assess the client further. Although family history is important, it is not the priority in this situation. These symptoms are consistent with worsening condition and possible increased intracranial pressure. Continuing with the tasks associated with discharge would not be appropriate.

The nurse is caring for a patient poststroke. Which action is most important prior to feeding the patient? Ordering a soft or pureed diet Placing the food in the unaffected side of the mouth Assessing the results of the swallowing studies Sitting the patient upright

Assessing the results of the swallowing studies

The nurse is caring for a patient post-stroke. Which action is most important prior to feeding the patient? Placing the food in the unaffected side of the mouth Ordering a soft or pureed diet Assessing the results of the swallowing studies Sitting the patient upright

Assessing the results of the swallowing studies It is most important for the nurse to review the results of the swallowing studies to ensure safety of the patient prior to feeding. While the other options are appropriate, they should only be completed after the nurse has reviewed the swallowing studies.

The nurse on the rehabilitation unit is planning care for a patient who recently experienced a stroke. Which intervention should the nurse implement to promote mobility for this patient? Encouraging fluid intake up to 2000 mL per day Assisting with range of motion exercises Administering oxygen per order Helping the patient to the bathroom every 2 hours

Assisting with range of motion exercises

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. Impaired muscle coordination c. Nausea and vomiting d. Respiratory distress

A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best priority nursing action to be taken? a. Know this is a normal finding for CVA. b. Perform a vision field assessment. c. Assist the client with feeding. d. Reposition the tray and plate.

A client with increased intracranial pressure is receiving mannitol via intravenous infusion. Which assessment finding is most important in determining the effectiveness of this treatment? a. Hyperpyrexia is resolving. b. Urine output is increased. c. Level of consciousness is improving. d. Blood pressure is rising.

A patient is receiving Mannitol for increased ICP. Which statement is INCORRECT about this medication? A. Mannitol will remove water from the brain and place it in the blood to be removed from the body. B. Mannitol will cause water and electrolyte reabsorption in the renal tubules. C. When a patient receives Mannitol the nurse must monitor the patient for both fluid volume overload and depletion. D. Mannitol is not for patients who are experiencing anuria.

After a stroke, sensory-perceptual changes increase the client's risk for what? A) Aspiration B) Injury C) Bleeding D) Infection

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client? a. Hypostatic pneumonia b. Brain tumor c. Epilepsy d. Trigeminal neuralgia

During the assessment of a patient with increased ICP, you note that the patient's arms are extended straight out and toes pointed downward. You will document this as: A. Decorticate posturing B. Decerebrate posturing C. Flaccid posturing

External ventricular drains monitor ICP and are inserted where? A. Subarachnoid space B. Lateral Ventricle C. Epidural space D. Right Ventricle

The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern? a. Physician maintains aseptic procedure. b. Cerebrospinal fluid is cloudy in nature. c. Client states a pressure relief in the head. d. Client states a piercing feeling.

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. Pulse and blood pressure c. Numbness and tingling d. Pain level

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. Blood vessels dilate circulating blood. b. Herniation occurs through the foramen magnum. c. Venous congestion occurs, causing peripheral edema. d. Additional inflammation occurs in the brain.

The nurse is caring for a client with GuillainBarré syndrome. Which assessment finding would indicate the need for oral suctioning? a. Decreased pulse rate, abdominal breathing b. Increased pulse rate, adventitious breath sounds c. Decreased pulse rate, respirations of 20 breaths/minute d.Increased pulse rate, respirations of 16 breaths/minute

The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan for this client reflects the client's problem eating due to jaw pain. To assist the client in meeting the adequate nutritional needs, what should the nurse suggest? a. Include fish, liver, and chicken in diet. b. Take small meals of nutrient and calorie-dense food. c. Include additional servings of fruits and raw vegetables. d. Increase the intake of calcium and proteins.

The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration? a. Intracranial hematoma b. Epidural hematoma c. Cerebral Hematoma d. Extradural hematoma e. Subdural hematoma

What assessment finding requires immediate intervention if found while a patient is receiving Mannitol? A. An ICP of 10 mmHg B. Crackles throughout lung fields C. BP 110/72 D. Patient complains of dry mouth and thirst

Which nursing assessment finding is most indicative of a hemorrhagic stroke? a. Client history of atrial fibrillation b. Sudden onset of breathing alterations c. Client history of hyperlipidemia d. Symptoms evolving over 24 to 48 hours

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? a. Cerebral b. Subdural c. Epidural d. Intracerebral Skeletal

Which patient below is at MOST risk for increased intracranial pressure? A. A patient who is experiencing severe hypotension. B. A patient who is admitted with a traumatic brain injury. C. A patient who recently experienced a myocardial infarction. D. A patient post-op from eye surgery.

While the nurse is making initial rounds after coming on shift, a client thrashes about in bed complaining of a severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having? a. Migraine b. Cluster c. Sinus d. Tension

You're providing education to a group of nursing students about ICP. You explain that when cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies. A student asks, "What is a normal cerebral perfusion pressure level?" Your response is: A. 5-15 mmHg B. 60-100 mmHg C. 30-45 mmHg D. >160 mmHg

The patient has rhinorrhea after a head injury. What action should you take? A. Pack the nares with sterile gauze. B. A loose collection pad may be placed under the nose. C. Suction the drainage with an inline suction catheter. D. Obtain a sample for culture.

B A loose collection pad may be placed under the nose. Do not place a dressing in the nasal cavity, and nothing should be placed inside the nostril. There is no need to culture the drainage. The concern is whether it is spinal fluid, which is determined by a test for glucose or the halo or ring sign.

A female patient has left-sided hemiplegia after an ischemic stroke that occurred 2 weeks earlier. How should you best promote the integrity of the patient's skin? A. Position the patient on her weak side most of the time. B. Alternate the patient between supine and side-lying positions. C. Avoid the use of pillows to promote independence in positioning. D. Establish a schedule for the massage of areas where skin breakdown emerges.

B A position change schedule should be established for stroke patients. An example is side-backside positioning, with a maximum duration of 2 hours for any position. The patient should be positioned on the weak or paralyzed side for only 30 minutes. Pillows may be used to facilitate positioning. Areas of skin breakdown should never be massaged.

An elderly patient fell at home. Which information from the patient's history makes this patient at high risk for an intracerebral bleed? A. History of a heart condition B. Taking warfarin (Coumadin) C. Has lost consciousness for 5 seconds D. History of migraine headaches

B Anticoagulant use is associated with increased hemorrhage and more severe head injury. A heart condition may have caused the syncope that caused the fall, but it was not solely responsible for increased bleeding. Concussions are usually minor injuries that resolve, and the typical signs include a brief disruption in level of consciousness (LOC). If the loss of consciousness is less than 5 minutes, patients are usually discharged. Headache by itself does not indicate a risk for intracerebral bleeding.

You are caring for a patient admitted with a subdural hematoma after a motor vehicle accident. Which change in vital signs would you interpret as a manifestation of increased intracranial pressure? A. Tachypnea B. Bradycardia C. Hypotension D. Narrowing pulse pressure

B Changes in vital signs indicative of increased ICP are known as Cushing's triad, which consists of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.

For a patient with a suspected stroke, which important piece of information should you obtain? A. Time of the patient's last meal B. Time at which stroke symptoms first appeared C. Patient's hypertension history and management D. Family history of stroke and other cardiovascular diseases

B During initial evaluation, the single most important point in the patient's history is the time of onset of stroke symptoms. If the stroke is ischemic, recombinant tissue plasminogen activator (tPA) must be administered within 3 to 4.5 hours of the onset of clinical signs; tPA reestablishes blood flow through a blocked artery and prevents brain cell death in patients with an acute onset of symptoms.

Which response can be expected in a patient with low oxygen concentration and acidosis? A. Decreased cerebral fluid flow with decreased cerebral pressure B. Vasodilation with increased cerebral pressure C. Systemic hypotension with decreased cerebral pressure D. Cerebral tissue hypertrophy with increased cerebral pressure

B Low concentration of oxygen ions and high concentration of hydrogen ions cause vasodilation, which can result in increased ICP if autoregulation has failed. The other options are not possible

What is the treatment of choice for normal pressure hydrocephalus? A. Donepezil (Aricept) B. Shunt C. Furosemide (Lasix) D. Aspiration

B Normal pressure hydrocephalus results from an obstruction in the flow of cerebrospinal fluid (CSF), which causes a buildup of CSF fluid in the brain. Manifestations of the condition include dementia, urinary incontinence, and difficulty walking. Meningitis, encephalitis, or head injury may cause the condition. If diagnosed early, it is treated by surgically inserting a shunt to divert the fluid.

The nurse is monitoring a client with increased intracranial pressure who is experiencing status epilepticus. Which intervention has the highest priority for this client? A.Contacting the provider for orders B.Establishing and maintaining an airway C.Administering diazepam intravenously D.Administering a solution of 50% dextrose

B Rationale: In management of status epilepticus, the highest priority is to establish and maintain an airway. Contacting the provider for orders would not take priority over establishing and maintaining an airway. Diazepam and a solution of 50% dextrose would be administered intravenously as a first-line agent but would not be the highest priority.

A homeless client presents to the emergency department (ED) complaining of severe chest pain. The client is well known to the ED, coming in frequently for various minor complaints. Which ethical principles should be most important for the nurse to consider? A.Nonmaleficence and beneficence B.Justice and fairness C.Accountability and responsibility D.Privacy and confidentiality

B Rationale: The principle of justice guides nurses in making decisions about setting priorities. Additionally, nurses must show fairness in treating individuals as equals. In this scenario, the nurse must treat the homeless client like any other client seeking care for chest pain. Accountability, responsibility, privacy, confidentiality, nonmaleficence, and beneficence are all important ethical considerations for the nurse but are not directly relevant to the situation.

How should you most accurately assess the position sense of a patient with a recent traumatic brain injury? A. Ask the patient to close his or her eyes and slowly bring the tips of the index fingers together. B. Ask the patient to maintain balance while standing with his or her feet together and eyes closed. C. Ask the patient to close his or her eyes and identify the presence of a common object on the forearm. D. Place the two points of a calibrated compass on the tips of the fingers and toes, and ask the patient to discriminate the points.

B The Romberg test is an assessment of position sense in which the patient stands with the feet together and then closes his or her eyes while attempting to maintain balance. The other tests of neurologic function do not directly assess position sense.

After a major head trauma, the patient's respiratory and cardiac functions are affected. Which area of the brain is damaged? A. Temporal lobe of the cerebrum B. Brainstem C. Cerebellum D. Spinal nerves

B The brainstem includes the midbrain, pons, and medulla. The vital centers concerned with respiratory, vasomotor, and cardiac function are located in the medulla. Integration of somatic, visual, and auditory data occurs in the temporal lobe. The cerebellum coordinates voluntary movement, trunk stability, and equilibrium. Motor and spinal nerves serve particular areas of the body.

What is important when obtaining a history of a patient with a neurologic problem? A. Have patient agree or disagree with suggested symptoms to obtain a thorough history. B. Mode of onset and course of illness are essential aspects. C. Check out neurologic problems caused by nutrition by asking about sodium. D. Assess for dementia using the Confusion Assessment Method (CAM).

B The mode of onset and the course of the illness are especially important aspects of the history. The nature of a neurologic disease process often can be described by these facts alone. Avoid suggesting certain symptoms or using leading questions. Nutritional deficits of B vitamins are most likely to cause neurologic problems. CAM is used to assess for delirium.

Preventing which problem is a priority nursing goal for a patient who had cranial surgery today? A. Pain B. Increased ICP C. Infection D. Malnutrition

B The primary goal of care after cranial surgery is prevention of increased ICP. Other priorities are monitoring neurologic function, fluid and electrolyte levels, and serum osmolality. The brain does not have pain receptors, although the patient can have a headache. However, increased ICP remains a priority. Infection is not a priority the day of surgery, and nutrition is important, but increased ICP is the priority.

Vasogenic cerebral edema increases ICP by A. shifting fluid in the gray matter. B. altering the endothelial lining of cerebral capillaries. C. leaking molecules from the intracellular fluid to the capillaries. D. altering the osmotic gradient flow into the intravascular component.

B Vasogenic cerebral edema occurs mainly in the white matter and is caused by changes in the endothelial lining of cerebral capillaries.

You plan care for the patient with increased ICP with the knowledge that the best way to position the patient is to A. keep the head of the bed flat. B. elevate the head of the bed to 30 degrees. C. maintain patient on the left side with the head supported on a pillow. D. use a continuous-rotation bed to continuously change patient position.

B You should maintain the patient with increased ICP in the head-up position. Elevation of the head of the bed to 30 degrees enhances respiratory exchange and aids in decreasing cerebral edema. You should position the patient to prevent extreme neck flexion, which can cause venous obstruction and contribute to elevated ICP. Elevation of the head of the bed reduces sagittal sinus pressure, promotes drainage from the head through the valveless venous system in the jugular veins, and decreases the vascular congestion that can produce cerebral edema. However, raising the head of the bed above 30 degrees may decrease the cerebral perfusion pressure (CPP) by lowering systemic blood pressure. Careful evaluation of the effects of elevation of the head of the bed on the ICP and the CPP is required.

A client with a traumatic brain injury is intubated and placed on mechanical ventilation. Which measurement should the nurse use to evaluate the effectiveness of these respiratory interventions? A.Glasgow Coma Scale score B.Arterial blood gas results C.Motor and sensory function D.Cranial nerve function

B Rationale: A client with an alteration in level of consciousness (LOC) may be unable to maintain an open airway and engage in spontaneous respirations. The client may need endotracheal intubation or mechanical ventilation. Arterial blood gases are used to guide the effectiveness of ventilation. Glasgow Coma Scale score, cranial nerve function, and motor and sensory function are used to determine the effect of intracranial pressure on body functioning.

The nurse is discussing the multiple medications with the family of a client diagnosed with increased intracranial pressure (IICP). The family member asks why the client is being given a gastric acid reducer. Which response by the nurse provides the correct explanation? A."Since they are not eating, we use a gastric acid reducer to neutralize the acid in their stomach." B."There is a higher risk for stress ulcers; therefore, we use an acid reducer to block gastric secretion." C."A gastric acid reducer helps to protect the inner lining of the stomach from ulcer-producing effects." D."We use a gastric acid reducer to adhere to ulcer sites and protect them from acids, bile salts, and enzymes."

B Rationale: Clients with IICP have a higher risk of stress gastritis and ulcers; thus, histamine H2 antagonists or proton pump inhibitors are used prophylactically to block histamine-induced gastric secretion. Antacids, not gastric acid reducers, neutralize acid in the stomach. Gastric acid reducers do not adhere to ulcer sites and protect them from acids, bile salts, and enzymes. A gastric acid reducer does not directly protect the inner lining of the stomach; it blocks histamine-induced gastric secretion.

The nurse in an emergency department (ED) shares with a fellow nurse that, due to the busy pace of the day, he has not even been able to go to the bathroom since he arrived for his shift 6 hours ago. Which response by the fellow nurse should best address this situation? A.Listening to the nurse's concerns and offering verbal encouragement to make it through the rest of the shift B.Offering to oversee the nurse's clients so that a 15-minute break can be taken C.Discussing better ways to prioritize and manage time with the nurse so that in the future he will be able to take needed breaks D.Encouraging the nurse to let the supervisor know so that appropriate actions can be taken

B Rationale: It is important that nurses take quick 15-minute breaks to refresh, reenergize, and take care of bodily functions, so the best response by the fellow nurse would be to cover for the nurse to allow this break to occur. Encouraging the nurse to let the supervisor know, listening to the nurse's concerns, and discussing better ways to manage time and prioritize would not provide the much-needed break for the nurse.

The medical-surgical nurse is planning the day immediately after receiving report. Which should be the primary nursing intervention when prioritizing care? A.Analyzing collected data B.Assessing client situations C.Ascertaining interventions D.Assigning staff to clients

B Rationale: The first step when prioritizing care is assessment. Assessment is the process of gathering information to make decisions. Assessment includes knowing individual clients' health statuses to prepare for anticipated or unanticipated changes. Ascertaining interventions would occur after the assessment. Analyzing collected data would occur after an assessment. Assigning staff to clients would occur after knowing the number and level of caregivers available to provide care.

A client is admitted to the emergency department with a rash on the trunk and extremities. The client reports difficulty breathing, chest tightness, and weakness. Respirations are 24 breaths/min and even, pulse is 90 beats/min and thready, and blood pressure is 96/70 mmHg. The client reports a recent history of a urinary tract infection and having been on sulfasalazine for the past 5 days. Which is the priority nursing assessment for this client? A.Peripheral edema B.Airway patency C.Gastrointestinal disturbances D.Urine discoloration

B Rationale: Using the ABCs (airway, breathing, and circulation) to establish priority nursing interventions, the nurse would first establish airway patency based on the client's symptoms of difficulty breathing. This would take priority over assessment for edema, urine discoloration, and gastrointestinal disturbances.

The Monro-Kellie hypothesis explains the compensatory relationship among the structures in the skull that play a role with intracranial pressure. Which of the following are NOT compensatory mechanisms performed by the body to decrease intracranial pressure naturally? Select all that apply: A. Shifting cerebrospinal fluid to other areas of the brain and spinal cord B. Vasodilation of cerebral vessels C. Decreasing cerebrospinal fluid production D. Leaking proteins into the brain barrier

B D

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? a.) Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. b.) Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. c.) Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. d.) Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

B ~ A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise.

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? a.) Vomiting continues b.) Intracranial pressure (ICP) is increased c.) The client needs mechanical ventilation d.) Blood is anticipated in the cerebralspinal fluid (CSF)

B ~ Sudden removal of CSF results in pressures lower in the lumbar area than the brain and favors herniation of the brain; therefore, LP is contraindicated with increased ICP. Vomiting may be caused by reasons other than increased ICP; therefore, LP isn't strictly contraindicated. An LP may be preformed on clients needing mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage and was obtained before signs and symptoms of ICP.

The home health nurse is caring for an 81-year-old who had a stroke 2 months ago. Based on information shown in the accompanying figure from the history, physical assessment, and physical therapy/occupational therapy, which nursing diagnosis is the highest priority for this patient? a. Impaired transfer ability b. Risk for caregiver role strain c. Ineffective health maintenance d. Risk for unstable blood glucose level

B ~ The spouse's household and patient care responsibilities, in combination with chronic illnesses, indicate a high risk for caregiver role strain. The nurse should further assess the situation and take appropriate actions. The data about the control of the patient's diabetes indicates that ineffective health maintenance and risk for unstable blood glucose are not priority concerns at this time. Because the patient is able to ambulate with a cane, the nursing diagnosis of impaired transfer ability is not supported.

Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient complains of having a stiff neck. b. The patient's blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

B ~ To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.

The nurse is caring for a school-age client who will be discharged from the hospital after receiving a ventriculoperitoneal (VP) shunt as treatment for increased intracranial pressure (IICP). The nurse has taught the parents to monitor the child for shunt malfunction. Which statement by the parents regarding when to notify the healthcare provider indicates that learning goals have been met? A) "If our child has a bulging soft spot, we will call the doctor." B) "If our child develops an altered level of consciousness, we will notify the doctor." C) "If we notice our child's head is expanding, we will notify the doctor." D) "If our child vomits, we will call the doctor."

B) "If our child develops an altered level of consciousness, we will notify the doctor."

The nurse is caring for a client in the neurologic intensive care unit (ICU) with head trauma. The client is being monitored for increased intracranial pressure (IICP). Using the Monro-Kellie hypothesis as a basis for explanation, which comment by the nurse to the client's family would be most appropriate? A) "It is normal for brain pressure to increase in times of stress." B) "Increasing brain pressure decreases the amount of blood flow to the brain itself." C) "The pressure in the brain is increasing because the brain is shrinking." D) "Because there is more pressure in the brain, the blood flow is also increasing."

B) "Increasing brain pressure decreases the amount of blood flow to the brain itself."

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 nurse's 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) "Stop smoking as soon as possible."

A rehabilitation nurse caring for a patient who has had a stroke is approached by the patient's family and asked why the patient has to do so much for herself when she is obviously struggling. What would be the nurse's 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 aren't 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) "The focus on care in a rehabilitation facility is to help the patient to resume as much self-care as possible."

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) Tonic-clonic seizures D) Shortness of breath

B) Alteration in level of consciousness (LOC)

Hydrocephalus results from an imbalance between production and absorption of which of the following? A) Blood B) Cerebrospinal fluid C) Oxygen D) Water

B) Cerebrospinal fluid

The nurse selects the diagnosis of Risk of Infection for a child who sustained a brain injury during an automobile accident. Which nursing intervention would be appropriate to include in this client's plan of care related to this diagnosis? A) Teach the family the importance of using seat belts. B) Change the client's dressings on a prescribed basis. C) Refer the family to support services in the community. D) Explain rules for visiting in the Intensive Care Unit.

B) Change the client's dressings on a prescribed basis.

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) Elevation of the head of the bed

Traumatic brain injury occurs when which of the following causes some degree of impairment to brain structure or function? A) Congenital disorder B) External force C) Infection D) Stress reaction

B) External force

A school-age client is experiencing photophobia, a sore neck, chills, and fever. During a physical assessment, the nurse uses the technique in the Exhibit. Why did the nurse use this technique when assessing the client? A) It is a routine part of the physical assessment. B) Flexion of the hips or knees would be consistent with meningitis. C) The nurse was assessing range of motion of the neck. D) This technique assesses optic nerve functioning.

B) Flexion of the hips or knees would be consistent with meningitis.

A patient has recently begun mobilizing during the recovery from an ischemic stroke. To protect the patient's safety during mobilization, the nurse should perform what action? A) Support the patient's 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 patient's family members do not participate in mobilization.

B) Have a colleague follow the patient closely with a wheelchair.

When a nurse provides a client with the guidance to wear seat belts and avoid mobile device use while driving, this measure is intended to lower the risk of which of the following? A) Cerebral edema B) Head trauma C) Hydrocephalus D) Intracranial tumors

B) Head trauma

The physician orders Alteplase (Activase) for a 58-year-old man diagnosed with an acute ischemic stroke. Which nursing action is most appropriate? A) Administer the medication by an IV route at 15 mL/hr for 24 hours. B) Insert two or three large-bore IV catheters before administering the medication. C) If gingival bleeding occurs, discontinue the medication and notify the physician. D) Reduce the medication infusion rate for a systolic blood pressure above 180 mm Hg.

B) Insert two or three large-bore IV catheters before administering the medication. Rationale: Before giving Alteplase, the nurse should start two or three large bore IVs. Bleeding is a major complication with fibrinolytic therapy, and venipunctures should not be attempted after Alteplase is administered. Altepase is administered IV with an initial bolus dose followed by an infusion of the remaining medication within the next 60 minutes. Gingival bleeding is a minor complication and may be controlled with pressure or ice packs. Control of blood pressure is critical prior to Altepase administration and for the following 24 hours. Before administering Altepase, a systolic pressure above 180 mm Hg or diastolic pressure above 110 mm Hg requires aggressive blood pressure treatment to reduce the risk of cerebral hemorrhage.

The nurse is reviewing results of diagnostic testing performed on a client with increased intracranial pressure (ICP) in preparation for an evaluation to be done by the healthcare provider during morning rounds. Which diagnostic test results should the nurse make available to the healthcare provider for review? Select all that apply. A) Bronchoscopy results B) MRI result C) Head CT scan with and without contrast D) Electroencephalogram E) Cerebrospinal fluid differential cell count

B) MRI result C) Head CT scan with and without contrast D) Electroencephalogram E) Cerebrospinal fluid differential cell count

A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patient's 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) Maintain and improve cerebral tissue perfusion.

A patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patient's admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the patient's 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) Maintain the patient on complete bed rest.

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) Recent intracranial pathology D) Current anticoagulation therapy E) Symptom onset greater than 3 hours prior to admission

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) Teaching the patient to perform deep breathing and coughing exercises

Which of the following statements best describes a seizure threshold? A) The threshold is the length of time a seizure will last. B) The threshold is the limit beyond which the occurrence of a seizure is possible. C) Unless a seizure results in convulsions, it is considered to be below the threshold. D) When the threshold is exceeded, a seizure is considered to be generalized.

B) The threshold is the limit beyond which the occurrence of a seizure is possible.

A school-age client loses consciousness after being hit in the head with a bat at baseball practice. The child was not wearing a helmet. The last set of vital signs showed heart rate 48, blood pressure 132/58 mmHg, and respiratory rate 28 and irregular. Based on this data, which conclusion by the nurse is the most appropriate? A) These vital signs indicate respiratory distress. B) These vital signs indicate increased intracranial pressure. C) These vital signs indicate cardiovascular disease. D) These vital signs indicate that this child has a spinal cord injury.

B) These vital signs indicate increased intracranial pressure.

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) White male, age 60, with history of uncontrolled hypertension

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. Used concurrently with heparin therapy b. Administer within 3 hours of onset of symptoms. c. Presence of an ischemic stroke d. The symptoms are no longer evolving. e. Administer intramuscular for faster response. f. Administer for hemorrhagic strokes.

B, C

The nurse is caring for a client who has increased intracranial pressure and a fever of 102°F. Which nursing intervention promotes normal intracranial pressure? (Select all that apply.) A. Increasing environmental stimuli B. Administering acetaminophen per order C. Monitoring level of consciousness D. Providing supplemental oxygen E. Flexing the neck to open the airway

B, C, D Rationale: Increased intracranial pressure can cause irregular and ineffective respirations. Supplemental oxygen helps prevent hypoxia and excess carbon dioxide, which is a vasodilator. A decreased level of consciousness can be a manifestation of pressure on the cerebral cortex. It can also be a manifestation of decreased oxygen levels in the brain. Hyperthermia increases intracranial pressure and affects hypothalamic function in clients with increased intracranial pressure; therefore, administering an antipyretic medication is appropriate. Excess environmental stimuli can increase intracranial pressure. Flexing the neck increases intracranial pressure by preventing blood return from the brain. The head and neck must be kept in neutral position.

A 35-year-old client has been in the hospital for 2 weeks recovering from increased intracranial pressure. Which instruction should the nurse provide to the client? (Select all that apply.) A. Discuss the care plan at the workplace. B. Take all medications as prescribed. C. Wear a helmet to prevent head injury. D. Remain on bedrest at all times of the day. E. Purchase a medical alert bracelet.

B, C, E Rationale: Nurses can teach clients who are at risk for impaired intracranial regulation about the importance of wearing a medical alert bracelet, discussing care plans at the school or workplace, and taking all medications as prescribed. For young children, health promotion may include wearing a helmet to prevent head injury during a seizure. There is no indication that requires complete bedrest.

Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply. a. Pain and stiffness of the extremities b. Cloudy cerebral spinal fluid c. Low antidiuretic hormone (ADH) levels d. Low white blood cell (WBC) count e. Low red blood cell (RBC) count f. Purpura of hands and feet

B, F

When caring for an older adult experiencing problems with intracranial regulation, which change noted by the nurse during care would be attributed to normal age-associated changes versus those indicative of issues requiring attention? (Select all that apply.) A.Some decline in mental status B.Slower fine finger movements C.Decreased perception of temperature sensation D.Alterations in long-term memory E.Slower impulse transmission and reaction to stimuli

B,C,E Rationale: Slower fine finger movements, decreased perception of temperature sensation, and slower impulse transmission and reaction to stimuli are normal changes of aging. Declining mental status and alterations in long-term memory are not normal age-associated changes and should be investigated.

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

B. A blood clot lodges in a cerebral vessel and blocks blood flow. Rationale: 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.

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

B. Dysphagia Rationale: 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 preparing to discharge an older adult who was admitted to the hospital after hitting their head during a fall. Which service is most important for the client when at home? A. In-home blood draws B. Home assessment C. Meals on Wheels D. Home pharmacy delivery

B. Home assessment Rationale: Health promotion education for older adults includes fall prevention and adhering to cautions that accompany prescription medications. Older adults who are at risk for falls may benefit from a home safety assessment. Other in-home services may be valuable but will not necessarily prevent a fall?which is why the client was admitted to the hospital.

The nurse is reviewing medications with a client. The nurse should teach the client that which medication may cause drowsiness and increase the risk for a fall? A. Antihypertensive B. Narcotic analgesic C. Anticoagulant D. Antipruritic

B. Narcotic analgesic Rationale: Nurses should review prescription and over-the-counter medications with all clients, making sure to discuss side effects that may affect intracranial regulation. For instance, blood thinners may increase the risk of hemorrhagic stroke, and medications such as narcotic analgesics may cause dizziness and put the client at risk for falls. Antihypertensives may cause dizziness that can put a client at risk for a fall. An antipruritic is used to relieve itching.

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

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

Which nursing goal is appropriate for a client with increased intracranial pressure (IICP)? A. Protection from increases in cerebral blood flow B. Protection from sudden increases in intracranial pressure C. Protection from risk factors D. Protection from sudden decreases in intracranial pressure

B. Protection from sudden increases in intracranial pressure Rationale: The nursing care of clients with IICP involves identifying those at risk and managing factors known to increase ICP. A major focus is protecting the client from sudden increases in ICP or decreases in cerebral blood flow.

A new graduate nurse is having difficulty prioritizing care and leaving the shift in a timely manner. The nurse manager notes that the new nurse rarely delegates tasks to the unlicensed assistive personnel (UAP) since a recent incident in which the new nurse delegated an inappropriate task to a UAP. Which action by the nurse manager should best help to address this situation? A. Encouraging the nurse not to let the recent experience impact future actions B. Reviewing state and facility guidelines concerning delegation with the nurse C. Having the UAP discuss with the nurse appropriate activities that he can do to assist the nurse with client care D. Reminding the nurse that she will quickly burn out if she does not delegate some care to the UAP

B. Reviewing state and facility guidelines concerning delegation with the nurse Rationale: To avoid pitfalls concerning delegation of activities, the nurse should be aware of state and facility guidelines. Thus, the best action of the nurse manager would be to discuss these guidelines with the new nurse. Encouraging the nurse not to let past experience guide future actions would not help the nurse to understand appropriate guidelines for delegation. Reminding the nurse that she will burn out quickly if she does not delegate tasks does not help the nurse learn to delegate tasks appropriately. Nurses should not rely solely on UAPs to indicate which tasks can appropriately be delegated; they should follow state and facility guidelines.

B. Speaking Rationale: 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.

Gail tells the nurse she is going to go outside to smoke a cigarette and will only be gone for a few minutes. Which statement is warranted in this situation? A. "Make sure you smoke in the smoking area only. The hospital has strict rules." B. "I should let you know that smoking is a strong risk factor for a brain attack." C. "That is just fine. I will be here taking care of your mother." D. "How long have you been smoking?"

B. "I should let you know that smoking is a strong risk factor for a brain attack." - The nurse should teach Gail that smoking is a modifiable risk factor that could prevent her from having a stroke. Smoking increases the risk for hypertension, which is a risk factor for a stroke.

Nancy is transferred to the Intermediate Care Unit after the MRI is completed. She has a 20 gauge saline lock in her right forearm and an 18 French indwelling (Foley) catheter. Gail is sitting by her mother's bed. The nurse asks Gail if there is anyone that can be called so she won't be alone. She informs the nurse that she is an only child and her father died years ago. Gail states, "I don't understand what a brain attack is. The healthcare provider told me my mother is in serious condition and they are going to run several tests. I just don't know what's going on. What happened to my mother?" Which response is best by the nurse? A. "How do you feel about what the healthcare provider said?" B. "Your mother has had a stroke, and the blood supply to the brain has been compromised." C. "I will call the healthcare provider so he/she can talk to you about your mother's serious condition." D. "I am sorry, but what happened to your mother is confidential and I cannot give you any information."

B. "Your mother has had a stroke, and the blood supply to the brain has been compromised." -The nurse has the knowledge, and the responsibility, to explain Nancy's condition to Gail.

A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. The nurse records the patients GCS score as a. 6 b. 7 c. 9 d. 11

B. 7- no opening of eyes = 1; incomprehensible words= 2, flexion withdrawal = 4 Total = 7

B. A loose collection pad may be placed under the nose. A loose collection pad may be placed under the nose. Do not place a dressing in the nasal cavity, and nothing should be placed inside the nostril. There is no need to culture the drainage. The concern is whether it is spinal fluid, which is determined by a test for glucose or the halo or ring sign.

19. Which patients are NOT a candidate for tissue plasminogen activator (tPA) for the treatment of stroke?* A. A patient with a CT scan that is negative. B. A patient whose blood pressure is 200/110. C. A patient who is showing signs and symptoms of ischemic stroke. D. A patient who received Heparin 24 hours ago.

B. A patient whose blood pressure is 200/110. D. A patient who received Heparin 24 hours ago. The answers are B and D. Patients who are experiencing signs and symptoms of a hemorrhagic stroke, who have a BP for >185/110, and has received heparin or any other anticoagulants etc. are NOT a candidate for tPA. tPA is only for an ischemic stroke.

A female patient has left-sided hemiplegia following an ischemic stroke that she experienced 4 days earlier. How should the nurse best promote the health of the patient's integumentary system? A. Position the patient on her weak side the majority of the time. B. Alternate the patient's positioning between supine and side-lying. C. Avoid the use of pillows in order to promote independence in positioning. D. Establish a schedule for the message of areas where skin breakdown emerges.

B. Alternate the patient's positioning between supine and side-lying. A position change schedule should be established for stroke patients. An example is side-back-side, with a maximum duration of 2 hours for any position. The patient should be positioned on the weak or paralyzed side for only 30 minutes. Pillows may be used to facilitate positioning. Areas of skin breakdown should never be massaged.

9. Practice Question •A patient with an ischemic stroke is placed on a cardiac monitor. Which cardiac dysrhythmia places the patient at risk of emboli? •A. Sinus bradycardia. •B. Atrial fibrillation. •C. Sinus tachycardia. •D. First-degree heart block.

B. Atrial fibrillation.

5. A patient's MRI imaging shows damage to the cerebellum a week after the patient suffered a stroke. What assessment findings would correlate with this MRI finding?* A. Vision problems B. Balance impairment C. Language difficulty D. Impaired short-term memory

B. Balance impairment The answer is B. The cerebellum is important for coordination and balance.

B. Bradycardia Changes in vital signs indicative of increased ICP are known as Cushing's triad, which consists of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.

20. You're assisting a patient who has right side hemiparesis and dysphagia with eating. It is very important to:* A. Keep the head of bed less than 30'. B. Check for pouching of food in the right cheek. C. Prevent aspiration by thinning the liquids. D. Have the patient extend the neck upward away from the chest while eating.

B. Check for pouching of food in the right cheek. The answer is B. Because the patient has weakness on the right side and dysphagia the nurse should regularly check for pouching of food in the right cheek. Pouching of food in the cheek can lead to aspiration or choking. The HOB should be >30′, liquids thickened per MD order, and the patient should tuck in the chin to the chest while swallowing.

7. A patient has right side brain damage from a stroke. Select all the signs and symptoms that occur with this type of stroke:* A. Right side hemiplegia B. Confusion on date, time, and place C. Aphasia D. Unilateral neglect E. Aware of limitations F. Impulsive G. Short attention span H. Agraphia

B. Confusion on date, time, and place D. Unilateral neglect F. Impulsive G. Short attention span The answers are B, D, F, and G. Patients who have right side brain damage will have LEFT side hemiplegia (opposite side), confused on date, time, and place, unilateral neglect (left side neglect), DENIAL about limitations, be impulsive, and have a short attention span. Agraphia, right side hemiplegia, aware of limitations, and aphasia occur in a LEFT SIDE brain injury.

The nurse recognizes the presence of Cushing's triad in the patient with a. Increased pulse, irregular respiration, increased BP b. decreased pulse, irregular respiration, increased pulse pressure c. increased pulse, decreased respiration, increased pulse pressure d. decreased pulse, increased respiration, decreased systolic BP

B. Cushing's triad consists of three vital sign measures that reflect ICP and its effect on the medulla, the hypothalamus, the pons, and the thalamus. Because these structures are very deep, Cushing's triad is usually a late sign of ICP. The signs include an increasing systolic BP with a widening pulse pressure, a bradycardia with a full and bounding pulse, and irregular respirations.

B. Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200 mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke, but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown.

The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke? A. Impulsivity B. Impaired speech C. Left-side neglect D. Short attention span

B. Impaired speech Clinical manifestations of left-sided brain damage include right hemiplegia, impaired speech/language, impaired right/left discrimination, and slow and cautious performance. Impulsivity, left-sided neglect, and short attention span are all manifestations of right-sided brain damage.

Which nursing diagnosis has the highest priority? A. Impaired physical mobility B. Impaired swallowing C. Self-care deficit D. Impaired social interaction

B. Impaired swallowing - According to Maslow's Hierarchy of Needs, physiological needs should be addressed first. Therefore, Nancy's dysphagia is the highest priority nursing diagnosis since she is at risk for aspiration.

The physician orders alteplase (Activase) for a 58-year-old man diagnosed with an acute ischemic stroke. Which nursing action is most appropriate? A. Administer the medication by an IV route at 15 mL/hr for 24 hours. B. Insert two or three large-bore IV catheters before administering the medication. C. If gingival bleeding occurs, discontinue the medication and notify the physician. D. Reduce the medication infusion rate for a systolic blood pressure above 180 mm Hg.

B. Insert two or three large-bore IV catheters before administering the medication. Before giving alteplase, the nurse should start two or three large bore IVs. Bleeding is a major complication with fibrinolytic therapy, and venipunctures should not be attempted after alteplase is administered. Altepase is administered IV with an initial bolus dose followed by an infusion of the remaining medication within the next 60 minutes. Gingival bleeding is a minor complication and may be controlled with pressure or ice packs. Control of blood pressure is critical prior to altepase administration and for the following 24 hours. Before administering altepase, a systolic pressure above 180 mm Hg or diastolic pressure above 110 mm Hg requires aggressive blood pressure treatment to reduce the risk of cerebral hemorrhage.

1. A patient is admitted with uncontrolled atrial fibrillation. The patient's medication history includes vitamin D supplements and calcium. What type of stroke is this patient at MOST risk for?* A. Ischemic thrombosis B. Ischemic embolism C. Hemorrhagic D. Ischemic stenosis

B. Ischemic embolism The answer is B. If a patient is in uncontrolled a-fib they are at risk for clot formation within the heart chambers. This clot can leave the heart and travel to the brain. Hence, an ischemic embolism type stroke can occur. An ischemic thrombosis type stroke is where a clot forms within the artery wall of the neck or brain.

8. Practice Question •Which statement is true about motor changes in a patient who has had a stroke? •A. Motor deficit is ipsilateral to the hemisphere affected. •B. Motor deficit is contralateral to the hemisphere affected. •C. Bowel and bladder function remain intact. •D. Flaccid paralysis is not an expected finding.

B. Motor deficit is contralateral to the hemisphere affected.

The ED physician has completed an assessment. Gail is sitting at the bedside while the ED nurse continues to assess Nancy every 15 minutes. Which assessment finding warrants immediate intervention by the nurse? A. Nancy has a negative Babinski's reflex bilaterally B. Nancy only responds to a painful stimuli C. Nancy's Glasgow Coma Scale (GCS) score increases D. Nancy's bilateral grip strength is unequal

B. Nancy only responds to painful stimuli - This decrease in responsiveness warrants immediate intervention by the nurse, indicating a worsening condition (increased intracranial pressure).

17. You receive a patient who is suspected of experiencing a stroke from EMS. You conduct a stroke assessment with the NIH Stroke Scale. The patient scores a 40. According to the scale, the result is:* A. No stroke symptoms B. Severe stroke symptoms C. Mild stroke symptoms D. Moderate stroke symptoms

B. Severe stroke symptoms The answer is B. Scores on the NIH stroke scale range from 0 to 42, with 0 (no stroke symptoms) and 21-42 (severe stroke symptoms).

B. Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure. The nurse should have the patient take some deep breaths.

3. You're educating a patient about transient ischemic attacks (TIAs). Select all the options that are incorrect about this condition: A. TIAs are caused by a temporary decrease in blood flow to the brain. B. TIAs produce signs and symptoms that can last for several weeks to months. C. A TIAs is a warning sign that an impending stroke may occur. D. TIAs don't require medical treatment.

B. TIAs produce signs and symptoms that can last for several weeks to months. D. TIAs don't require medical treatment. The answers are B and D. Options A and C are CORRECT statements about TIAs. However, option B is wrong because TIAs produce signs and symptoms that can last a few minutes to hours and resolve (NOT several weeks to months). Option D is wrong be TIAs do require medical treatment.

11. Practice Question •A patient has been diagnosed with a large lesion of the parietal lobe and demonstrates loss of sensory function. Which nursing intervention is applicable to this patient? •A. Play music for the patient for at least 30 minutes each day. •B. Teach the patient to test the water temperature used for bathing. •C. Position the patient at 90 degrees upright foo all meals. •D. Use a picture of the patient's spouse and ask the patient to state the spouse's name.

B. Teach the patient to test the water temperature used for bathing.

A patient with a head injury has bloody drainage from the ear. To determine whether CSF is present in the drainage, the nurse a. examines the tympanic membrane for a tear b. tests the fluid for a halo sign on a white dressing c. tests the fluid with a glucose identifying strip or stick d. collects 5 mL of fluid in a test tube and sends it to the laboratory for analysis

B. Tests the fluid for a halo sing on a white dressing- Testing clear drainage for CSF in nasal or ear drainage may be done with a Dextrostik or Tes-Tape strip, but if blood is present, the glucose in the blood will produce and unreliable result. To test bloody drainage, the nurse should test the fluid for a halo or ring that occurs when a yellowish ring encircles blood dripped onto a white pad or towel

B. The spouse's household and patient care responsibilities, in combination with chronic illnesses, indicate a high risk for caregiver role strain. The nurse should further assess the situation and take appropriate actions. The data about the control of the patient's diabetes indicates that ineffective health maintenance and risk for unstable blood glucose are not priority concerns at this time. Because the patient is able to ambulate with a cane, the nursing diagnosis of impaired transfer ability is not supported.

B. To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.

The most basic functions of the body, such as breathing, blood pressure, and swallowing, are controlled by the: A. cerebrum. B. brain stem. C. cerebral cortex. D. cerebellum.

B. brain stem.

The nurse plans care for a patient with increased ICP with the knowledge that the best way to position the patient is to a. keep the head of the bed flat b. elevate the head of the bed to 30 degrees c. maintain patient on the left side with the head supported on a pillow d. use a continuous rotation bed to continuously change patient position

B. elevate the head of the bed to 30 degrees

B. elevate the head of the bed to 30 degrees. You should maintain the patient with increased ICP in the head-up position. Elevation of the head of the bed to 30 degrees enhances respiratory exchange and aids in decreasing cerebral edema. You should position the patient to prevent extreme neck flexion, which can cause venous obstruction and contribute to elevated ICP. Elevation of the head of the bed reduces sagittal sinus pressure, promotes drainage from the head through the valveless venous system in the jugular veins, and decreases the vascular congestion that can produce cerebral edema. However, raising the head of the bed above 30 degrees may decrease the cerebral perfusion pressure (CPP) by lowering systemic blood pressure. Careful evaluation of the effects of elevation of the head of the bed on the ICP and the CPP is required.

A nurse is positioning a client with increased ICP. Which position would the nurse avoid? A. head midline B. head turned to the side C. neck in neutral position D. head of bed elevated 30-45 degrees

B. head turned to the side The head of a client with increased ICP should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the neck or turning the head side to side . The head of the bed should be raised 30-45 degrees . Use of proper position promotes venous drainage from the cranium to keep ICP down

A patient has been receiving scheduled doses of phenytoin (Dilantin) and begins to experience diplopia. The nurse immediately assesses the patient for A. an aura or focal seizure. B. nystagmus or confusion. C. abdominal pain or cramping. D. irregular pulse or palpitations.

B. nystagmus or confusion. Diplopia is a sign of phenytoin toxicity. The nurse should assess for other signs of toxicity, which include neurologic changes, such as nystagmus, ataxia, confusion, dizziness, or slurred speech. An aura, focal seizure, abdominal pain or cramping, irregular pulse, or palpitations are not associated with phenytoin toxicity.

When you are obtaining a medical history from the family of a suspected stroke patient, it is MOST important to determine: A. if the patient has been hospitalized before. B. when the patient last appeared normal. C. the patient's overall medication compliance. D. if there is a family history of a stroke.

B. when the patient last appeared normal.

B: Surgical clipping of they aneurysm- Surgical management with clipping of an aneurysm to decrease re bleeding and vasospasm is an option for a stroke cause by rupture of a cerebral aneurysm. Placement of coils into the lumens of the aneurysm by intercentional radiologists is increasing in popularity. Hyperventilation therapy would increase vasodilation and the potential for hemorrhage. Thrombolytic therapy would be absolutely contraindicated, and if a vessel is patent, osmotic diuretics may leak into tissue, pulling fluid out of the vessel and increasing edema.

To promote communication during rehabilitation of the patient with aphasia, an appropriate nursing intervention is to a. use gestures, pictures, and music to stimulate patient responses b. talk about activities of daily living (ADLs) that are familiar to the patient c. structure statements so that patient does not have to respond verbally d. use flashcards with simple words and pictures to promote language recall

B: Talk about ADLs that are familiar to the patient- during rehabilitation, the patient with aphasia needs frequent, meaningful verbal stimulation that has relevance for him. Conversation by the nurse and family should address ADLs that are familiar to the patient. Gestures, pictures, and simple statements are more appropriate in the acute phase, when patients may be overwhelmed with verbal stimuli. Flashcards are often perceived by the patient as childish and meaningless

The presence of the ___________ reflex after the age of 2 indicates cerebral damage.

Babinski

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 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 Antiplatelet Beta blocker Anticoagulant

Beta blocker

Which of the following is the most common side effect of tissue plasminogen activator (tPA)? a) Increased intracranial pressure (ICP) b) Hypertension c) Headache d) Bleeding

Bleeding Bleeding is the most common side effect of tPA. The patient is closely monitored for bleeding (at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness). Headache, increased ICP, and hypertension are not side effects of tPA.

This part of the brain consists of the midbrain, pons, and medulla oblongata and controls breathing, blood pressure, and heart rate. It regulates vomiting, hiccupping, coughing, and sneezing. Ten pairs of cranial nerves originate in this area. A network of fibers called the reticular activating system (RAS) is located in this part of the brain. The RAS regulates the sleep-wake cycle. The reticular formation within this structure integrates sensory information from the peripheral nervous system and relays the information to the cerebral cortex.

Brainstem

Thrombotic strokes often occur at places where arteries ___ & where ___ may have narrowed the arteries for years.

Branch; plaques

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.

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

Brief period of neurological deficit

A 73-year-old client is visiting the neurologist. The client reports light-headedness, speech disturbance, and left-sided weakness that have lasted for several hours. In the examination, an abnormal sound is auscultated in an artery leading to the brain. What is the term for the auscultated discovery? a) Atherosclerotic plaque b) TIA c) Diplopia d) Bruit

Bruit A neurologic examination during an attack reveals neurologic deficits. Auscultation of the artery may reveal a bruit (abnormal sound caused by blood flowing over a rough surface within one or both carotid arteries). The term for the auscultated discovery is bruit.

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

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. Alert and oriented times three b. Blood pressure 180/98 mm Hg c. Grade V on the HuntHess Scale d. Complaint of severe splitting headache

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. Cluster headaches can cause severe debilitating pain. c. Migraines often coincide with menstrual cycle. d. Headaches are the most common type of reported pain.

A client who has experienced an initial transient ischemic attack (TIA) states: I'm glad it wasn't anything serious. Which is the best nursing response to this statement? a. TIA symptoms are short lived and resolve within 24 hours. b. I sense that you are happy it was not a stroke. c. TIA is a warning sign. Let's talk about lowering your risks. d.People who experience a TIA will develop a stroke.

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? a. Administer morning dose of anticonvulsant. b. Administer Percocet as ordered. c. Elevate the head of the bed. d. Complete a head-to-toe assessment.

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 is minor and has no real consequences. b. A concussion is a blow to the head that bruises the brain. c. A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain. d. A concussion is a blow to the head that is hard enough for the brain to bounce off the other side of the skull.

A nurse is working in a neurologist's office. The physician orders a Romberg test. Which nursing action is correct? a. Have the client close his eyes and discriminate between dull and sharp. b. Have the client touch his nose with one finger. c. Have the client close his eyes and stand erect. d. Have the client close his eyes and jump on one foot.

A patient has a ventriculostomy. Which finding would you immediately report to the doctor? A. Temperature 98.4 'F B. CPP 70 mmHg C. ICP 24 mmHg D. PaCO2 35

A patient is experiencing hyperventilation and has a PaCO2 level of 52. The patient has an ICP of 20 mmHg. As the nurse you know that the PaCO2 level will? A. cause vasoconstriction and decrease the ICP B. promote diuresis and decrease the ICP C. cause vasodilation and increase the ICP D. cause vasodilation and decrease the ICP

A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication? A. Bradycardia B. Decerebrate posturing C. Restlessness D. Unequal pupil size

According to question 16, the patient's blood pressure is 130/88. What is the patient's mean arterial pressure (MAP)? A. 42 B. 74 C. 102 D. 88

The intensive care unit has four clients received from a violent motor vehicle accident. When assessing the clients, which client would the nurse assess first? a. The client with an open head injury b. The client with a concussion c. The client with a basilar fracture d. The client with a coup injury

The nurse and physician are viewing a brain scan, which indicates bleeding at the point of impact to the skull and edema on the opposite side. The client is sleeping but can be aroused. The client has no memory of accident. The nurse provides all details to the next shift and is most accurate to report which type of injury? a. Coup injury b. Head injury c. Contrecoup injury d. Contusion

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 whose father has Parkinson's disease b. The client who was in a bike accident last summer c. The client who played soccer in college d. The client with history of seizures

Which neurons transmit impulses from the CNS? a. Sensory b. Dendrites c. Motor d. Neurilemma

A patient's sudden onset of hemiplegia has necessitated a computed tomography (CT) of her head. Which assessment should you complete before this diagnostic study? A. Assess the patient's immunization history. B. Screen the patient for any metal parts or a pacemaker. C. Assess the patient for allergies to shellfish, iodine, or dyes. D. Assess the patient's need for tranquilizers or antiseizure medications.

C Allergies to shellfish, iodine, or dyes contraindicate the use of contrast media for CT. The patient's immunization history is not a central consideration, and the presence of metal in the body does not preclude the use of CT as a diagnostic tool. The need to assess for allergies supersedes the need for tranquilizers or antiseizure medications in most patients.

Which option is most indicative of a skull fracture after blunt head trauma? A. Facial edema B. Epitasis C. Otorrhea positive for glucose D. Laceration oozing blood

C An indication of a basal fracture is cerebrospinal fluid (CSF) leakage from the ear, which confirms that the fracture has traversed the dura. Periorbital ecchymosis can indicate a skull fracture, but generalized facial edema does not. The head is vascular, and it is not unusual to have a nosebleed; a positive ring sign (halo sign) indicates a skull fracture. A superficial laceration does not indicate a skull fracture.

You explain to the patient with a stroke who is scheduled for angiography that the test is used to determine the A. presence of increased intracranial pressure (ICP). B. site and size of the infarction. C. patency of the cerebral blood vessels. D. presence of blood in the cerebrospinal fluid.

C Angiography provides visualization of cerebral blood vessels, can provide an estimate of perfusion, and can detect filling defects in the cerebral arteries.

What sign would make you suspect the cause of increased ICP involves the hypothalamus? A. Contralateral hemiparesis B. Ipsilateral pupil dilation C. Rise in temperature D. Decreased urine output

C If the ICP affects the hypothalamus, there can be a change in the body temperature. Increasing ICP can cause changes in motor ability, with contralateral hemiparesis. Compression of the cranial nerve III causes dilation of the pupil on the side of the mass (ipsilateral). Decreased urine output is not specific for hypothalamic function.

A patient with right-sided hemiplegia and aphasia resulting from a stroke most likely has involvement of the A. brainstem. B. vertebral artery. C. left middle cerebral artery. D. right middle cerebral artery.

C If the middle cerebral artery is involved in a stroke, the expected clinical manifestations include aphasia, motor and sensory deficit, and hemianopsia on the dominant side and include neglect, motor and sensory deficit, and hemianopsia on the nondominant side.

A patient experiencing TIAs is scheduled for a carotid endarterectomy. You explain that this procedure is done to A. decrease cerebral edema. B. reduce the brain damage that occurs during a stroke in evolution. C. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow. D. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation.

C In carotid endarterectomy, the atheromatous lesions are removed from the carotid artery to improve blood flow.

Bladder training for a male patient who has urinary incontinence after a stroke includes A. limiting fluid intake. B. keeping a urinal in place at all times. C. assisting the patient to stand to void. D. catheterizing the patient every 4 hours.

C In the acute stage of stroke, the primary urinary problem is poor bladder control and incontinence. Nurses should promote normal bladder function and avoid the use of indwelling catheters. A bladder retraining program consists of (1) adequate fluid intake, with most given between 8:00 AM and 7:00 PM; (2) scheduled toileting every 2 hours using a bedpan, commode, or bathroom; and (3) observing signs of restlessness, which may indicate the need for urination. Intermittent catheterization may be used for urinary retention (not urinary incontinence). During the rehabilitation phase after a stroke, nursing interventions focused on urinary continence include (1) assessment for bladder distention by palpation; (2) offering the bedpan, urinal, commode, or toilet every 2 hours during waking hours and every 3 to 4 hours at night; (3) focusing the patient on the need to urinate with a direct command; (4) assistance with clothing and mobility; (5) scheduling most fluid intake between 7:00 AM and 7:00 PM; and (6) encouraging the usual position for urinating (standing for men and sitting for women).

A patient with increased ICP has mannitol (Osmitrol) prescribed. Which option is the best indication that the drug is achieving the desired therapeutic effects? A. Urine output increases from 30 mL to 50 mL/hour. B. Blood pressure remains less than 150/90 mm Hg. C. The LOC improves. D. No crackles are auscultated in the lung fields.

C LOC is the most sensitive indicator of ICP. Mannitol is an osmotic diuretic that works to decrease the ICP by plasma expansion and an osmotic effect. Although the other options may indicate a therapeutic effect of a diuretic, they are not the main reason this drug is given.

What is most important finding for you to act on for a patient who had a craniotomy? A. Sodium: 134 mEq/L B. While blood cell (WBC) count: 11,000/μL C. Urine specific gravity: 1.001 D. Blood urea nitrogen (BUN): 25 mg/dL

C Patients need frequent monitoring for sodium regulation, onset of diabetes insipidus, and severe hypovolemia. Normal specific gravity for urine should not be below 1.003 and this low value is a priority.

Which sensory-perceptual deficit is associated with a left-brain stroke? A. Overestimation of physical abilities B. Difficulty judging position and distance C. Slow and possibly fearful performance of tasks D. Impulsivity and impatience at performing tasks

C Patients with a left-brain stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-brain stroke.

The nurse is assessing a client with a recent head injury. Upon previous assessment, the client's vital signs were blood pressure 140/90 mmHg, pulse 74 beats/min, and respirations 22 breaths/min and irregular. Upon this assessment, the nurse notes a blood pressure of 152/70 mmHg, pulse of 48 beats/min, and more irregular respirations. Which condition does the nurse suspect is occurring? A.Epidural hematoma B.Autonomic dysreflexia C.Cushing triad D.Decreasing intracranial pressure (ICP)

C Rationale: Cushing triad is a set of clinical signs that indicate increasing intracranial pressure (ICP). They include bradycardia, widening pulse pressure, and irregular respirations; thus, the nurse would suspect this client is experiencing Cushing triad. This would not characterize a hematoma, autonomic dysreflexia, or decreasing ICP.

During a neurologic assessment of a client, the nurse received an affirmative response to the question, "Have you ever been diagnosed with a neurologic illness?" Which follow-up question would be most important for the nurse to ask this client? A."When was your last blood work done?" B."Do you have noticeable tremors? Do you feel you are clumsier?" C."What helped the problem? What made it worse?" D."Are you experiencing pain?"

C Rationale: General interview questions important during a neurologic assessment include whether or not the client has been diagnosed with a neurologic illness. If the nurse receives an affirmative response, it should be followed by questions concerning what helped it and what made it worse to gather further information. A follow-up question about pain would not necessarily help to provide more information about a diagnosis of a neurologic illness. Asking about when the last blood work was done could help gather information about issues related to seizures and their treatment. Asking about tremors or clumsiness would help provide more information concerning reported changes in sensory perception.

What pathophysiological changes should the nurse expect to see in a client with increased intracranial pressure? A.Alteration of electrical discharges in the brain to cause involuntary movement B.Removal of fluid from interstitial spaces reducing excess body fluid C.An oxygen deficit that leads to changes in personality, memory, and judgment D.Transmission of sensory and motor impulses to the cerebrum for interpretation

C Rationale: Increased intracranial pressure (IICP) is a sustained elevated cranial pressure of 15 mmHg or higher in adults. This leads to an oxygen deficit in brain tissue, which causes changes in personality, memory, and judgment. A diuretic removes fluid from interstitial spaces to reduce excess body fluid. A seizure disorder alters electrical discharges in the brain to cause involuntary movement. Spinal nerves transmit sensory and motor impulses to the cerebrum for interpretation.

A client presents to the emergency department (ED) complaining of pain and burning on urination. The client also tells the triage nurse that she noted blood in the urine the past few times she urinated, so she thought she should come to the emergency department. In which category should the nurse classify the client's problem to prioritize care in relation to other clients in the ED? A.Urgent B.Emergent C.Nonurgent D.Immediate

C Rationale: Symptoms indicate that this client may be experiencing a urinary tract infection, which would be considered nonurgent since a delay in treatment would not result in a life-threatening situation. It would not meet the criteria for urgent or emergent/immediate.

An obstruction of the anterior cerebral arteries affects A. visual imaging. B. balance and coordination. C. judgment, insight, and reasoning. D. visual and auditory integration for language comprehension.

C The anterior cerebral artery feeds the medial and anterior portions of the frontal lobes. The anterior portion of the frontal lobe controls higher-order processes such as judgment and reasoning.

What is the purpose of the blood-brain barrier? A. To protect the brain by cushioning B. To inhibit damage from external trauma C. To keep harmful agents away from brain tissue D. To provide the blood supply to brain tissue

C The blood-brain barrier is a physiologic barrier between capillaries and brain tissue. The structure of the brain's capillaries is different from others, and substances that are harmful are not allowed to enter brain tissue. Lipid-soluble compounds enter the brain easily, but water-soluble and ionized drugs enter slowly. The spinal fluid and meninges help cushion the brain. The skull protects from external trauma. Blood is supplied to the brain from the internal carotid arteries and the vertebral arteries.

The nurse is providing discharge teaching to an older adult. Which information should the nurse include in the session to help the older adult avoid development of IICP? A."You should stop driving and exchange your license for a non-driver identification card." B."With any early signs of infection, be sure to call your healthcare provider." C."Make sure to use your walker as we discussed." D."Be sure to check your blood sugar more frequently than previously to manage your diabetes."

C Rationale: Falls are the most common cause of IICP in older adults; thus, the nurse should ensure that the client implements strategies such as using a walker to prevent falls. Infections, motor vehicle crashes, and the presence of other illnesses also can lead to IICP in the older adult, but they are not the most common causes of IICP.

The nurse caring for a client with diabetes mellitus receives a report from another nurse that the client is experiencing a hypoglycemic episode. The nurse immediately prepares to administer 50 mL of D50 IVP. Upon entering the room, the nurse notes that the client seems alert and does not have any current complaints and decides not to administer the D50. Which pitfall was avoided by the nurse in this situation? A.Incomplete assessment B.Poor time management C.Relying solely on another's assessment D.Failure to do periodic assessments

C Rationale: In this situation, the nurse prepared to administer D50 IVP based on the other nurse's assessment. Using this information to set priorities could have resulted in a negative client outcome. The potential pitfall in this situation was not created by an incomplete assessment, poor time management, or failure to do periodic assessments.

The nurse is reviewing the intracranial pressure (ICP) readings for a child with a brain tumor. Which reading should the nurse interpret as normal for the child? A.8 mmHg B.1 mmHg C.3 mmHg D.12 mmHg

C Rationale: Normal ICP readings for a child are between 3 and 7 mmHg; thus, 3 mmHg would be considered a normal reading.

A new graduate nurse is having difficulty prioritizing care and leaving the shift in a timely manner. The nurse manager notes that the new nurse rarely delegates tasks to the unlicensed assistive personnel (UAP) since a recent incident in which the new nurse delegated an inappropriate task to a UAP. Which action by the nurse manager should best help to address this situation? A.Encouraging the nurse not to let the recent experience impact future actions B.Reminding the nurse that she will quickly burn out if she does not delegate some care to the UAP C.Reviewing state and facility guidelines concerning delegation with the nurse D.Having the UAP discuss with the nurse appropriate activities that he can do to assist the nurse with client care

C Rationale: To avoid pitfalls concerning delegation of activities, the nurse should be aware of state and facility guidelines. Thus, the best action of the nurse manager would be to discuss these guidelines with the new nurse. Encouraging the nurse not to let past experience guide future actions would not help the nurse to understand appropriate guidelines for delegation. Reminding the nurse that she will burn out quickly if she does not delegate tasks does not help the nurse learn to delegate tasks appropriately. Nurses should not rely solely on UAPs to indicate which tasks can appropriately be delegated; they should follow state and facility guidelines.

The nurse is providing care for several clients with neurologic dysfunction. Which client should be placed closest to the nurses' station? A.A preoperative 68-year-old client who was diagnosed with an astrocytoma B.A 72-year-old client who is 2 days postoperative for a carotid endarterectomy C.A newly admitted 65-year-old client who experienced an acute subdural hematoma D.An 80-year-old client with viral meningitis who was admitted 3 days ago

C Rationale: When prioritizing care, the nurse needs to consider all relevant factors. A newly admitted client with a recent subdural hematoma would be considered a high priority due to risk for seizures, stroke, brain herniation, and so forth and should be placed closest to the nurses' station. A client 3 days postmeningitis, a preoperative client, and a client who is 2 days postoperative for a carotid endarterectomy would have more stability and less priority than a newly admitted client with a subdural hematoma.

C ~ A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours, the client again loses consciousness. Garbled speech is known as dysarthria. An interval in which the client is alert but can't recall recent events is known as amnesia. Warning symptoms or auras typically occur before seizures.

A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care? a.) No precautions are required as long as antibiotics have been started b.) Maintain enteric precautions c.) Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics d.) Maintain neutropenic precautions

C ~ A major priority of nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is ordered. The child is also placed on respiratory isolation for at least 24 hours while culture results are obtained and the antibiotic is having an effect.

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assess the patient's gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed short-acting insulin. d. Infuse the prescribed IV metoprolol (Lopressor).

C ~ Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. The other actions require more education and scope of practice and should be done by the registered nurse (RN).

The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a left-handed patient with left-sided hemiplegia. Which intervention should be included in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the right hand. d. Teach the patient the "chin-tuck" technique.

C ~ Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the left-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the right hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.

A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has: a.) A cerebral lesion b.) A temporal lesion c.) An intact brainstem d.) Brain death

C ~ Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected in the auditory canal. A normal response that indicates intact function of cranial nerves III, IV, and VIII is conjugate eye movements toward the side being irrigated, followed by rapid nystagmus to the opposite side. Absent or dysconjugate eye movements indicate brainstem damage.

When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place objects needed on the patient's left side. d. Teach the patient that the left visual deficit will resolve.

C ~ During the acute period, the nurse should place objects on the patient's unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.

Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 pounds above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patient's usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television.

C ~ Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not as much as hypertension.

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? a.) To reduce intraocular pressure b.) To prevent acute tubular necrosis c.) To promote osmotic diuresis to decrease ICP d.) To draw water into the vascular system to increase blood pressure

C ~ Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern.

Which of the following signs and symptoms of increased ICP after head trauma would appear first? a.) Bradycardia b.) Large amounts of very dilute urine c.) Restlessness and confusion d.) Widened pulse pressure

C ~ The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there's damage to the posterior pituitary.

For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: a.) Prevent respiratory alkalosis. b.) Lower arterial pH. c.) Promote carbon dioxide elimination. d.) Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg

C ~ The goal in treatment is to prevent acidemia by eliminating carbon dioxide.

A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient's wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient? a. Interrupted family processes related to effects of illness of a family member b. Situational low self-esteem related to increasing dependence on spouse for care c. Disabled family coping related to inadequate understanding by patient's spouse d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia

C ~ The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. There is no indication that the patient has impaired nutrition.

A 47-year-old patient will attempt oral feedings for the first time since having a stroke. The nurse should assess the gag reflex and then a. order a varied pureed diet. b. assess the patient's appetite. c. assist the patient into a chair. d. offer the patient a sip of juice.

C ~ The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless.

The school nurse is teaching a group of adolescent athletes about reducing the risk for sustaining traumatic brain injuries (TBI). To provide client-centered education to this population, which information is most appropriate for the school nurse to include in the teaching session? A) "A fall from even a low height can cause traumatic brain injury." B) "A traumatic brain injury can occur to anyone from a wide range of causes." C) "If you are injured in a game or practice, don't play through the pain." D) "Wearing seat belts can protect against injuries in motor vehicle collisions."

C) "If you are injured in a game or practice, don't play through the pain."

The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps: 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated Put these steps in order in which they occur. A) 635241 B) 352416 C) 236145 D) 162534

C) 236145

A nurse is planning a teaching exercise on prevention of traumatic brain injury and identifying examples of people with a higher risk of TBI. Which of the following people is not in a higher-risk group for a TBI? A) A 2-year-old child B) A 13-year-old adolescent C) A 44-year-old office worker D) A 77-year-old retiree

C) A 44-year-old office worker

Which clinical manifestation is associated with a mild concussion? A) Bleeding in the brain B) Difficulty breathing C) Acute headache D) Prolonged unconsciousness

C) Acute headache

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) Advanced age

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

C) Bleeding

The nurse notices that a client who sustained a head injury from a motor vehicle crash begins to demonstrate an abnormal posture. (See image.) What does this posture suggest to the nurse about the client's brain functioning? A) Improved level of consciousness B) Developing a seizure disorder C) Brainstem impairment D) Corticospinal tract impairment

C) Brainstem impairment

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) Depression

A patient who is possibly experiencing a stroke is NOT eligible for thrombolytic (fibrinolytic) therapy if he or she: A) Has had a prior heart attack. B) Is older than 60 years of age. C) Has bleeding within the brain. D) Has a GCS score that is less than 8.

C) Has bleeding within the brain.

Which types of sports are most likely to cause concussion and traumatic brain injury? A) Competitive B) Energetic C) High-impact D) Team

C) High-impact

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 patient's medication dosages at home

C) How to correctly modify the home environment

Which of the following infant clients presenting with traumatic brain injury (TBI) is least likely the victim of child abuse? A) Infant with contusion sustained from fall from high chair B) Infant with contusion, unknown cause C) Infant with diffuse axonal injury following involvement as passenger in a vehicle collision D) Infant with diffuse axonal injury, unknown cause

C) Infant with diffuse axonal injury following involvement as passenger in a vehicle collision

An older adult client is experiencing a tonic-clonic (grand mal) seizure exceeding 10 minutes in length. Which medication should the nurse prepare to administer to this client? A) Intramuscular injection of diazepam B) Intramuscular injection of phenytoin C) Intravenous diazepam slowly over several minutes D) Oral administration of gabapentin

C) Intravenous diazepam slowly over several minutes

1. 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 patient's hand in pronation.

C) Place a pillow in the axilla when there is limited external rotation.

The nurse is providing care for a client with a head injury and wants to decrease the client's risk for developing increased intracranial pressure (IICP). Which assessment data indicates that the nurse is successful? A) Body temperature elevated 1 degree in 4 hours B) Absent gag reflex C) Pupils equal and reactive to light D) Sluggish response to verbal stimuli

C) Pupils equal and reactive to light

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) Take antihypertensive medication as ordered.

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 patient's plan of care? A) The patient's 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) The patient should be placed in a prone position for 15 to 30 minutes several times a day.

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

C) To remove atherosclerotic plaques blocking cerebral flow

C, D, A, B The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.

The nurse caring for a client with increased intracranial pressure should recognize that which compensatory mechanism stimulates the cerebral blood vessels to regulate cerebral pressure? (Select all that apply.) A. Potassium B. Serum uric acid C. Carbon dioxide D. Lactic acid E. Carbonic acid

C, D, E Rationale: Lactic acid, carbonic acid, and carbon dioxide are chemicals that stimulate the dilation or contraction of blood vessels within the brain, which aids in regulation of cerebral pressure. Cerebral hemorrhage also regulates dilation or constriction of the cerebral blood vessels in response to the amount of blood flow within the brain. Serum uric acid and potassium do not affect cerebral pressure.

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. Percutaneous transluminal coronary artery angioplasty e. Balloon angioplasty of the carotid artery followed by stent placement

C, E

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. Exposure to flashing light b. Prolonged positioning c. Red wine d. Nausea e. Menstruation f. Change in environmental temperature

C, E

Which of the following assessment findings would indicate an increasing intracranial pressure (ICP) in a client with head trauma? Select all that apply. a. Brisk pupil response b. Glasgow Coma Scale of 15 c. Elevated systolic blood pressure d. Generalized pain e. Stiff neck f. Wide pulse pressure

C, E, F

The nurse is prioritizing client care as low, medium, or high priority for the current assignment. Which client should the nurse identify as having a high-priority circumstance? (Select all that apply.) A.A client who is experiencing extreme bouts of diarrhea B.An extremely confused older client C.A client with emphysema and a pulse oximeter reading of 88 D.A client who is receiving warfarin (Coumadin) E.A client with congestive heart failure and shortness of breath

C,D,E Rationale: High-priority circumstances include clients with a risk for bleeding, such as a client receiving warfarin (Coumadin), clients with ineffective breathing patterns, and clients with impaired gas exchange. A confused client and a client with diarrhea would have medium-priority circumstances.

C. 1 Rationale: 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.

The nurse is providing care for several clients with neurologic dysfunction. Which client should be placed closest to the nurses' station? A. A preoperative 68-year-old client who was diagnosed with an astrocytoma B. A 72-year-old client who is 2 days postoperative for a carotid endarterectomy C. A newly admitted 65-year-old client who experienced an acute subdural hematoma D. An 80-year-old client with viral meningitis who was admitted 3 days ago

C. A newly admitted 65-year-old client who experienced an acute subdural hematoma Rationale: When prioritizing care, the nurse needs to consider all relevant factors. A newly admitted client with a recent subdural hematoma would be considered a high priority due to risk for seizures, stroke, brain herniation, and so forth and should be placed closest to the nurses' station. A client 3 days postmeningitis, a preoperative client, and a client who is 2 days postoperative for a carotid endarterectomy would have more stability and less priority than a newly admitted client with a subdural hematoma.

A client is admitted to the emergency department with a rash on the trunk and extremities. The client reports difficulty breathing, chest tightness, and weakness. Respirations are 24 breaths/min and even, pulse is 90 beats/min and thready, and blood pressure is 96/70 mmHg. The client reports a recent history of a urinary tract infection and having been on sulfasalazine for the past 5 days. Which is the priority nursing assessment for this client? A. Gastrointestinal disturbances B. Peripheral edema C. Airway patency D. Urine discoloration

C. Airway patency Rationale: Using the ABCs (airway, breathing, and circulation) to establish priority nursing interventions, the nurse would first establish airway patency based on the client's symptoms of difficulty breathing. This would take priority over assessment for edema, urine discoloration, and gastrointestinal disturbances.

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? A. Stool softener B. Beta blocker C. Antiplatelet D. Anticoagulant

C. Antiplatelet Rationale: 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).

The nurse working in a community clinic is reviewing the clients to be seen for the day. Which client should require more time in the schedule? A. A 20-year-old who is being seen for evaluation of insulin pump management B. A 50-year-old who is being seen for blood pressure recheck C. A 75-year-old with recent cognitive decline D. A 32-year-old with newly diagnosed diabetes who is returning for a blood glucose recheck

C. A 75-year-old with recent cognitive decline Rationale: An older client with cognitive issues may require more time than do other clients due to both developmental and cognitive issues. Blood pressure rechecks, insulin pump follow-up, and blood glucose rechecks of young and middle-aged adults would not necessarily require more time.

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? A. Antiplatelet B. Anticoagulant C. Beta blocker D. Thiazide diuretic

C. Beta blocker Rationale: 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.

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? A. Calling the healthcare provider about the results B. Ordering a pureed diet C. Carefully monitoring for coughing after giving the client a thickened beverage D. Documenting the results of the swallowing studies

C. Carefully monitoring for coughing after giving the client a thickened beverage Rationale: 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.

C. Critical Rationale: In this situation, a blood pressure medication was administered to the wrong client who has low blood pressure, creating a critical situation to which the nurse needs to respond quickly since the client's condition could become life threatening. This would not be an acute or nonacute situation, as it is a medium-high priority. It is not likely that this error would result in death of the client, so the choice of imminent death would not be appropriate.

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

C. Improving muscle strength and coordination Rationale: 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.

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? A. Occupational therapy B. Speech and language therapy C. Physical therapy D. Home health

C. Physical therapy Rationale: 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.

A client is ready for discharge from the hospital after being treated for increased intracranial pressure. Which statement confirms that the client's spouse understands the discharge instructions? A. "My spouse does not need to do anything differently when we get home." B. "My spouse can continue to use a nicotine patch." C. "My spouse should avoid alcohol as it can increase the risk of injury." D. "My spouse can take any over-the-counter medication."

C. "My spouse should avoid alcohol as it can increase the risk of injury." Rationale: Nurses should instruct clients to avoid alcohol, which can increase the risk of injury, and products that contain nicotine, which increase the heart rate and blood pressure and cause vasoconstriction that can increase the client's risk of stroke. The healthcare provider must review all over-the-counter medications for possible contraindications.

C. Pop-up Rationale: Events such as new admissions that are unexpected and require that nurses take time and attention away from their plan for the day are referred to as pop-ups. Pitfalls are unforeseen situations that harbor consequences for nurses and can result in client harm. Urgent and nonurgent events are methods of triaging and setting priorities for care.

Gail starts to cry and states, "Mom was just fine last week when we went out to eat and to a show. I love my mom so much, and I am so scared. She is all I have." How should the nurse respond? A. "I am sure everything will be all right." B. "I will notify the chaplain to come and sit with you so you won't be alone." C. "I know this is scary for you. Would you like to sit and talk?" C. "I am sure your mother knows you are here. Just keep talking to her."

C. "I know this is scary for you. Would you like to sit and talk? -This therapeutic response provides acknowledgment of Gail's fears, and the nurse offers to take time to discuss the situation.

Gail tells the nurse, "One of the people in the waiting room was telling me about an operation that her mother had to prevent a stroke. Do you know anything about that?" A. "There is currently no surgery that can help prevent a stroke." B. "I am sure your healthcare provider will discuss that with you at a later date." C. "That procedure is only done with small strokes, not like the one your Mom had." D. "Yes, it is a carotid endarterectomy, and your mother may be able to have one."

C. "That procedure is only done with small strokes,not like the one your Mom had." - This surgery is indicated for clients with symptoms of transient ischemic attack (TIA), or mild stroke, found to be due to severe carotid artery stenosis or moderate stenosis with other significant risk factors.

18. In order for tissue plasminogen activator (tPA) to be most effective in the treatment of stroke, it must be administered?* A. 6 hours after the onset of stroke symptoms B. 3 hours before the onset of stroke symptoms C. 3 hours after the onset of stroke symptoms D. 12 hours before the onset of stroke symptoms

C. 3 hours after the onset of stroke symptoms The answer is C. tPa dissolves the clot causing the blockage in stroke by activating the protein that causes fibrinolysis. It should be given within 3 hours after the onset of stroke symptoms. It can be given 3 to 4.5 hours after onset IF the patient meets strict criteria. It is used for acute ischemia stroke, NOT hemorrhagic!!

2. Which patient below is at most risk for a hemorrhagic stroke? A. A 65 year old male patient with carotid stenosis. B. A 89 year old female with atherosclerosis. C. A 88 year old male with uncontrolled hypertension and a history of brain aneurysm repair 2 years ago. D. A 55 year old female with atrial flutter.

C. A 88 year old male with uncontrolled hypertension and a history of brain aneurysm repair 2 years ago. The answer is C. A hemorrhagic stroke occurs when bleeding in the brain happens due to a break in a blood vessel. Risk factors for a hemorrhagic stroke is uncontrolled hypertension, history of brain aneurysm, old age (due to aging blood vessels.) All the other options are at risk for an ischemic type of stroke.

A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.

C. A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin.

C. Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. The other actions require more education and scope of practice and should be done by the registered nurse (RN).

11. You're patient has expressive aphasia. Select all the ways to effectively communicate with this patient?* A. Fill in the words for the patient they can't say. B. Don't repeat questions. C. Ask questions that require a simple response. D. Use a communication board. E. Discourage the patient from using words.

C. Ask questions that require a simple response. D. Use a communication board. The answers are C and D. Patients with expressive aphasia can understand spoken words but can't respond back effectively or at all. Therefore be patient, let them speak, be direct and ask simple questions that require a simple response, and communicate with a dry erase board etc.

A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent a fever. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.

C. Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains.

C. Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the left-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the right hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.

C. During the acute period, the nurse should place objects on the patient's unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.

5. Practice Question •The nurse is caring for a patient at risk for increased ICP elated to ischemic stroke. For what purpose does the nurse place the patient's head in a midline neutral position? •A. Provide comfort for the patient. •B. Protect the cervical spine. •C. Facilitate venous drainage from the brain. •D. Decrease pressure from the cerebrospinal fluid.

C. Facilitate venous drainage from the brain.

Which nursing care task should the nurse delegate to the UAP? A. Assist Nancy to eat her breakfast B. Use a walker to help Nancy ambulate down the hall C. Give Nancy a bed bath and change the bed linens D. Flush Nancy's saline lock with 2 ml of normal saline

C. Give Nancy a bed bath and change the bed linens - The UAP can assist Nancy with bathing and then change the bed linens. This task does not require professional judgment or expertise

C. Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not as much as hypertension.

Nancy is experiencing pain in her right shoulder. The nurse is aware that up to 70% of clients with a brain attack experience severe pain in the shoulder that prevents them from learning new skills. Shoulder function helps clients achieve balance, perform transfer skills, and participate in self-care activities.Which intervention should the nurse implement when addressing this condition? A. Move Nancy by lifting with the affected shoulder B. Assist Nancy to keep the affected arm in a dependent position as much as possible C. Instruct Nancy to clasp the right hand with the left hand and raise both hands above the head D. Remind Nancy to perform active range of motion exercises daily

C. Instruct Nancy to clasp the right hand with the left hand and raise both hands above the head - This exercise helps prevent "frozen shoulder" and will aid the nurse when moving or positioning the client.

With a diagnosis of a brain attack (stroke), which priority intervention should the nurse include in Nancy's plan of care? A. Monitor INR daily B. Assess neurological status every shift C. Keep the head of the bed elevated D. Evaluate platelet levels daily

C. Keep the head of the bed elevated - Maintaining a patent airway is essential to support oxygenation and cerebral perfusion. Elevating the head of the bed 30 degrees aids in preventing the tongue from falling backward and obstructing the airway.

The nurse explains to the patient with a stroke who is scheduled for angiography that this test is used to determine the A. Presence of increased ICP B. Site and size of the infarction C. Patency of the cerebral blood vessels D. Presence of blood in the cerebrospinal fluid

C. Patency of the cerebral blood vessels (Rationale: Angiography provides visualization of cerebral blood vessels and can help estimate perfusion and detect filling defects in the cerebral arteries.)

While the nurse performs ROM on an unconscious patient with increased ICP, the patient experiences severe decerebrate posturing reflexes. The nurse should a. use restraints to protect the patient from injury b. administer CNS depressants to lightly sedate the patient c. perform the exercises less frequently because posturing can increase ICP d. continue the exercises because they are necessary to maintain musculoskeletal function

C. Perform the exercises less frequently because posturing can increase ICP- If reflex posturing occurs during ROM or positioning of the patient, these activities should be done less frequently until the patient's condition stabilizes, because posturing can case increases in ICP. Neither restraints nor CNS depressants would be indicated.

Which intervention should the nurse implement to prevent joint deformities? A. Place the elbow lower than the shoulder and the wrist lower than the elbow on the affected side. B. Position the fingers so that they are totally flexed in a slight pronation position. C. Place Nancy in a pone position for 15 minutes at least 4 times a day. D. Apply splints to the arms and legs during the day but remove at night

C. Place Nancy in a prone position for 15 minutes at least 4 times a day - This helps to promote hyperextension of the hip joints, which helps prevent knee and hip flexion contractures.

A patient experiencing TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to A. Decrease cerebral edema B. Reduced the brain damage that occurs during a stroke in evolution C. Prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow D. Provide a circulator bypass around thrombotic plaques obstructing cranial circulation

C. Prevent a stroke by removing atherosclerotic plaques blocking cerebral blood low (Rationale: In a carotid endarterectomy, the atheromatous lesion is removed from the carotid artery to improve blood flow.)

The nurse is planning psychosocial support for the patient and family of the patient who suffered a stroke. What factor will most likely have the greatest impact on positive family coping with the situation? A. Specific patient neurologic deficits B. The patient's ability to communicate C. Rehabilitation potential of the patient D. Presence of complications of a stroke

C. Rehabilitation potential of the patient Although a patient's neurologic deficit might initially be severe after a stroke, the ability of the patient to recover is most likely to positively impact the family's coping with the situation. Providing explanations and emotional support beginning in the acute phase through the rehabilitation phase will facilitate coping. Emphasizing successes will offer the most realistic hope for the patient's rehabilitation and helps maintain hope for the patient's future abilities.

A 54-year old man is recovering from a skull fracture with a subacute subdural hematoma. He has return of motor control and orientation but appears apathetic and has reduced awareness of his environment. When planning discharge or the patient, the nurse explains to the patient and the family that a. continuous improvement in the patient's condition should occur until he has returned to pre trauma status b. the patient's complete recovery may take years, and the family should plan for his long term dependent care c. the patient is likely to have long term emotional and mental changes that may require continued professional help d. role changes in family members will be necessary because the patient will be dependent on his family for care and support

C. Residual mental and emotional changes of brain trauma with personality changes are often the most incapacitating problems following head injury and are common in patients who have been comatose longer than 6 hours. Families must be prepared for changes in the patient's behavior to avoid family-patient friction and maintain family functioning, and professional assistance may be required. There is no indication he will be dependent on others for care, but he likely will not return to pre trauma status

The neurologist also prescribes a magnetic resonance imaging (MRI) of the head STAT. Which data warrants immediate intervention by the nurse concerning this diagnostic test? A. Allergy to shellfish B. History of atrial fibrillation C. Right hip replacement D. Elevated blood pressure

C. Right hip replacement -The magnetic field generated by the MRI is so strong that metal-containing items are strongly attracted to the magnet. Because the hip joint is made of metal, a lead shield must be used during the procedure.

16. A patient who has hemianopia is at risk for injury. What can you educate the patient to perform regularly to prevent injury?* A. Wearing anti-embolism stockings daily B. Consume soft foods and tuck in chin while swallowing C. Scanning the room from side to side frequently D. Muscle training

C. Scanning the room from side to side frequently The answer is C. Hemianopia is limited vision in half of the visual field. The patient needs to scan the room from side to side to prevent injury.

Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? A. Overestimation of physical abilities B. Difficulty judging position and distance C. Slow and possibly fearful performance of tasks D. Impulsivity and impatience at performing tasks

C. Slow and possibly fearful performance of tasks Patients with a left-sided stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-sided stroke.

Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? A. Overestimation of physical abilities. B. Difficulty judging position and distance. C. Slow and possibly fearful performance of tasks. D. Impulsivity and impatience at performing tasks.

C. Slow and possibly fearful performance of tasks. Patients with a left-sided stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-sided stroke.

C. The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. There is no indication that the patient has impaired nutrition.

C. The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed.

13. You're reading the physician's history and physical assessment report. You note the physician wrote that the patient has apraxia. What assessment finding in your morning assessment correlates with this condition?* A. The patient is unable to read. B. The patient has limited vision in half of the visual field. C. The patient is unable to wink or move his arm to scratch his skin. D. The patient doesn't recognize a pencil or television.

C. The patient is unable to wink or move his arm to scratch his skin

C. The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless.

Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin? a. The patient has atrial fibrillation. b. The patient has dysphasia. c. The patient states, "I suddenly developed a terrible headache." d. The patient has a history of brief episodes of right hemiplegia.

C. The patient states, "I suddenly developed a terrible headache" A sudden-onset headache is typical of a hemorrhage and aspirin is contraindicated

After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about a. cerebral aneurysm clipping. b. heparin intravenous infusion. c. oral low-dose aspirin therapy. d. tissue plasminogen activator (tPA).

C. The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.

Because Nancy is right-handed and is having difficulty performing activities of daily living with the left arm, the nurse also includes the nursing diagnosis "self-care deficit" in the care plan. Which intervention would the nurse implement to address this nursing diagnosis? A. Use narrow grip utensils to accommodate a weak grasp B. Recommend a regular type toilet seat with grab hand bars C. Utilize plate guards when Nancy is eating D. Discourage Nancy from using assistive devices

C. Utilize plate guards when Nancy is eating - Plate guards prevent food from being pushed off the plate. Using plate guards and other assistive devices will encourage independence in a client with a self-care deficit.

During the change of shift report a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgment.

C. Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first? a. patient with a skull fracture whose nose is bleeding b. elderly patient with a stroke who is confused and whose daughter is present c. patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale d. patient who had a craniotomy for a brain tumor who is now 3 days postoperative and has had continued emesis

C. patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale

The left cerebral hemisphere controls: A. heart rate and pupil reaction. B. the right side of the face. C. the right side of the body. D. breathing and blood pressure.

C. the right side of the body.

Which intervention should the nurse delegate to the LPN when caring for a patient following an acute stroke? a. assess the patient's neurologic status b. assess the patient's gag reflex before beginning feeding c. administer ordered antihypertensives and platelet inhibitors d. teach the patient's caregivers strategies to minimize unilateral neglect

C: Administer ordered antihypertensives and platelet inhibitors- medication administration is within the scope of practice for an LPN. Assessment and teaching are within the scope of practice for the RN.

Which of the following is the best treatment for acute ischemic stroke? a. heparin b. LMWH c. Alteplase d. Eptifibatie e. Warfarin Which of the following is the best treatment for acute ischemic stroke? a. heparin b. LMWH c. Alteplase d. Eptifibatie e. Warfarin

C: Alteplase

A thrombus that develops in a cerebral artery does not always cause a loss of neurologic function because a. the body can dissolve the atherosclerotic plaques as they form b. some tissues of the brain do not require constant blood supply to prevent damage c. circulation through the circle of Willis may provide blood supply to the affected area of the brain d. neurologic deficits occur only when major arteries are occluded by thrombus formation around an atherosclerotic plaque

C: Circulation through the circle of Willis may provide blood supply to the affected area of the brain. The communication between cerebral arteries in the circle of Willing provides a collateral circulation, which may maintain circulation to an area of the brain if its original blood supply is obstructed. ALl areas of the brain require constant blood supply, and atherosclerotic plaques are not readily reversed. Neurologic deficits can result from ischemia cause by many factors.

The incidence of ischemic stroke in patients with TIAs and other risk factors is reduced with administration of a. furosemide (Lasix) b. lovastatin (Mevacor) c. daily low dose aspirin d. nimodipine (Nimotop)

C: Daily low dose aspirin- the administration of antiplatelet agents, such as aspirin, dipyridamole (Persantine), and ticlopdipine (Ticlid), reduces the incidence of stroke in those at risk. Anticoagulants are also used for prevention of embolic strokes but increase the risk for hemorrhage. Diuretics are not indicated for stroke prevention other than for their role in controlling BP, and antilipemic agents have bot been found to have a significant effect on stroke prevention. The calcium channel blocker nimodipine is used in patients with subarachnoid hemorrhage to decrease the effects of vasospasm and minimize tissue damage.

A patient with a stroke has a right sided hemiplegia. The nurse prepares family members to help control behavior changes seen with this type of stroke by teaching them to a. ignore undesirable behaviors manifested by the patient b. provide directions to the patient verbally in small steps c. distract the patient from inappropriate emotional responses d. supervise all activities before allowing the patient to pursue them independently

C: Distract the patient from inappropriate emotional responses- patients with left-sided brain damage from stroke often experience emotional lability, inappropriate emotional responses, mood swings, and uncontrolled tears or laughter disproportionate or out of context with the situation. The behavior is upsetting and embarrassing to both the patient and the family, and the patient should be distracted to minimize its presence. Patients with right-brain damage often have impulsive, rapid behavior that supervision and direction.

In promoting health maintenance for prevention of strokes, the nurse understands that the highest risk for the most common type of stroke is present in a. African Americans b. women who smoke c.individuals with hypertension and diabetes d. those who are obese with high dietary fat intake

C: Individuals with hypertension and diabetes- The highest risk factors for thrombotic stroke are hypertension and diabetes. African Americans have a higher risk for stroke than do white persons but probably because they have a greater incidence of hypertension. Factors such as obesity, diet high in saturated fats and cholesterol, cigarette smoking, and excessive alcohol use are also risk factors but carry less risk than hypertension.

A carotid endarterectomy is being considered as a treatment for a patient who has had several TIAs. The nurse explains to the patient that this surgery a. is used to restore blood to the brain following an obstruction of a cerebral artery b. involves intracranial surgery to join a superficial extracranial artery to an intracranial artery c. involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke d. is sued to open a stenosis in a carotid artery with a balloon and stent to restore cerebral circulation

C: Involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke- An endarterectomy is a removal of an atherosclerotic plaque, and plaque in the carotid artery may impair circulation enough to cause a stroke. A carotid endarterectomy is performed to prevent a cerebrovascular accident (CVA), as are most other surgical procedures. An extacranial-intracranial bypass involves cranial surgery to bypass a sclerotic intacranial artery. Percutaneous transluminal angioplasty uses a balloon to compress stenotic areas in the carotid and vertebrobasilar arteries and often includes inserting a stent to hold the artery open.

A patient with right hemisphere stroke has a nursing diagnosis of unilateral neglect related to sensory perceptual deficits. During the patient's rehabilitation, it is important for the nurse to a. avoid positioning the patient on the affected side b. place all objects for care on the patient's unaffected side c. teach the patient to care consciously for the affected side d. protect the affected side from injury with pillows and supports

C: Teach the patient to care consciously for the affected side- unilateral neglect, or neglect syndrome, occurs when the patient with a stroke is unaware of the affected side of the body, which puts the patient at risk for injury. During the acute phase, the affected side is cared for by the nurse with positioning and support, during rehabilitation the patient is taught to care consciously for and attend to the affected side of the body to protect it from injury. Patients may be positioned on the affected side for up to 30 minutes.

The neurologic functions that are affected by a stroke are primarily related to a. the amount of tissue area involved b. the rapidity of onset of symptoms c. the brain area perfused by the affected artery d. the presence or absence of collateral circulation

C: The brain area perfused by the affected artery- clinical manifestation of altered neurologic function differ, depending primarily on the specific cerebral artery involved and the area of the brain that is perfused by the artery. The degree of impairment depends on rapidity of onset, the size of the lesion, and the presence of collateral circulation.

An appropriate food for a patient with a stroke who has mild dysphagia is a. fruit juices b. pureed meat c. scrambled eggs d. fortified milkshakes

C: scrambled eggs- soft foods that provide enough texture, flavor, and bulk to stimulate swallowing should be used for the patient with dysphasia. Thin liquids are difficult to swallow, and patients may not be able to control them in the mouth. Pureed foods are often too bland and to smooth, and milk products should be avoided because they tend to increase the viscosity of mucus and increase salivation.

A nurse in the emergency department is providing care for a client who has increased intracranial pressure (IICP) from a traumatic brain injury from a motor vehicle crash. The nurse anticipates orders for which diagnostic tests in the care of this client? (Select all that apply.) CT of the head Intracranial pressure monitor Electromyogram Cardiac monitoring ABGs

CT of the head Intracranial pressure monitor Cardiac monitoring ABGs Rationale An intracranial pressure monitor will give information about intracranial pressure. This information can be used to manage the medications and fluids for this client. A CT of the head will give information about possible hemorrhage and diffuse axonal injuries. Cardiac monitoring would be essential to monitor cardiac rate and rhythm. Arterial blood gases give information about oxygen and carbon dioxide levels in the blood. This information is used to manage artificial airways and mechanical ventilation. Electromyography is used to measure skeletal muscle activity. It would not be used in the diagnosis of a client with traumatic brain injury.

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 patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom? a) Cerebral aneurysm b) Cardiogenic emboli c) Large artery thrombosis d) Small artery thrombosis

Cerebral aneurysm A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache.

The clinic nurse assesses a client with a history of transient ischemic attacks (TIA) who was advised to lose weight, change diet to lower cholesterol, and maintain treatment of hypertension. The client has chosen not to take this advice, leading the nurse to conclude the client is at increased risk for:

Cerebrovascular accident (CVA)

The nurse is caring for a patient who is suspected of having a cerebral infarction. Which intervention should be the priority? PLAC test Head computerized tomography (CT) scan Lumbar puncture for cerebrospinal fluid (CSF) examination Complete history and physical assessment

Complete history and physical assessment A complete history and physical assessment, including a thorough neurologic examination and time of onset of stroke manifestations is the immediate priority. A PLAC test screens for recurrent stroke risk. Cerebral infarctions are visible in a head CT scan after 6-8 hours poststroke. A lumbar puncture should only be completed for patients with no risk of increased intracranial pressure (ICP).

The nurse is caring for a patient who is suspected of having a hemorrhagic stroke. Which diagnostic procedure should the nurse expect to be performed first? Lumbar puncture for cerebrospinal fluid examination Magnetic resonance imaging (MRI) PLAC test Computerized tomography (CT) scan

Computerized tomography (CT) scan

The nurse is caring for a patient who is suspected of having a hemorrhagic stroke. Which diagnostic procedure should the nurse expect to be performed first? Computerized tomography (CT) scan Lumbar puncture for cerebrospinal fluid examination Magnetic resonance imaging (MRI) PLAC test

Computerized tomography (CT) scan The CT is the first diagnostic imaging test used to diagnose presence of a hemorrhage, tumors, aneurysm, edema, and tissue necrosis. An MRI may be ordered depending on the CT findings. PLAC testing is completed to detect high levels of an enzyme associated with high risk of stroke. Lumbar puncture may reveal frank blood in the cerebrospinal fluid of a patient with hemorrhagic stroke.

When caring for a patient who has had a head injury, which assessment information is of most concern to the nurse? a. The blood pressure increases from 120/54 to 136/62. b. The patient is more difficult to arouse. c. The patient complains of a headache at pain level 5 of a 10-point scale. d. The patient's apical pulse is slightly irregular.

Correct Answer: B Rationale: The change in level of consciousness (LOC) is an indicator of increased ICP and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache is not unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual. Cognitive Level: Application Text Reference: p. 1470 Nursing Process: Assessment NCLEX: Physiological Integrity

A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L), a decreasing level of consciousness (LOC) and complains of a headache. All of the following orders have been received. Which one should the nurse accomplish first? a. Administer acetaminophen (Tylenol) 650 mg orally. b. Administer 5% hypertonic saline intravenously. c. Draw blood for arterial blood gases (ABGs). d. Send patient to radiology for computed tomography (CT) of the head.

Correct Answer: B Rationale: The patient's low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse's first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased ICP. Drawing ABGs and obtaining a CT scan may add some useful information, but the low sodium level may lead to seizures unless it is addressed quickly. Cognitive Level: Application Text Reference: p. 1470 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 130/72, pulse 90, respirations 32 b. Blood pressure 148/78, pulse 112, respirations 28 c. Blood pressure 156/60, pulse 60, respirations 14 d. Blood pressure 110/70, pulse 120, respirations 30

Correct Answer: C Rationale: Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the ICP has increased and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.

A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial pressure of 24 mm Hg. The nurse determines that the cerebral perfusion pressure (CPP) of this patient indicates a. high blood flow to the brain. b. normal intracranial pressure (ICP). c. impaired brain blood flow. d. adequate cerebral perfusion.

Correct Answer: C Rationale: The patient's CPP is 56, below the normal of 70 to 100 mm Hg and approaching the level of ischemia and neuronal death. The patient has low cerebral blood flow/perfusion. Normal ICP is 0 to 15 mm Hg. Cognitive Level: Application Text Reference: p. 1468 Nursing Process: Assessment NCLEX: Physiological Integrity

A patient with a head injury has an arterial blood pressure is 92/50 mm Hg and an intracranial pressure of 18 mm Hg. Which action by the nurse is appropriate? a. Document and continue to monitor the parameters. b. Elevate the head of the patient's bed. c. Notify the health care provider about the assessments. d. Check the patient's pupillary response to light.

Correct Answer: C Rationale: The patient's cerebral perfusion pressure is only 46 mm Hg, which will rapidly lead to cerebral ischemia and neuronal death unless rapid action is taken to reduce ICP and increase arterial BP. Documentation and monitoring are inadequate responses to the patient's problem. Elevating the head of the bed will lower the ICP but may also lower cerebral blood flow and further decrease CPP. Changes in pupil response to light are signs of increased ICP, so the nurse will only take more time doing this without adding any useful information. Cognitive Level: Analysis Text Reference: pp. 1468-1469 Nursing Process: Implementation NCLEX: Physiological Integrity

Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a head injury. To evaluate the effectiveness of the therapy, the nurse should a. monitor oxygen saturation. b. check arterial blood gases (ABGs). c. monitor intracranial pressure (ICP). d. assess patient breath sounds.

Correct Answer: C Rationale: The purpose of hyperventilation for a patient with a head injury is reduction of ICP, and ICP should be monitored to evaluate whether the therapy is effective. Although oxygen saturation and ABGs are monitored in patient's receiving hyperventilation, they do not provide data about whether the therapy is successful in reducing ICP. Breath sounds are assessed, but they are not helpful in determining whether the hyperventilation is effective. Cognitive Level: Application Text Reference: p. 1475 Nursing Process: Evaluation NCLEX: Physiological Integrity

A 50-year-old client is exhibiting progressive signs of Huntington's disease. The client verbalizes a wish to die and has become withdrawn. Poor appetite is noted, sleep pattern is disturbed, and the choreiform movements are worsening. Which nursing diagnosis best reflects the needs of this client? a. Disturbed Sleep Pattern b. Impaired Home Maintenance c. Altered Nutrition d. Hopelessness

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.

A client has just been diagnosed with a cerebral aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client? a. Take an antacid frequently. b. Avoid fiber in the diet. c. Take an herbal form of feverfew. d. Avoid heavy lifting.

During the eye assessment of a patient with increased ICP, you need to assess the oculocephalic reflex. If the patient has brain stem damage what response will you find? A. The eyes will roll down as the head is moved side to side. B. The eyes will move in the opposite direction as the head is moved side to side. C. The eyes will roll back as the head is moved side to side. D. The eyes will be in a fixed mid-line position as the head is moved side to side.

The brain stem holds the medulla oblongata. What is the function of the medulla oblongata? a. Controls striated muscle activity in blood vessel walls b. Transmits sensory impulses from the brain to the spinal cord c. Controls parasympathetic nerve impulses in the pons d. Transmits motor impulses from the brain to the spinal cord

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. Don't worry. The aneurysm has probably been there since birth. c. The headache can be an indication that the aneurysm is growing. d. Your physician wants to evaluate the location and condition of the aneurysm.

The home health nurse is caring for a client with Parkinson's disease. The nurse understands that the purpose of adding selegiline with carbidopa-levodopa to the medication regime should result in which purpose? a. Replaces dopamine b. Relieves symptoms of dyskinesia c. Prevents side effects from carbidopa-levodopa d. Slows the progression of the disease

The nurse is caring for a client who has had intracranial surgery and is being discharged home. What instructions would the nurse give the client besides instructions on the medication? a. You can cover the incision with your hair. b. You can expect swelling above the incision. c. Understand that headaches are uncommon. d. Expect sensory changes, such as hearing a clicking sound, around the bone flap.

The nurse is caring for a client who was discovering unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse? a. Tylenol may be administered for aches. b. Follow up with regular physician is encouraged. c. A light meal may be eaten if desired. d. Observe for any signs of behavioral changes.

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 firm mattress c. Bandages and tape d. A cervical collar

The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm? a. Electroencephalogram b. Myelogram c. Echoencephalography d. Cerebral angiography

While positioning a patient in bed with increased ICP, it important to avoid? A. Midline positioning of the head B. Placing the HOB at 30-35 degrees C. Preventing flexion of the neck D. Flexion of the hips

What information provided by the patient can help differentiate a hemorrhagic stroke from a thrombotic stroke? A. Sensory disturbance B. A history of hypertension C. Presence of motor weakness D. Sudden onset of severe headache

D A hemorrhagic stroke usually causes sudden onset of symptoms, including neurologic deficits, headache, nausea, vomiting, decreased level of consciousness, and hypertension. Ischemic stroke symptoms may progress in the first 72 hours as infarction and cerebral edema increase. Reference: 1464

The patient had a blunt head injury. What is most important for you to do before the patient's discharge? A. Have the patient sign the discharge papers. B. Teach the patient how to perform the Glasgow Coma Scale (GCS). C. Tell the patient to return if he has a headache. D. Ensure there is a responsible adult to check on the patient

D Complications from a head injury can arise 2 to 3 days later, and the discharged patient must have a responsible adult who can stay with or check on the patient. The patient may understand the instructions but without an objective observer, he or she would not be aware whether some of the key symptoms were occurring. A patient would not know how to do the GCS if impaired or confused. A headache is not a concern, but a worsening headache unrelieved by over-the-counter medications needs to be checked.

Paralysis of lateral gaze indicates a lesion of cranial nerve A. II. B. III. C. IV. D. VI.

D Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) are responsible for eye movement. The lateral rectus eye muscle is innervated by cranial nerve VI and is the primary muscle that is responsible for lateral eye movement

Which of the following patients is at highest risk for a stroke? A. An obese, 45-year-old Native American B. A 35-year-old Asian American woman who smokes C. A 32-year-old, white woman taking oral contraceptives D. A 65-year-old African American man with hypertension

D Nonmodifiable risk factors for stroke include age (>65 years), male gender, ethnicity or race (African Americans > Hispanics, Native Americans/Alaska Natives, and Asian Americans > whites), and family history of stroke or personal history of a transient ischemic attack or stroke. Modifiable risk factors for stroke include hypertension (most important), heart disease (especially atrial fibrillation), smoking, excessive alcohol consumption (causes hypertension), abdominal obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet (high in saturated fat and low in fruits and vegetables), and drug abuse (especially cocaine). Other risk factors for stroke include a diagnosis of diabetes mellitus, increased serum cholesterol, birth control pills (high levels of progestin and estrogen), history of migraine headaches, inflammatory conditions, hyperhomocysteinemia, and sickle cell disease.

A patient being monitored has an ICP pressure of 12 mm Hg. You understand that this pressure reflects A. a severe decrease in cerebral perfusion pressure. B. an alteration in the production of cerebrospinal fluid. C. the loss of autoregulatory control of intracranial pressure. D. a normal balance between brain tissue, blood, and cerebrospinal fluid.

D Normal ICP ranges from 10 to 15 mm Hg. A sustained pressure above the upper limit is considered abnormal.

D Normal ICP ranges from 5 to 15 mm Hg. A sustained pressure above the upper limit is considered abnormal.

The nurse is assessing a client's peripheral circulation after cardiac catheterization. Which finding is the highest priority? A.The client's toes are warm and pink. B.The femoral site is soft and free of hematoma or bleeding. C.Pulses are palpable and bounding. D.The client is experiencing numbness in the toes.

D Rationale: After cardiac catheterization, a finding that the client is experiencing numbness may indicate a complication of the procedure, thus it would be the highest priority. Warm and pink toes, palpable, bounding pulses, and a femoral site free of hematoma and bleeding are all normal findings.

A client with increased intracranial pressure (IICP) is also hyponatremic. Which intravenous medication should the nurse anticipate administering to address fluid removal? A.Corticosteroid B.Antiepileptic C.Proton pump inhibitor D.Osmotic diuretic

D Rationale: Osmotic diuretics are used in clients with IICP to promote water excretion and to address hyponatremia. Proton pump inhibitors protect the gastrointestinal tract. Corticosteroids increase mortality in the IICP client and are not administered. Antiepileptic drugs prevent seizure activity.

The nurse assesses a client admitted post?head trauma and notes small reactive pupils, an intact oculocephalic reflex, decorticate posturing, and respirations. The nurse should suspect that damage has progressed to which area of the brain? A.Pons B.Midbrain C.Medulla D.Diencephalon

D Rationale: Small reactive pupils, an intact oculocephalic reflex, decorticate posturing, and Cheyne-Stokes respirations would indicate damage that has progressed to the diencephalon. These symptoms do not characterize damage to the pons, midbrain, or medulla.

Which option is the most sensitive indication of increased ICP? A. Papilledema B. Cushing's triad C. Projectile vomiting D. Change in the level of consciousness (LOC)

D The LOC is the most sensitive and reliable indicator of the patient's neurologic status. Changes in LOC are a result of impaired cerebral brain flow. Papilledema and Cushing's triad are late signs. Projectile vomiting is not a sensitive indicator.

What action should you take as part of care for a patient who had a craniotomy? A. Use promethazine (Phenergan) for nausea. B. Position the patient on the operative side if a bone flap was removed. C. Administer phenytoin (Dilantin) by rapid intravenous push (IVP) every 6 hours. D. Keep the head in alignment with the trunk.

D The primary goal of care after cranial surgery is prevention of increased intracranial pressure (ICP), which includes keeping the body in alignment. Use of promethazine is discouraged because it can increase somnolence and alter the accuracy of a neurologic assessment. The patient is not positioned on the operative side if a bone flap was removed (craniectomy). Dilantin is administered slowly, no faster than 25 to 50 mg/min. Reference: 1450

What is the most common visual field change resulting from a brain lesion? A. Diplopia B. Blurred vision C. Presbyopia D. Hemianopsia

D Visual field changes resulting from brain lesions are usually diagnosed as hemianopsia (one half of the visual field) or quadrantanopsia (one fourth of the visual field) or monocular vision.

The nurse is planning the day on a general medical unit. Which activity should the nurse prioritize as "must do" and not advisable to be delegated to unlicensed assistive personnel (UAP)? A.Ambulating a stable client to the bathroom B.Assisting clients with hygienic care activities C.Collecting vital signs on assigned clients D.Health teaching for a client being discharged poststroke

D Rationale: "Must do" activities carry the highest priority for completion and should not be delegated. Health teaching and discharge teaching must be done by the nurse. Collecting vital signs, ambulating a stable client to the bathroom, and assisting clients with hygienic activities can all be safely delegated to unlicensed assistive personnel (UAPs).

The nurse prioritizes care for a client with diabetes mellitus using Maslow's hierarchy of needs. Which need is identified as the priority for this client? A.The nurse teaches the client proper home safety techniques to prevent diabetic wounds. B.The client attends classes to deal with body image after amputation of the right leg. C.The client joins the local American Diabetes Association support group. D.The nurse teaches the client how to properly change dressings on the right-leg amputation site.

D Rationale: When prioritizing care based on Maslow's hierarchy of needs, physiological needs will come before safety, social, and esteem needs. Caring for an amputation site is meeting a physiological need. Attending a class to deal with body-image issues addresses an esteem need. Teaching the client about safety techniques to prevent diabetic wounds addresses a safety need. Joining a support group meets an esteem need.

A pediatric client is admitted to the neuro ICU with a closed-head injury sustained after falling out of a tree house. The mechanisms of injury this young client most likely sustained would be: a.) Acceleration b.) Penetrating c.) Rotational d.) Deceleration

D ~ Deceleration injury occurs when the brain stops rapidly in the cranial vault. As the skull ceases movement, the brain continues to move until it hits the skull. The force of deceleration causes injury at the site of impact. An example of this is a victim of a fall.

The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? a.) Sternal rub b.) Pressure on the orbital rim c.) Squeezing the sternocleidomastoid muscle d.) Nail bed pressure

D ~ Motor testing on the unconscious client can be done only by testing response to painful stimuli. Nailbed pressure tests a basic peripheral response. Cerebral responses to pain are testing using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? a. Complete blood count (CBC) b. Chest radiograph (Chest x-ray) c. 12-Lead electrocardiogram (ECG) d. Noncontrast computed tomography (CT) scan

D ~ Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the less brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.

Problems with memory and learning would relate to which of the following lobes? a.) Frontal b.) Occipital c.) Parietal d.) Temporal

D ~ The temporal lobe functions to regulate memory and learning problems because of the integration of the hippocampus. The frontal lobe primarily functions to regulate thinking, planning, and judgment. The occipital lobe functions regulate vision. The parietal lobe primarily functions with sensory function.

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).

D ~ The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.

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) 13%

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) Absolute bed rest in a quiet, nonstimulating environment

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) Call the physician immediately.

A nurse is performing a neurologic assessment on a 9-year-old child who has displayed unexplained changes in behavior. Which assessment finding is consistent with a neurologic deficit? A) Child has a negative Babinski reflex. B) Child recalls names of well-known cartoon characters. C) Child is able to walk backward heel to toe. D) Child is incapable of balancing on one foot.

D) Child is incapable of balancing on one foot.

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 patient's plan of care? A) Adult failure to thrive B) Post-trauma syndrome C) Hyperthermia D) Disturbed sensory perception

D) Disturbed sensory perception

What should be included in the patient's 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) Exercise the affected extremities passively four or five times a day.

A seizure that is not provoked by known stimuli is known as which of the following? A) Acquired B) Congenital C) Febrile D) Idiopathic

D) Idiopathic

Which events are associated with the loss of autoregulation? A) Both intracranial pressure and cerebral perfusion decrease. B) Both intracranial pressure and cerebral perfusion increase. C) Intracranial pressure decreases and cerebral perfusion increases. D) Intracranial pressure increases and cerebral perfusion decreases.

D) Intracranial pressure increases and cerebral perfusion decreases.

Which statement about cerebral edema or ischemia is true? A) It often causes a skull fracture. B) It is an example of a lacerating injury. C) It is an example of a penetrating injury. D) It is often secondary to a traumatic brain injury.

D) It is often secondary to a traumatic brain injury.

The statement "A decrease in level of consciousness may lead to a decrease in respiration" best describes the relationship between intracranial regulation and which of the following? A) Acid-base balance B) Cognition C) Mobility D) Oxygenation

D) Oxygenation

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 patient's room low. B) Place the patient's clock on the affected side. C) Approach the patient on the side where vision is impaired. D) Place the patient's extremities where she can see them.

D) Place the patient's extremities where she can see them.

You are assessing the arm drift component of the Cincinnati Prehospital Stroke Scale on a 60-year-old woman. When she holds both of her arms out in front of her and closes her eyes, both of her arms immediately fall to her sides. You should: A) Instruct the patient to keep her eyes open and then repeat the arm drift test. B) Defer this part of the test and assess her for facial droop and slurred speech. C) Repeat the arm drift test and ensure that her palms are facing downward. D) Repeat the arm drift test, but move the patient's arms into position yourself.

D) Repeat the arm drift test, but move the patient's arms into position yourself.

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 nurse's 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) Report this to the physician as a possible sign of clinical deterioration.

A client presents with a mild concussion following a fall. Which nursing diagnosis is least likely to be made for this client? A) Acute Pain B) Acute Confusion C) Nausea D) Risk for Post-Trauma Syndrome

D) Risk for Post-Trauma Syndrome

What type of seizure does not affect memory or awareness and occurs when abnormal electrical activity is contained to a limited area of the brain? A) Absence B) Complex focal C) Generalized D) Simple focal

D) Simple focal

The nurse is caring for a toddler-age client who starts to have a tonic-clonic (grand mal) seizure while in a crib in the hospital. The child's jaws are clamped shut. What is the most appropriate nursing action? A) Place a tongue blade between the child's jaws. B) Restrain the child to prevent injury. C) Prepare the suction equipment. D) Stay with the child to observe for complications.

D) Stay with the child to observe for complications.

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) The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.

Health promotion efforts concerning intracranial regulation that focus on the proper use of protective equipment for outdoor activities and vehicle restraint systems are designed to anticipate and prevent alterations to intracranial regulation related to what? A) Prescription drug side effects B) Congenital hydrocephalus C) Stroke D) Trauma

D) Trauma

Which client should the nurse assess first after receiving the change-of-shift report? A. A client with a bowel obstruction who is complaining of nausea B. A client with type 1 diabetes mellitus with blood glucose of 82 mg/dL C. A client with hypertension with a blood pressure of 168/88 mmHg D. A client with heart failure who is complaining of shortness of breath

D. A client with heart failure who is complaining of shortness of breath Rationale: Using the ABCs (airway, breathing, and circulation) as a guide, the nurse should first assess the client with shortness of breath. This would take priority over a client complaining of nausea, a client with an elevated (but not critically elevated) blood pressure, and a client with a normal blood glucose reading.

The medical-surgical nurse is planning the day immediately after receiving report. Which should be the primary nursing intervention when prioritizing care? A. Analyzing collected data B. Assigning staff to clients C. Ascertaining interventions D. Assessing client situations

D. Assessing client situations Rationale: The first step when prioritizing care is assessment. Assessment is the process of gathering information to make decisions. Assessment includes knowing individual clients' health statuses to prepare for anticipated or unanticipated changes. Ascertaining interventions would occur after the assessment. Analyzing collected data would occur after an assessment. Assigning staff to clients would occur after knowing the number and level of caregivers available to provide care.

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? A. Cautious observation only B. Extracranialintracranial bypass C. Carotid endarterectomy D. Carotid angioplasty with stenting

D. Carotid angioplasty with stenting Rationale: 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.

A homeless client presents to the emergency department (ED) complaining of severe chest pain. The client is well known to the ED, coming in frequently for various minor complaints. Which ethical principles should be most important for the nurse to consider? A. Privacy and confidentiality B. Nonmaleficence and beneficence C. Accountability and responsibility D. Justice and fairness

D. Justice and fairness Rationale: The principle of justice guides nurses in making decisions about setting priorities. Additionally, nurses must show fairness in treating individuals as equals. In this scenario, the nurse must treat the homeless client like any other client seeking care for chest pain. Accountability, responsibility, privacy, confidentiality, nonmaleficence, and beneficence are all important ethical considerations for the nurse but are not directly relevant to the situation.

D. Nonurgent Rationale: Symptoms indicate that this client may be experiencing a urinary tract infection, which would be considered nonurgent since a delay in treatment would not result in a life-threatening situation. It would not meet the criteria for urgent or emergent/immediate.

Which collaborative therapy should the nurse request when a client needs to learn to swallow following damage to the associated area of the brain? A. Recreational therapy B. Physical therapy C. Occupational therapy D. Speech therapy

D. Speech therapy Rationale: Speech therapy may be needed if the client needs to learn to eat or talk following damage to the associated areas of the brain. Physical therapy to prevent muscle atrophy may be necessary for a client who is unconscious or bedridden. Occupational therapy can help the client regain any motor skills needed to perform activities of daily living. Recreational therapy works to restore motor, social, and cognitive functioning, build confidence, develop coping skills, and integrate skills learned in treatment settings into community settings.

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

D. The client with right-sided paralysis flexing and extending only the left knee Rationale: 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.

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? A. Atherosclerotic buildup in affected arteries must be greater than 90%. B. The stroke must be hemorrhagic in nature. C. Aspirin therapy must have been received for 6 months for tPA to be effective. D. The stroke must have occurred within 3 hours of administering the medication.

D. The stroke must have occurred within 3 hours of administering the medication. Rationale: 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.

A parent brings a 12-year-old to the clinic after a fall from a bicycle. Which statement by the nurse is a health promotion intervention to minimize future risk of increased intracranial pressure? A. "Thank goodness your child sustained only a few cuts and bruises." B. "Let's hope this doesn't happen again." C. "What will you do in the future to prevent this from happening?" D. "How do you feel about your child wearing a helmet while riding their bicycle?"

D. "How do you feel about your child wearing a helmet while riding their bicycle?" Rationale: Health promotion related to intracranial regulation generally involves anticipatory guidance related to the client's age, development, and activities. It also includes providing information about protective equipment for outdoor activities and vehicle restraint systems. While the other answer options are valid statements, by asking an open-ended question with the suggestion of protective equipment, a conversation can begin.

The nurse is teaching a senior citizen's group about signs and symptoms of a stroke. Which statement by the nurse would provide accurate information? A. "Take the person to the hospital if a headache lasts for more than 24 hours." B. "Stroke symptoms usually start when the person is awake and physically active." C. "A person with a transient ischemic attack has mild symptoms that will go away." D. "Call 911 immediately if a person develops slurred speech or difficulty speaking."

D. "Call 911 immediately if a person develops slurred speech or difficulty speaking." Medical assistance should be obtained immediately for someone with signs and symptoms of a stroke such as sudden numbness; weakness; paralysis of the face, arm, or leg (especially on one side of the body); sudden confusion; trouble speaking or understanding; slurred speech; sudden trouble seeing in one or both eyes; sudden trouble walking; dizziness; loss of balance or coordination; or a sudden, severe headache with no known cause. A person with signs and symptoms of a transient ischemic attack should seek medical attention immediately because it is unknown if the symptoms will resolve or persist and progress to a stroke. Onset of signs and symptoms of a stroke vary depending on the type. Onset of an ischemic thrombotic stroke usually occurs at rest. Onset of an ischemic embolic stroke is not related to rest or activity, and onset of a hemorrhagic stroke usually occurs with activity.

As the nurse assesses Nancy, Gail asks, "Why isn't my mother a candidate for thrombolytic therapy?" A. "Since your mother was alert on admission, she is not a candidate to receive this medication. B. "I think that is something you should discuss with your mother's healthcare provider." C. "tPA is usually not administered to anyone older than 65 years." D. "She is not a candidate because of therapeutic time constraints related to this medication."

D. "She is not a candidate because of therapeutic time constraints related to this medication." - Thrombolytic therapy is contraindicated in clients with symptom onset longer than 3 hours prior to admission. Nancy had symptoms for 24 hours before being brought to the medical center.

Of the following patients, the nurse recognizes that the one with the highest risk for stroke is a(n): A. obese 45-year old Native American. B. 35-year-old Asian American woman who smokes. C. 32-year-old white woman taking oral contraceptives. D. 65-year-old African American man with hypertension.

D. 65-year-old African American man with hypertension. Nonmodifiable risk factors for stroke include age (older than 65 years), male gender, ethnicity or race (incidence is highest in African Americans; next highest in Hispanics, Native Americans/Alaska Natives, and Asian Americans; and next highest in white people), and family history of stroke or personal history of a transient ischemic attack or stroke. Modifiable risk factors for stroke include hypertension (most important), heart disease (especially atrial fibrillation), smoking, excessive alcohol consumption (causes hypertension), abdominal obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet (high in saturated fat and low in fruits and vegetables), and drug abuse (especially cocaine). Other risk factors for stroke include a diagnosis of diabetes mellitus, increased serum levels of cholesterol, birth control pills (high levels of progestin and estrogen), history of migraine headaches, inflammatory conditions, hyperhomocystinemia, and sickle cell disease.

Successful achievement of patient outcomes for the patient with cranial surgery would be best indicated by the a. ability to return home in 6 days b. ability to meet all self-care needs c. acceptance of residual neurologic deficits d. absence of signs and symptoms of increased ICP

D. Absence of signs and symptoms of increased ICP- The primary goal after cranial surgery is prevention of increased ICP, and interventions to prevent ICP and infection postoperatively are nursing priorities. The residual deficits, rehabilitation potential, and ultimate function of the patient depend on the reason for surgery, the postoperative course, and the patient's general state of health

Which condition is considered a non-modifiable risk factor for a brain attack? A. High cholesterol levels B. Obesity C. History of atrial fibrillation D. Advanced age

D. Advanced age - People over age 55 are a high-risk group for a brain attack because the incidence of stroke more than doubles in each successive decade of life. Non-modifiable risk factor means the client cannot do anything to change the risk factor.

The nurse suspects the presence of an arterial epidural hematoma in the patient who experiences a. failure to regain consciousness following a head injury b. a rapid deterioration of neurologic function within 24 to 48 hours following a head injury c. nonspecific, nonlocalizing progression of alteration in LOC occurring over weeks or months d. unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC

D. An arterial epidural hematoma is the most acute neurologic emergency, and the typical symptoms include unconsciousness at the scene, with a brief lucid interval followed by a decrease in LOC. An acute subdural hematoma manifests signs within 48 hours of an injury; a chronic subdural hematoma develops over weeks or months

A 74-year-old man who has right-sided extremity paralysis related to a thrombotic stroke develops constipation. Which action should the nurse take first? A. Assist the patient to the bathroom every 2 hours. B. Provide incontinence briefs to wear during the day. C. Administer a bisocodyl (Dulcolax) rectal suppository every day. D. Arrange for several servings per day of cooked fruits and vegetables.

D. Arrange for several servings per day of cooked fruits and vegetables. Patients after a stroke frequently have constipation. Dietary management includes the following: fluid intake of 2500 to 3000 mL daily, prune juice (120 mL) or stewed prunes daily, cooked fruit three times daily, cooked vegetables three times daily, and whole-grain cereal or bread three to five times daily. Patients with urinary incontinence should be assisted to the bathroom every 2 hours when appropriate. Suppositories may be ordered for short-term management if the patient does not respond to increased fluid and fiber. Incontinence briefs are indicated as a short-term intervention for urinary incontinence.

A patient admitted with possible stroke has been aphasic for 3 hours and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question? a. Keep head of bed elevated at least 30 degrees. b. Infuse normal saline intravenously at 75 mL/hr. c. Administer tissue plasminogen activator (tPA) per protocol. d. Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.

D. Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.

When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis a. to monitor and record the blood pressure daily. b. that Plavix will dissolve clots in the cerebral arteries. c. that Plavix will reduce cerebral artery plaque formation. d. to call the health care provider if stools are bloody or tarry.

D. Clopidogrel (Plavix) inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.

Due to her deteriorating condition, Nancy is immediately referred to the neurologist. The ED nurse realizes that Nancy has probably suffered a left-sided brain attack. Which clinical manifestation further supports this assessment? A. Spatial-perceptual deficits. B. Visual field deficit on the left side C. Paresthesia of the left side D. Global aphasia

D. Global aphasia -Global aphasia refers to difficulty speaking, listening, and writing. Symptoms vary from person to person. Aphasia may occur secondary to any brain injury involving the left hemisphere.

D. Heart rate decreases from 75 to 55 beats/minute Cushing's triad is systolic hypertension with a widening pulse pressure, bradycardia with a full and bounding pulse, and slowed respirations. The rise in blood pressure is an attempt to maintain cerebral perfusion, and it is a neurologic emergency because decompensation is imminent. The other options are not part of Cushing's triad

6. A patient is demonstrating signs and symptoms of stroke. The patient reports loss of vision. What area of the brain do you suspect is affected based on this finding?* A. Brain stem B. Hippocampus C. Parietal lobe D. Occipital lobe

D. Occipital lobe The answer is D. The occipital lobe is responsible for vision and color perception.

D. Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control and asking the patient to stop will lead to embarrassment.

Nancy is experiencing homonymous hemianopsia as a result of her brain attack. Which nursing intervention would the nurse implement address this condition? A. Request that the dietary department thicken all liquids on Nancy's meal and snack trays. B. Turn Nancy every 2 hours and perform active range of motion exercises. C. Speak slowly and clearly to assist Nancy in forming sounds to words D. Place the objects Nancy needs for activities of daily living on the left side of the table.

D. Place the objects Nancy needs for activities of daily living on the left side of the table. - Homonymous hemianopsia is loss of the visual field on the same side as the paralyzed side. This results in the client neglecting that side of the body, so it is beneficial to place objects on that side. Nancy had a left-hemisphere brain attack so her right side is the weak side.

D. Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time.

D. Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the less brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.

10. You're patient who had a stroke has issues with understanding speech. What type of aphasia is this patient experiencing and what area of the brain is affected?* A. Expressive; Wernicke's area B. Receptive, Broca's area C. Expressive; hippocampus D. Receptive; Wernicke's area

D. Receptive; Wernicke's area

A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions

D. Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.

The female patient has been brought to the ED with a sudden onset of a severe headache that is different from any other headache she has had previously. When considering the possibility of a stroke, which type of stroke should the nurse know is most likely occurring? A. TIA B. Embolic stroke C. Thrombotic stroke D. Subarachnoid hemorrhage

D. Subarachnoid hemorrhage Headache is common in a patient who has a subarachnoid hemorrhage or an intracerebral hemorrhage. A TIA is a transient loss of neurologic function usually without a headache. A headache may occur with an ischemic embolic stroke, but severe neurologic deficits are the initial symptoms. The ischemic thrombotic stroke manifestations progress in the first 72 hours as infarction and cerebral edema increase.

A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin administration. d. tissue plasminogen activator (tPA) infusion.

D. The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.

D. The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.

2. Practice Question •A patient presents to the ED with signs and symptoms of an ischemic stroke. What is the priority factor when considering fibrinolytic therapy? •A. age older than 80 years. •B. History of stroke. •C. Recent surgery. •D. Time of onset of symptoms.

D. Time of onset of symptoms.

Which intervention is most appropriate when communicating with a patient suffering from aphasia following a stroke? A. Present several thoughts at once so that the patient can connect the ideas. B. Ask open-ended questions to provide the patient the opportunity to speak. C. Finish the patient's sentences to minimize frustration associated with slow speech. D. Use simple, short sentences accompanied by visual cues to enhance comprehension.

D. Use simple, short sentences accompanied by visual cues to enhance comprehension. When communicating with a patient with aphasia, the nurse should present one thought or idea at a time. Ask questions that can be answered with a "yes," "no," or simple word. Use visual cues and allow time for the individual to comprehend and respond to conversation.

Skull radiographs and a computed tomography (CT) scan provide evidence of a depressed parietal fracture with a subdural hematoma in a patient admitted to the emergency department following an automobile accident. In planning care for the patient, the nurse anticipates that a. the patient will receive life-support measures until the condition stabilizes b. immediate burr holes will be made to rapidly decompress the intracranial activity c. the patient will be treated conservatively with close monitoring for changes in neurologic condition d. the patient will be taken to surgery for a craniotomy for evacuation of blood and decompression of the cranium

D. When there is a depressed fracture and fractures with loose fragments, a craniotomy is indicated to elevate the depressed bone and remove free fragments. A craniotomy is also indicated in cases of acute subdural and epidural hematomas to remove the blood and control the bleeding. Burr holes may be used in an extreme emergency for rapid decompression, but with a depressed fracture, surgery would be the treatment of choice

When assessing arm movement of a patient with a suspected stroke, you should: A. expect to see one arm slowly drift down to the patient's side. B. ask the patient to hold his or her arms up with the palms down. C. observe the patient for approximately 5 minutes. D. ask the patient to close his or her eyes during the assessment.

D. ask the patient to close his or her eyes during the assessment.

Interruption of cerebral blood flow may result from all of the following, EXCEPT: A. a thrombus. B. an acute arterial rupture. C. an embolism. D. cerebral vasodilation.

D. cerebral vasodilation.

A client who has had a plaster of Paris cast applied to his forearm is receiving pain medication. To detect early manifestations of compartment syndrome, which of these assessments should the nurse make? A.) Observe the color of the fingers B.) Palpate the radial pulse under the cast C.) Check the cast for odor and drainage D.) Evaluate the response to analgesics

D.) Evaluate the response to analgesics

A nursing intervention is indicated for the patient with hemiplegia is a. the use of a footboard to prevent plantar flexion b. immobilization of the affected arm against the chest with a sling c. positioning the patient in bed with each joint lower than the joint proximal to it d. having the patient perform passive ROM of the affected limb with the unaffected limb

D: Having the patient perform passive ROM of the affected limb with the unaffected limb- active ROM should be initiated on the unaffected side as soon as possible, and passive ROM of the affected side should be started on the first day. Having the patient actively exercise the unaffected side provides the patient with active and passive ROM as needed. Use of footboards is controversial because they stimulate plantar flexion. The unaffected arm should be supported, but immobilization may precipitate a painful shoulder-hand syndrome. The patient should be positioned with each joint higher than the joint proximal to it to prevent dependent edema.

The nurse can assist the patient and the family in coping with the long term effects of a stroke by a. informing family members that the patient will need assistance with almost all ADLs b. explaining that the patient's prestroke behavior will return as improvement progresses c. encouraging the patient and family members to seek assistance from family therapy or stroke support groups d. helping the patient and family understand the significance of residual stroke damage to promote problem solving and planning

D: Helping the patient and family understand the significance of residual stroke damage to promote problem solving and planning- the patient and family need accurate and complete information about the effects of the stroke to problem solve and make plans for chronic care of the patient. It is uncommon for patients with major strokes to return completely to pre stroke function, behaviors, and role, and both the patient and family will mourn these losses. The patient's specific needs for care must be identified, and rehabilitation efforts should be continued at home. Family therapy and support groups may be helpful for some patients and families.

The priority intervention in the emergency department for the patient with a stroke is a. intravenous fluid replacement b. administration of osmotic diuretics to reduce cerebral edema c. initiation of hypothermia to decrease the oxygen needs of the brain d. maintenance of respiratory function with a patent airway and oxygen administration

D: Maintenance of respiratory function with a patent airway and oxygen administration- the first priority in acute management of the patient with a stroke is preservation of life. Because the patient with a stroke may be unconscious or have a reduced gag reflex, it is most important to maintain a patent airway for the patient and provide oxygen if respiratory effort is impaired. IV fluid replacement, treatment with osmotic diuretics, and perhaps hypothermia may be used for further treatment.

A patient's wife asks the nurse why her husband did not receive the clot busting medication (tPA) she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What should the nurse respond? a. He didn't arrive within the time frame for that therapy b. Not every is eligible for this drug. Has he had surgery lately? c. You should discuss the treatment of your husband with your doctor d. The medication you are talking about dissolves clots and could cause more bleeding in your husband's head

D: The medication you are talking about dissolves clots and could cause more bleeding in your husband's head- tPA dissolves clots and increases the risk for bleeding. It is not used with hemorrhagic strokes. If the patient had a thrombotic/embolic stroke the time frame would be important as well as a history of surgery. The nurse should answer the question as accurately as possible and then encourage the individual to talk with the primary care physician if he or she has further questions.

A patient comes to the emergency department immediately after experiencing numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient request discharge. The nurse stresses that it is important for the patient to be evaluated primarily because a. the patient has probably experienced an asymptomatic lacunar stroke b. the symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours c. neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off d. the patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease

D: The patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease- A TIA is a temporary focal loss of neurologic function caused by ischemia of an area of the brain, usually lasting only about 3 hours. TIAs may be due to microemboli from heart disease or carotid or cerebral thrombi and are a warning of progressive disease. Evaluation is necessary to determine the cause of the neurologic deficit and provide prophylactic treatment if possible.

The nurse is caring for a patient on the stroke rehabilitation unit. Which intervention should the nurse question? Encouraging bladder training by having the patient void on a schedule Decreasing fluid intake to prevent aspiration and decrease urinary frequency Teaching the patient Kegel exercises Using positive reinforcement

Decreasing fluid intake to prevent aspiration and decrease urinary frequency Decreasing fluid intake is not appropriate, as it can cause constipation. Fluid intake should be increased, if safe, to stimulate intestinal motility. The other answer choices are good methods to improve continence of urine.

The nurse is performing a neuro assessment on the patient. In addition to LOC what is assessed to evaluate cognitive changes that may be occurring?

Denial of illness, Proprioceptive dysfunction, Impairment of memory & Decreased ability to concentrate

The nurse is caring for a patient diagnosed with stroke. Which complication is the nurse least likely to expect? Constipation Dysphagia Diarrhea Stool impaction

Diarrhea Gastrointestinal complications of stroke include dysphagia, constipation, and stool impaction. Diarrhea is not an expected complication of stroke. Bowel habits may be altered as a result of cognitive deficits, immobility, and dehydration.

The nurse is caring for a patient with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which of the following postoperative findings would cause the nurse the most concern? a) Blood pressure (BP): 128/86 mm Hg b) Neck pain: 3/10 (0 to 10 pain scale) c) Mild neck edema d) Difficulty swallowing

Difficulty swallowing The patient's inability to swallow without difficulty would cause the nurse the most concern. Difficulty in swallowing, hoarseness or other signs of cranial nerve dysfunction must be assessed. The nurse focuses on assessment of the following cranial nerves: facial (VII), vagus (X), spinal accessory (XI), and hypoglossal (XII). Some edema in the neck after surgery is expected; however, extensive edema and hematoma formation can obstruct the airway. Emergency airway supplies, including those needed for a tracheostomy, must be available. The patient's neck pain and mild BP elevation need addressing but would not cause the nurse the most concern. Hypotension is avoided to prevent cerebral ischemia and thrombosis. Uncontrolled hypertension may precipitate cerebral hemorrhage, edema, hemorrhage at the surgical incision, or disruption of the arterial reconstruction.

What will alteration in level of consciousness (LOC) look like for this patient? Name two symptoms.

Drowsiness, slight slurring of speech, sluggish pupillary reaction

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? Placing the client in a side-lying position Monitoring mental status and level of consciousness Monitoring respiratory status Encouraging active range-of-motion exercises

Encouraging active range-of-motion exercises

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

Encouraging active range-of-motion exercises

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 patient with aphasia. Which of the following strategies will the nurse use to facilitate communication with the patient? a) Avoiding the use of hand gestures b) Establishing eye contact c) Speaking in complete sentences d) Speaking loudly

Establishing eye contact The following strategies should be used by the nurse to encourage communication with a patient with aphasia: face the patient and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the patient time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the patient uses and handles an object, say what the object is. It helps to match the words with the object or action, be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the patient or make it difficult to sort out the message being spoken. (less)

The nurse is caring for a patient with aphasia. Which of the following strategies will the nurse use to facilitate communication with the patient? a) Speaking in complete sentences b) Speaking loudly c) Avoiding the use of hand gestures d) Establishing eye contact

Seen first? 1. a lethargic 2 month old who refuses to nurse for 8 hours 2. A 2 year old complaining of elbow pain and deformity 3. A 5 year old who is flushed and has a temp of 101.9 4. A 6 yr old with 2 episodes of vomiting and a sore throat

First see 2 month old due to dehydration and acidosis, kidneys can't concentrate urine, metabolism 2x as fast as an adult Although temp is high, nurse can request antipyretic Vomiting is a risk for dehydration but age of child can withstand more than an infant

Get an order to decrease IV fluids.

Pt. with stroke is having some trouble swallowing. Which feeding technique is the SAFEST option to prevent aspiration?

Give small spoonful's of custard

A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? a) Phenytoin (Dilantin) b) Methyldopa (Aldomet) c) Heparin sodium d) Dexamethasone (Decadron)

Heparin sodium Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a client with hemorrhagic stroke, the physician may use dexamethasone to decrease cerebral edema and pressure; methyldopa, to reduce blood pressure; and phenytoin, to prevent seizures.

History of type 1 diabetes mellitus since adolescence Type I diabetes mellitus is a risk factor for stroke. Cessation of cigarette smoking is an example of a lifestyle modification to reduce the risk of stroke. One glass of red wine with dinner is not considered overindulgence in alcohol. Controlling hyperlipidemia with medication is a good example of controlling risk of stroke through medication.

After teaching about stroke in a child, the nurse asked a group of parents to list the clinical manifestations. Which response by a parent indicates a need for further education? Severe headaches Hyperalertness Unilateral neglect Dizziness and mood changes

Hyperalertness Symptoms of stroke in children include decreased coordination and loss of balance, dizziness and mood changes, severe headaches, unilateral neglect, and sleepiness (not hyperalertness).

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regime, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is: a) Dyslipidemia b) Obesity c) Hypertension d) Smoking

Hypertension Hypertension is the most modifiable risk factor for either ischemic or hemorrhagic stroke. Unfortunately, it remains under-recognized and undertreated in most communities.

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. After completing ordered diagnostic tests, the physician indicates to the client what caused the symptoms that brought him to the hospital. What is the origin of the client's symptoms? a) Hypertension b) Cardiac disease c) Diabetes insipidus d) Impaired cerebral circulation

Impaired cerebral circulation TIAs result from impaired blood circulation in the brain, which can be caused by atherosclerosis and arteriosclerosis, cardiac disease, or diabetes. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by cardiac disease. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by diabetes. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by hypertension.

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

Improving muscle strength and coordination

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.

A patient experienced an ischemic stroke in the right anterior cerebral artery. Which clinical manifestation should the nurse expect to find? Dysphagia Problems with gait Homonymous hemianopia Inability to make decisions

Inability to make decisions

A patient experienced an ischemic stroke in the right anterior cerebral artery. Which clinical manifestation should the nurse expect to find? Inability to make decisions Homonymous hemianopia Dysphagia Problems with gait

Inability to make decisions For a patient who experienced an ischemic stroke involving the right anterior cerebral artery, the nurse should expect to see weakness or paralysis of the left foot or leg; sensory loss in the left leg, foot, and toes; an inability to make decisions; and urinary incontinence. Homonymous hemianopia would be seen if the internal carotid artery or middle cerebral artery were affected by the ischemic stroke. Problems with gait and dysphagia would be evident with an ischemic stroke that involved the vertebral artery.

The nurse is administering oxygen to a client experiencing a stroke in order to prevent hypoxia and hypercapnia. This will also lessen the risk for which finding?

Increased intracranial pressure (IICP)

A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant? a) Elevated blood pressure b) Decreased level of consciousness (LOC) c) Increased urine output d) Decreased heart rate

Increased urine output The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.

Which of the following is a contraindication for the administration of tissue plasminogen activator (t-PA)? a) Systolic blood pressure less than or equal to 185 mm Hg b) Ischemic stroke c) Intracranial hemorrhage d) Age 18 years of age or older

Intracranial hemorrhage Intracranial hemorrhage, neoplasm, or aneurysm is a contraindication to t-PA. Clinical diagnosis of ischemic stroke, age 18 years of age or older, and a systolic BP less than or equal to 185 mm Hg are eligibility criteria. (less)

TIAs, thromboses, embolisms, & lacunar strokes are all types of (hemorrhagic/ischemic?) stroke.

Ischemic

___ strokes occur when arterial supply to the brain is blocked, usually by the narrowing of arteries or by clots moving from the heart (heart attack, AFib).

Ischemic

Drugs aimed at preventing stroke usually work to prevent (hemorrhagic/ischemic?) stroke.

Ischemic (bc usually they are clot-breaking drugs)

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? a) Maintaining the client in a quiet environment b) Keeping the client in one position to decrease bleeding c) Positioning the client to prevent airway obstruction d) Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess

A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment? a) Limited attention span and forgetfulness b) Visual agnosia c) Auditory agnosia d) Lack of deep tendon reflexes

Lack of deep tendon reflexes Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation. Damage to the lower motor neurons may cause decreased muscle tone, flaccid muscle paralysis, and a decrease in or loss of reflexes.

The nurse caring for a client with increased intracranial pressure should recognize that which compensatory mechanism stimulates the cerebral blood vessels to regulate cerebral pressure? (Select all that apply.) Lactic acid Serum uric acid Carbonic acid Potassium Carbon dioxide

Lactic acid Carbonic acid Carbon dioxide Lactic acid, carbonic acid, and carbon dioxide are chemicals that stimulate the dilation or contraction of blood vessels within the brain, which aids in regulation of cerebral pressure. Cerebral hemorrhage also regulates dilation or constriction of the cerebral blood vessels in response to the amount of blood flow within the brain. Serum uric acid and potassium do not affect cerebral pressure.

Manifestations of right brain damage

Left homonymous hemianopsia, agnosia, quick impulsive behavior, neglect of the left side of the body

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? a) Left-sided cerebrovascular accident (CVA) b) Completed Stroke c) Transient ischemic attack (TIA) d) Right-sided cerebrovascular accident (CVA)

Left-sided cerebrovascular accident (CVA) When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? a) Left-sided cerebrovascular accident (CVA) b) Right-sided cerebrovascular accident (CVA) c) Transient ischemic attack (TIA) d) Completed Stroke

An alert client presents at the urgent care center after a fall. Which assessment should the nurse perform? (Select all that apply.) Level of consciousness (LOC) Vital signs Body mass index Anthropometric measurements Pupillary size and reaction to light

Level of consciousness (LOC) Vital signs Pupillary size and reaction to light Assessment of the neurologic status establishes the client's clinical condition and provides a baseline for measuring changes. Assessment areas include LOC, behavior, motor/sensory functions, pupillary size and reaction to light, and vital signs. Body mass index (BMI) and anthropometric measurements are commonly used during nutritional assessment.

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem? a) Pregabalin (Lyrica) b) Diphenhydramine (Benadryl) c) Heparin d) Lioresal (Baclofen)

Lioresal (Baclofen) Spasticity, particularly in the hand, can be a disabling complication after stroke. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity (although the effect is temporary, typically lasting 2 to 4 months) (Teasell, Foley, Pereira, et al., 2012). Other treatments for spasticity may include stretching, splinting, and oral medications such as baclofen (Lioresal). (less)

Match each symptoms of stroke that affects the RIGHT hemisphere

Loss of depth perception, Cannot recognize faces, Impaired sense of humor, Denial of illness & Loss of Hearing

The nurse suspects that a newborn may be experiencing a stroke. Which diagnostic procedure should the nurse anticipate being ordered to confirm the suspicion? Fetal ultrasound Magnetic resonance imaging (MRI) Blood glucose check X-ray

Magnetic resonance imaging (MRI) Stroke in newborns is diagnosed through MRI, ultrasound, or head computed tomography (CT) scan. A fetal ultrasound is not appropriate because the newborn has already been delivered. An x-ray is not indicated at this time. Blood glucose may cause jerking movements, but the jerking movements are one-sided and accompanied by other signs of stroke (staring and apnea).

Which of the following is accurate regarding a hemorrhagic stroke? a) It is caused by a large-artery thrombosis. b) One of the main presenting symptoms is numbness or weakness of the face. c) Main presenting symptom is an "exploding headache." d) Functional recovery usually plateaus at 6 months.

Main presenting symptom is an "exploding headache." One of hemorrhagic stroke's main presenting symptom is an "exploding headache." In ischemic stroke, functional recovery usually plateaus at 6 months; it may be caused by a large artery thrombosis and may have a presenting symptoms of numbness or weakness of the face

The nurse is caring for a client with increased intracranial pressure (IICP) who is supported with mechanical ventilation. Which intervention should the nurse implement to ensure adequate oxygenation for this client? (Select all that apply.) Maintaining partial pressure of arterial carbon dioxide of 35 mmHg Maintaining partial pressure of arterial oxygen of 100 mmHg Performing suctioning as needed Implementing measures to prevent atelectasis and fluid accumulation Initiating hyperventilation

Maintaining partial pressure of arterial carbon dioxide of 35 mmHg Maintaining partial pressure of arterial oxygen of 100 mmHg Performing suctioning as needed Implementing measures to prevent atelectasis and fluid accumulation Maintaining an appropriate arterial oxygen and carbon dioxide assists in oxygenation and prevents respiratory distress. Performing suctioning ensures a patent airway, and preventing atelectasis and fluid accumulation allows for gas exchange in the alveoli. Judicious hyperventilation is only used as an emergency intervention for clients with IICP and impending herniation.

The nurse is reviewing medications with a client. The nurse should teach the client that which medication may cause drowsiness and increase the risk for a fall? Anticoagulant Narcotic analgesic Antihypertensive Antipruritic

Narcotic analgesic Nurses should review prescription and over-the-counter medications with all clients, making sure to discuss side effects that may affect intracranial regulation. For instance, blood thinners may increase the risk of hemorrhagic stroke, and medications such as narcotic analgesics may cause dizziness and put the client at risk for falls. Antihypertensives may cause dizziness that can put a client at risk for a fall. An antipruritic is used to relieve itching.

The client is being treated for increased intracranial pressure (IICP). Which of these manifestations should indicate to the nurse that the outcomes are being met for this client? (Select all that apply.) No redness or drainage at site of intraventricular catheter Intracranial pressure = 14 mmHg Blood pressure = 118/76 Verbalizes need to increase stimuli Lethargic

No redness or drainage at site of intraventricular catheter Intracranial pressure = 14 mmHg Blood pressure = 118/76 Rationale The client should maintain ICP less than< 20 mmHg. The blood pressure should be normal. Client and significant others will verbalize the reasons for, and how to maintain, a low-stimuli environment, not high stimuli. The client will remain free of infection including redness and drainage at the sites of insertion. The client will maintain adequate cerebral perfusion, and level of consciousness should return to normal and not be lethargic.

Which of the following is the initial diagnostic test for a stroke? a) Noncontrast CT scan b) Transcranial Doppler studies c) ECG d) Carotid Doppler

Noncontrast CT scan The initial diagnostic test for a stroke is a nonconstrast CT scan performed emergently to determine if the event is ischemic or hemorrhagic. Further diagnostics include a carotid Doppler, ECG, and a transcranial Doppler. (less)

Which of the following would alert the nurse that the client has experienced a transient ischemic attack (TIA)?

Numbness and tingling at the corner of the mouth

The nurse is caring for a patient who is having difficulty eating and swallowing following a stroke. Which rehabilitative team member should the nurse consult regarding this issue? Case manager Dietitian Physical therapist Occupational therapist

Occupational therapist

The nurse is caring for a patient who is having difficulty eating and swallowing following a stroke. Which rehabilitative team member should the nurse consult regarding this issue? Case manager Physical therapist Dietitian Occupational therapist

Occupational therapist The occupational therapist provides interventions that help the patient learn to eat and drink. The physical therapist provides interventions that improve muscle strength and coordination, such as walking, sitting, and changing positions. The dietitian helps plan nutritious meals that meet the patient's specific needs. The patient needs assistance with feeding and swallowing. The case manager makes certain the patient receives care that is appropriate for the patient's specific needs.

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? Occupational therapy Physical therapy Speech and language therapy Home health

Occupational therapy

Which client is most at risk for increased intracranial pressure? (Select all that apply.) Older adult Newborn infant Pregnant obese woman School-aged child Adolescent

Older adult Newborn infant Pregnant obese woman School-aged child Adolescent Falls continue to be the major cause of traumatic brain injury leading to increased intracranial pressure (IICP). Older adults are more prone to falls due to sensory and motor losses, as well as medication use. Adolescents are at risk for motor vehicle crashes and trauma resulting from violence. Premature newborn infants are at an increased risk of IICP. School-aged children are prone to falling. School-aged children are at risk for bicycle, swimming, or activity-related accidents that cause IICP. Obese women of childbearing age often have idiopathic intracranial hypertension. During pregnancy, these women must be closely monitored for increased intracranial pressure.

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.

Characteristics of embolic stroke

Onset unrelated to activity, quick onset and resolution, associated with endocardial disorders

Oral contraceptive use

The nurse is caring for a patient on the stroke unit. Which should be the nurse's priority action? Ordering a pureed or soft diet Monitoring swallowing studies prior to every meal Instructing the patient to hyperextend the neck while swallowing Teaching the patient to place food behind the front teeth on the affected side of the mouth

Ordering a pureed or soft diet

This lobe processes sensory information such as shapes, temperature, pain, and two-point discrimination.

Parietal

A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best nursing action to be taken? a) Reposition the tray and plate. b) Perform a vision field assessment. c) Know this is a normal finding for CVA. d) Assist the client with feeding.

Perform a vision field assessment. The nurse should perform a vision field assessment to evaluate the client forhemianopia. This finding could indicate damage to the visual area of the brain as a result of evolving CVA. Repositioning the tray and assisting with feeding would not be the best nursing action until new finding has been evaluated. Hemianopia can be associated with a CVA but, when presenting as a new finding, should be evaluated and reported immediately. (less)

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 is caring for a patient with dysphagia. Which of the following interventions would be contraindicated while caring for this patient? a) Allowing ample time to eat b) Assisting the patient with meals c) Testing the gag reflex prior to offering food or fluids d) Placing food on the affected side of mouth

Placing food on the affected side of mouth Interventions for dysphagia include placing food on the unaffected side of the mouth, allowing ample time to eat, assisting the patient with meals, and testing the patient's gag reflex prior to offering food or fluids.

What do platelets need to be above for Tissue Plasminogen Activator (tPA)?

Platelet count ≥100,000/mm

Pt. with right cerebral hemisphere stroke may have safety issues related to which factor?

Poor impulse control

A nurse in the intensive care unit is providing care for a client with increased intracranial pressure (IICP). The nurse monitors the client for which manifestations of IICP? (Select all that apply.) Projectile vomiting Decreased level of consciousness Dilated pupils Increased heart rate Decreased blood pressure

Projectile vomiting Decreased level of consciousness Dilated pupils Rationale Projectile vomiting is a manifestation of increased intracranial pressure. This is caused by pressure on the brainstem from swollen brain tissue. Dilated pupils are a manifestation of increased intracranial pressure. This is caused by pressure on the cranial nerves and vision pathways within the brain. A decreased level of consciousness is a manifestation of increased intracranial pressure. This is caused by pressure on the cerebral cortex and decreased oxygenation of the brain tissues. Increased intracranial pressure causes increased blood pressure, especially the systolic blood pressure. This worsens until there is a wide difference between the systolic blood pressure and the diastolic blood pressure. Increased intracranial pressure causes lowered heart rate. This is caused by the body's attempt to compensate for increased blood pressure.

Which nursing goal is appropriate for a client with increased intracranial pressure (IICP)? Protection from increases in cerebral blood flow Protection from sudden decreases in intracranial pressure Protection from risk factors Protection from sudden increases in intracranial pressure

Protection from sudden increases in intracranial pressure The nursing care of clients with IICP involves identifying those at risk and managing factors known to increase ICP. A major focus is protecting the client from sudden increases in ICP or decreases in cerebral blood flow.

A nurse in the intensive care unit is providing care for a client with increased intracranial pressure from a traumatic brain injury. The client has a fever of 102 °F. Which interventions will the nurse use to promote normal intracranial pressure? (Select all that apply.) Provide supplemental oxygen Administer acetaminophen per order Flex the neck to open the airway Suction for no more than 10 seconds per pass Monitor level of consciousness

Provide supplemental oxygen Administer acetaminophen per order Suction for no more than 10 seconds per pass Monitor level of consciousness Rationale Hyperthermia increases intracranial pressure. Hyperthermia also affects hypothalamic function in clients with increased intracranial pressure; therefore, administering an antipyretic medication is appropriate. Prolonged suctioning can increase intracranial pressure. It also causes decreased oxygen levels. Increased intracranial pressure can cause irregular and ineffective respirations. Supplemental oxygen helps prevent hypoxia. It also helps prevent excess carbon dioxide, which is a vasodilator. A decreased level of consciousness can be a manifestation of pressure on the cerebral cortex. It can also be a manifestation of decreased oxygen levels in the brain. Flexing the neck increases intracranial pressure by preventing blood return from the brain. The head and neck must be kept in neutral position.

The nurse is providing diet-related advice to a male patient following a cerebrovascular accident (CVA). The patient wants to minimize the volume of food and yet meet all nutritional elements. Which of the following suggestions should the nurse give to the patient about controlling the volume of food intake? a) Provide a high-fat diet. b) Include dry or crisp foods and chewy meats. c) Always serve hot or tepid foods. d) Provide thickened commercial beverages and fortified cooked cereals.

Provide thickened commercial beverages and fortified cooked cereals. Patients with CVA or other cerebrovascular disorders should lose weight and therefore should minimize their volume of food consumption. To ensure this, the nurse may provide thickened commercial beverages, fortified cooked cereals, or scrambled eggs. Patients should avoid eating high-fat foods, and serving foods hot or tepid will not minimize the volume consumed by the patient. Foods such as peanut butter, bread, tart foods, dry or crisp foods, and chewy meats should also be avoided because they cause choking.

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? Developing an alternate means of communicating Providing reassurance and support Maintaining fluid, oxygen, and nutritional status Providing behavioral and cognitive therapy when the condition stabilizes

Providing reassurance and support

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.

A 35-year-old client has been in the hospital for 2 weeks recovering from increased intracranial pressure. Which instruction should the nurse provide to the client? (Select all that apply.) Purchase a medical alert bracelet. Wear a helmet to prevent head injury. Remain on bedrest at all times of the day. Discuss the care plan at the workplace. Take all medications as prescribed.

Purchase a medical alert bracelet. Discuss the care plan at the workplace. Take all medications as prescribed. Nurses can teach clients who are at risk for impaired intracranial regulation about the importance of wearing a medical alert bracelet, discussing care plans at the school or workplace, and taking all medications as prescribed. For young children, health promotion may include wearing a helmet to prevent head injury during a seizure. There is no indication that requires complete bedrest.

78. The nurse educator is discussing fire safety with new employees. List in order of performance the following actions the nurse should teach to ensure the safety of clients and employees in the case of fire on the unit. 1. Extinguish. 2. Rescue. 3. Confine. 4. Alert.

RACE

A nurse in the emergency department is providing care for a client diagnosed with increased intracranial pressure (IICP). The client is experiencing a decreasing level of consciousness. Which collaborative treatment would the nurse question for this client? Place client on mechanical ventilator to increase oxygen and eliminate carbon dioxide Intubate the client with an endotracheal tube Administer intravenous 0.45% saline infusion t. Administer intravenous mannitol

Rationale The nurse would not administer hypotonic intravenous fluids for this client. Hypotonic fluids will cause water to move into the brain cells. This will increase intracranial pressure. The other interventions are expected and appropriate for clients with IICP.

Psychometric factors

Reliability Validity Diagnostic accuracy Responsiveness

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

Rupture of a fragile arterial vessel in the brain Ruptured aneurysm in the brain Traumatic injury to the brain

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.

The healthcare provider ordered diagnostic tests for a client with suspected increased intracranial pressure (IICP). Which tests should the nurse expect to show signs of IICP and help confirm the diagnosis and possible treatment needed? (Select all that apply.) Chest x-ray Serum osmolality Arterial blood gases (ABGs) CT scan Stool guaiac test

Serum osmolality Arterial blood gases (ABGs) CT scan Rationale Some tests taken in clients with an intracranial hematoma will be expected to be normal: a chest x-ray and a stool guaiac test. Other tests, such as a CT, arterial blood gases, and serum osmolality can often produce valuable information about the cause of IICP and the treatment.

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: a) Footdrop and external hip rotation b) Severe headache and early change in level of consciousness c) Confusion or change in mental status d) Weakness on one side of the body and difficulty with speech

An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following reasons? a) She is not within the treatment time window. b) She had surgery 6 weeks ago. c) She is taking digoxin. d) She is taking coumadin.

She is taking coumadin. To be eligible for thrombolytic therapy, the client cannot be taking coumadin. Initiation of thrombolytic therapy must be within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetelol do not prohibit thrombolytic therapy.

Which assessment finding for a client should the nurse attribute to increased intracranial pressure? (Select all that apply.) Fluid intake for the past 24 hours Slowed pupillary responses to light Decreased heart rate Decreased motor status and strength Altered level of consciousness

Slowed pupillary responses to light Decreased heart rate Decreased motor status and strength Altered level of consciousness Neurologic assessments of a client with a head injury include assessment of the level of consciousness. Decreased level of consciousness will often be the first indication of an increase in intracranial pressure. Assessment of the vital signs will reveal a slowed heart and respiratory rate and increased blood pressure. The motor status and strength will decrease. The pupillary response to light will be slow. Previous oral fluid intake is not associated with a head injury, but ongoing fluid monitoring and limitation may be part of the treatment plan.

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.

Which collaborative therapy should the nurse request when a client needs to learn to swallow following damage to the associated area of the brain? Physical therapy Occupational therapy Recreational therapy Speech therapy

Speech therapy Speech therapy may be needed if the client needs to learn to eat or talk following damage to the associated areas of the brain. Physical therapy to prevent muscle atrophy may be necessary for a client who is unconscious or bedridden. Occupational therapy can help the client regain any motor skills needed to perform activities of daily living. Recreational therapy works to restore motor, social, and cognitive functioning, build confidence, develop coping skills, and integrate skills learned in treatment settings into community settings.

What do doctors have to verify before giving a pt thrombolytic therapy for stroke?

That the stroke is not hemorrhagic (the drug will cause further bleeding if it is)

The nurse assess which client as being at highest risk for hypertension? 1. The female adolescent African American who is underweight and exercises five times a week 2. The white middle-aged adult who smokes a pack of cigarettes a day and is not active 3. The white woman with central obesity who drinks two to three alcoholic drinks per day approximately four times a week 4. The African American woman who enjoys a diet high in sodium and is above a healthy weight

The African American woman who enjoys a diet high in sodium and is above a healthy weight

10. Which of the following is contraindicated in a patient with increased ICP? A. Lumbar puncture B. Midline position of the head C. Hyperosmotic diuretics D. Barbiturates medications

The answer is A. LPs are avoided in patients with ICP because they can lead to possible brain herniation.

14. You're maintaining an external ventricular drain. The ICP readings should be? A. 5 to 15 mmHg B. 20 to 35 mmHg C. 60 to 100 mmHg D. 5 to 25 mmHg

The answer is A. Normal ICP should be 5 to 15 mmHg.

11. You're collecting vital signs on a patient with ICP. The patient has a Glascoma Scale rating of 4. How will you assess the patient's temperature? A. Rectal B. Oral C. Axillary

The answer is A. This GCS rating demonstrates the patient is unconscious. If a patient is unconscious the nurse should take the patient's temperature either via the rectal, tympanic, or temporal method. Oral and axillary are not reliable.

18. During the assessment of a patient with increased ICP, you note that the patient's arms are extended straight out and toes pointed downward. You will document this as: A. Decorticate posturing B. Decerebrate posturing C. Flaccid posturing

The answer is B.

21. A patient is receiving Mannitol for increased ICP. Which statement is INCORRECT about this medication? A. Mannitol will remove water from the brain and place it in the blood to be removed from the body. B. Mannitol will cause water and electrolyte reabsorption in the renal tubules. C. When a patient receives Mannitol the nurse must monitor the patient for both fluid volume overload and depletion. D. Mannitol is not for patients who are experiencing anuria.

The answer is B. All the other options are correct. Mannitol will PREVENT (not cause) water and electrolytes (specifically sodium and chloride) from being reabsorbed....hence it will leave the body as urine.

9. External ventricular drains monitor ICP and are inserted where? A. Subarachnoid space B. Lateral Ventricle C. Epidural space D. Right Ventricle

The answer is B. External ventricular drains (also called ventriculostomy) are inserted in the lateral ventricle.

6. Which patient below is at MOST risk for increased intracranial pressure? A. A patient who is experiencing severe hypotension. B. A patient who is admitted with a traumatic brain injury. C. A patient who recently experienced a myocardial infarction. D. A patient post-op from eye surgery.

The answer is B. Remember head trauma, cerebral hemorrhage, hematoma, hydrocephalus, tumor, encephalitis etc. can all increase ICP.

5. You're providing education to a group of nursing students about ICP. You explain that when cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies. A student asks, "What is a normal cerebral perfusion pressure level?" Your response is: A. 5-15 mmHg B. 60-100 mmHg C. 30-45 mmHg D. >160 mmHg

The answer is B. This is a normal CPP. Option A represents a normal intracranial pressure.

8. A patient has a ventriculostomy. Which finding would you immediately report to the doctor? A. Temperature 98.4 'F B. CPP 70 mmHg C. ICP 24 mmHg D. PaCO2 35

The answer is C. A ventriculostomy is a catheter inserted in the area of the lateral ventricle to assess ICP. It will help drain CSF during increase pressure readings and measure ICP. The nurse must monitor for ICP levels greater than 20 mmHg and report it to the doctor.

4. A patient is experiencing hyperventilation and has a PaCO2 level of 52. The patient has an ICP of 20 mmHg. As the nurse you know that the PaCO2 level will? A. cause vasoconstriction and decrease the ICP B. promote diuresis and decrease the ICP C. cause vasodilation and increase the ICP D. cause vasodilation and decrease the ICP

The answer is C. An elevated carbon dioxide level (52 is high...normal 35-45) in the blood will cause vasodilation (NOT constriction), which will increase ICP (normal ICP 5 to 15 mmHg). Therefore, many patients with severe ICP may need to be mechanical ventilated so PaCO2 levels can be lowered (30-35), which will lead to vasoconstriction and decrease ICP (with constriction there is less blood volume and flow going to the brain and this helps decrease pressure)....remember Monro-Kellie hypothesis.

17. According to question 16, the patient's blood pressure is 130/88. What is the patient's mean arterial pressure (MAP)? A. 42 B. 74 C. 102 D. 88

The answer is C. MAP is calculated by taking the DBP (88) and multiplying it by 2. This equals 176. Then take this number and add the SBP (130). This equals 306. Then take this number and divide by 3, which equal 102.

15. Which patient below with ICP is experiencing Cushing's Triad? A patient with the following: A. BP 150/112, HR 110, RR 8 B. BP 90/60, HR 80, RR 22 C. BP 200/60, HR 50, RR 8 D. BP 80/40, HR 49, RR 12

The answer is C. These vital signs represent Cushing's triad. There is an increase in the systolic pressure, widening pulse pressure of 140 (200-60=140), bradycardia, and bradypnea.

20. During the eye assessment of a patient with increased ICP, you need to assess the oculocephalic reflex. If the patient has brain stem damage what response will you find? A. The eyes will move in the same direction as the head is moved side to side. B. The eyes will move in the opposite direction as the head is moved side to side. C. The eyes will roll back as the head is moved side to side. D. The eyes will be in a fixed position as the head is moved side to side.

The answer is D. This is known as a negative doll's eye and represents brain stem damage. It is a very bad sign.

13. Select all the signs and symptoms that occur with increased ICP: A. Decorticate posturing B. Tachycardia C. Decrease in pulse pressure D. Cheyne-stokes E. Hemiplegia F. Decerebrate posturing

The answers are A, D, E, and F. Option B is wrong because bradycardia (not tachycardia) happens in the late stage along with an INCREASE (not decrease) in pulse pressure

2. The Monro-Kellie hypothesis explains the compensatory relationship among the structures in the skull that play a role with intracranial pressure. Which of the following are NOT compensatory mechanisms performed by the body to decrease intracranial pressure naturally? Select all that apply: A. Shifting cerebrospinal fluid to other areas of the brain and spinal cord B. Vasodilation of cerebral vessels C. Decreasing cerebrospinal fluid production D. Leaking proteins into the brain barrier

The answers are B and D. These are NOT compensatory mechanisms, but actions that will actually increase intracranial pressure. Vasoconstriction (not dilation) decreases blood flow and helps lower ICP. Leaking of protein actually leads to more swelling of the brain tissue. Remember water is attracted to protein (oncotic pressure).

A nurse is explaining the steps of the ischemic cascade that occurs during a stroke. Which should the nurse include as the first step? Brain cells are damaged when the cell membranes allow water to enter the cells. The damaged cells release chemicals affecting other cells around them. The blood supply is cut off to part of the brain. Leukocytes enter the area of damage, causing more damage to the brain.

The blood supply is cut off to part of the brain.

A nurse is explaining the steps of the ischemic cascade that occurs during a stroke. Which should the nurse include as the first step? Leukocytes enter the area of damage, causing more damage to the brain. The blood supply is cut off to part of the brain. The damaged cells release chemicals affecting other cells around them. Brain cells are damaged when the cell membranes allow water to enter the cells.

The blood supply is cut off to part of the brain. While all are the steps that occur during the ischemic cascade, the first step during an ischemic cascade is cutting off the blood supply to a part of the brain.

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.

A patient diagnosed with a thrombotic stroke is receiving treatment to restore normal cerebral blood flow. Which process does the nurse understand may cause further damage to the brain? The blood supply is cut off to part of the brain. The damaged cells release chemicals affecting other cells around them. The cell membranes allow water to enter the cell, causing damage to the cells. Localized blood flow gets restored.

The damaged cells release chemicals affecting other cells around them.

The nurse is completing a health history for a patient who is suspected of having an acute stroke. Which assessment finding should the nurse immediately report to the healthcare provider? The onset of symptoms was 2.5 hours ago. The patient's father died of a stroke. The patient has a 20-year history of smoking two packs of cigarettes per day. The patient has never had a stroke before.

The onset of symptoms was 2.5 hours ago.

A patient is preparing to go home following a recent stroke. Which behavior indicates that the patient has met nursing care plan goals? The patient's family is at the bedside daily assisting the patient with all activities of daily living. The patient is sipping water with meals to help with swallowing. The patient has experienced minimal complications from reduced mobility and dysphagia. The patient is participating in range of motion exercises each day.

The patient has experienced minimal complications from reduced mobility and dysphagia.

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? Atherosclerotic buildup in affected arteries must be greater than 90%. 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.

The stroke must have occurred within 3 hours of administering the medication.

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.

The nurse is caring for a patient who is suspected of having an acute stroke. Which is the most important information to gather from the family? Smoking history Time of onset of symptoms Family history of stroke Patient history of stroke

Time of onset of symptoms

The nurse is caring for a patient who is suspected of having an acute stroke. Which is the most important information to gather from the family? Patient history of stroke Family history of stroke Time of onset of symptoms Smoking history

Time of onset of symptoms Time of onset of stroke symptoms will determine course of treatment. Fibrinolytic therapy has strict time guidelines that must be adhered to, so it is essential to know the time of onset of symptoms. The other information is good to have, but not as essential as time of onset.

A client with increased intracranial pressure is prescribed mannitol. The family asks, "What is the purpose of this medication?" The nurse's response should be based on which action of the drug? To create a sodium and potassium balance To enhance renal excretion of retained protein To prevent tiny stress hemorrhages in the brain To draw fluid from the brain tissue

To draw fluid from the brain tissue Mannitol is used in the treatment of increased intracranial pressure to draw fluid out of the brain, thereby reducing intracranial pressure. Mannitol does not establish a sodium and potassium balance. Mannitol does not enhance excretion of serum protein, which is not an intended outcome. The medication does not prevent hemorrhages within the brain.

The nurse is requesting collaborative therapy from physical therapy for a client with increased intracranial pressure. Which reason supports this request? To determine if transfer to a skilled nursing facility is required To assess the living accommodations before the client's discharge to home To work with the nutritionist to determine effective methods to meet nutritional needs To recommend interventions for resulting hemiparesis or hemiplegia

To recommend interventions for resulting hemiparesis or hemiplegia The purpose of a physical therapy consult for a client with an alteration in intracranial pressure is to address the client's motor skills and strength in performing daily activities requiring mobility. This is especially necessary if any hemiparesis or hemiplegia has resulted. A nurse or social worker involved in home care would most likely assess the client's home environment. The nutritionist would address the client's nutritional needs; the physical or occupational therapist may be included in the plan to recommend effective accommodations for the motor skills that are involved in the eating process. Many factors and individuals are involved in the decision to transfer a client to a skilled nursing facility. This decision would most likely be directed through a social service consult.

The nurse assessing a client who presents with an altered level of consciousness (LOC) should suspect which condition? (Select all that apply.) Traumatic brain injury Hematoma Sciatica Seizure activity Cerebral infarction

Traumatic brain injury Hematoma Seizure activity Cerebral infarction Localized and systemic disorders can alter LOC. Processes occurring in the brain that may directly destroy or compress the neurologic structures are numerous but include increased intracranial pressure, cerebral infarction, hematoma, hydrocephalus, intracranial hemorrhage, tumors, infections, traumatic brain injury, seizure activity, and recovery. Sciatica, although painful, does not cause an alteration of LOC.

The patient asks the nurse if they are at risk for a stroke. Which should the nurse ask about in the health history to determine the patient's risk? Breath sounds Level of consciousness Skin integrity Use of cigarettes

Use of cigarettes

Use of cigarettes When caring for a patient at risk for stroke, the nurse will determine the patient's history of smoking during the health history portion of the nursing assessment. The other items would be assessed during the patient's physical examination.

The nurse is obtaining a blood pressure for a client with primary hypertension. The nurse ensures accuracy of the blood pressure by completing which intervention? 1. Placing the arm in a dependent position, bare-armed, below the level of the heart 2. Measuring the blood pressure after the client has rested for 2 minutes 3. Using a cuff that covers 80% of the limb 4. Taking the client's blood pressure in the dominant arm

Using a cuff that covers 80% of the limb

The nurse is planning care for a patient who has garbled speech after a stroke. Which intervention should the nurse include? Using flash cards to express needs Consulting the patient's family to discuss the patient's needs Using long and complex sentences when speaking to the patient Encouraging quick responses from the patient

Using flash cards to express needs

The nurse is planning care for a patient who has garbled speech after a stroke. Which intervention should the nurse include? Consulting the patient's family to discuss the patient's needs Encouraging quick responses from the patient Using long and complex sentences when speaking to the patient Using flash cards to express needs

Using flash cards to express needs The nurse would use flash cards to facilitate communication with this patient. The other interventions are inappropriate and will not enhance communication with this patient.

The client has an increase in intracranial pressure caused by an increase in capillary permeability. The nurse should recognize this as which type of cerebral edema? Bacterial Cytotoxic Vasogenic Hormonal

Vasogenic Rationale Vasogenic cerebral edema is caused by an increase in capillary permeability of cerebral vessels. Retained fluid in the neurons and endothelial cells associated with sodium and water retention is the cause of cytotoxic cerebral edema. Hormonal and bacterial are not types of cerebral edema.

The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke? a) Footdrop and external hip rotation b) Vomiting and seizures c) Severe headache and early change in level of consciousness d) Weakness on one side of the body and difficulty with speech

Weakness on one side of the body and difficulty with speech The main presenting symptoms for an ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Footdrop and external hip rotation are things that can occur if a stroke victim is not turned or positioned correctly.

The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure? A Side-lying, with legs pulled up and head bent down onto the chest B Side-lying, with a pillow under the hip C Prone, in a slight Trendelenburg's position D Prone, with a pillow under the abdomen

The nurse is preparing to assess the cranial nerve function of Esther Moskowicz, an 85-year-old client who is experiencing a stroke. Which technique should the nurse use to determine Mrs. Moskowicz's extraocular movements? a Watch the eyes move as an H is drawn in the air b Observe for location and strength of eyelids c Place a Snellen chart on the wall d Shine a light into each eye

The spouse of a client who has increased intracranial pressure (IICP) asks the nurse what is happening in her husband's brain. Based on the pathophysiology, which is the best response by the nurse? a "Something in the brain, its blood, or surrounding fluid is off balance and has caused an increased pressure." b "The blood flow to the brain has increased and is causing an increased pressure." c "There must be a tumor causing the increase in pressure we are seeing." d "Your husband's low blood pressure is causing the brain to have too much fluid in it.

What should the nurse do to reduce the risk of traumatic brain injury in people over the age of 65? a Conduct a home safety assessment b Restrict movement with chemical restraints c Suggest a reduction in activity d Prevent participation in contact sports

Which of the following values is considered normal for ICP? A 0 to 15 mm Hg B 25 mm Hg C 35 to 45 mm Hg D 120/80 mm Hg

Which phrase describes a reflex? a Rapid, involuntary, predictable motor response to a stimulus b Relay center for all information coming into the brain c Brain matter responsible for muscle movement and balance d Control center that regulates heart rate and blood pressure

a newly admitted patient diagnosed with a right sided brain stroke has homonymous hemianopsia. early in the case of the patient what should the nurse do ? a. place objects on the right side within the patients field of vision b. approach the patient from the left side to assess the patients ability to compensate c. place objects on the left side to assess the patients ability to compensate d. patch the affected eye to encourage patient to turn the head to scan the environments

a nurse is caring for a client with a head injury who has increased ICP. The physician plans to reduce cerebral edema by constricting cerebral blood vessels. Which physician order would serve this purpose? a. hyperventilation per mechanical ventilation b. insertion of a ventricular shunt c. furosemide d solu medrol

four days following a stroke, a patient is to start oral fluids and feedings. before feeding the patient, what should the nurse do first? a. check the patient's gag reflex b. order a soft diet for the paitnet c. raise the head of the bed to a sitting position d. assess the patients ability to swallow tiny amounts of crushed ice

what is an appropriate nursing intervention to promote communication during rehab of the patient with aphasia? a. allow time for the individual to complete their thoughts b. use gestures, pic utters, and music to stimulate patients responses c. structure statements so that the patient does not have to respond verbally d. use flashcards with simple words and pictures to promote recall of language

Mr. Tacy is a 62-year-old man who developed a brain abscess and experienced an increase in intracranial pressure. His initial symptoms were headaches upon rising, blurred vision, elevated temperature, and occasional slurring of his speech. He received intravenous antibiotics and supportive treatment. In teaching Mr. Tacy about his care, which instructions would you provide? a "Avoid coughing and blowing your nose." b "Push with your arms and legs when moving up in bed." c "Take a laxative every other day so you do not become constipated." d "When resting in bed, tighten your leg muscles and relax them several times an hour."

a Coughing and blowing the nose increase intracranial pressure and should be avoided. The action of tightening and relaxing leg muscles is a form of isometric exercises, which increases intracranial pressure. It is important not to strain at stool or to become constipated. Monitoring stools is important, but a laxative may not be needed, especially every 2 days. Repositioning in bed while using the arms and legs to move initiates the Valsalva maneuver, which increases intracranial pressure; it should be avoided.

What is the optimal position of head and neck that would promote adequate venous drainage of the cerebral tissue? a Head and neck in normal body alignment b Lateral rotation of the head to either side c Slight flexion of the neck d Slight hyperextension of the neck

a Having the head and neck in normal body alignment promotes venous drainage from the veins of the cerebral tissue. Positions of hyperextension, flexion, and rotation may reduce venous drainage by applying a twisting pressure on the veins of the neck

In addition to measuring intracranial pressure, what is the purpose of inserting an intraventricular catheter for a client with alteration of intracranial pressure? a To drain cerebrospinal fluid b To administer medication to reduce cerebral inflammation c To shunt excess cerebrospinal fluid around an obstruction in the ventricular system d To resect excess brain tissue

a In addition to measuring intracranial pressure, an intraventricular catheter is used to drain cerebrospinal fluid. It does not shunt fluid around an obstructed area, act as a conduit for medication administration, or resect excess brain tissue.

The nurse caring for the client with a closed head injury obtains an intracranial pressure (ICP) reading of 17mmHg. The nurse should recognize that: a The ICP is elevated and the Dr. should be notified b. The ICP is normal therefore no further action is needed c. The ICP is low and the client needs additional IV fluids d. The ICP reading is not as reliable as the Glascow coma scale

a Normal ICP ranges 4mmHG-10 mmHg with upper limits of 15 mmHG

The nurse is caring for a client with a traumatic brain injury. Which assessment finding indicates that the client would benefit from a histamine H2 antagonist? a Stool guaiac positive b Blood pressure increasing to 168/88 mmHg c Body temperature of 101degrees°F d Restlessness and easily agitated

a Rationale A positive stool guaiac indicates bleeding somewhere within the gastrointestinal tract. A histamine H2 antagonist reduces the risk of developing gastric stress ulcers. A body temperature elevation indicates the need for an antipyretic. Restlessness and agitation indicates an increase in intracranial pressure. A rising blood pressure could indicate pain or the need for vasoactive medication to control intracranial pressure.

Mrs. Williamson is a 45-year-old woman who came to the hospital via ambulance after a car accident in which she experienced a fractured right femur, internal bleeding, and a severe head injury. Which intravenous solution would you anticipate the healthcare provider ordering? a 5% dextrose in normal saline b 0.9% normal saline c Ringer lactate d 0.45% normal saline

a The osmolality of the hypertonic intravenous solution in intended to pull fluid from the cerebral tissue into the venous circulation, thus reducing fluid retention in the intracranial cavity. 5% dextrose in normal saline is a hypertonic solution. 0.9% normal saline, 0.45% normal saline, and Ringer lactate are either isotonic or hypotonic solutions, which would not pull edema from cerebral tissue.

What is the cause of vasogenic cerebral edema? a An increase in capillary permeability of cerebral vessels resulting in extracellular edema b Alteration in hormonal or electrolyte balance resulting in diffuse brain swelling c An increase in fluid retention of the neurons and endothelial brain cells related to sodium and water imbalance d Infiltration of brain cells by bacterial microorganisms resulting in a shift in osmotic pressure

a Vasogenic cerebral edema is caused by an increase in capillary permeability of cerebral vessels. Retained fluid in the neurons and endothelial cells associated with sodium and water retention is the cause of cytotoxic cerebral edema. Hormonal and sodium alterations that result in diffuse brain tissue swelling are characteristics of cytotoxic cerebral edema. Bacterial invasion of brain tissue results in encephalitis, not cerebral edema.

The nurse is caring for a client with a closed head injury. A late sign of ICP is: a. changes in pupil reactivity and equality b. restlessness and irritability c. complaints of headache d. irritability

a all other answers are early signs

The nurse is caring for a client with a head injury who has an icp monitor in place. Assessment reveals the ICP reading is 66. What is the nurses best action? a. Notify the provider immediately. b. record the reading as the only action c. turn the client and recheck the reading d. place the client supine

a normal ICP is 10-20

During the secondary assessment of a patient with a stroke, what should be included (select all that apply)? a. gaze b. sensation c. facial palsy d. proprioception e. current medications f. distal motor function

a, b, c, d, f

which statement describe characteristics of a stroke caused by an intracerebral hemorrhage> (select all that apply)? a. carries poor prognosis b. caused by rupture of a vessel c. strong association with hypertension d. commonly occurs during or after sleep e. creates a mass that compresses the brain

a, b, c, e

The nurse is monitoring a patient for increased ICP following a head injury. What are manifestations of increased ICP (select all that apply)? a. Fever d. Right pupil dilated greater than left pupil b. Oriented to name only e. Decorticate posturing to painful stimulus c. Narrowing pulse pressure

a, b, d, e. The first sign of increased ICP is a change in LOC. Other manifestations are dilated ipsilateral pupil, changes in motor response such as posturing, and fever, which may indicate pressure on the hypothalamus. Changes in vital signs would be an increased SBP with widened pulse pressure and bradycardia.

Which events cause increased ICP (select all that apply)? a. Vasodilation d. Edema from initial brain insult b. Necrotic tissue edema e. Brainstem compression and herniation c. Blood vessel compression

a, b, d. Increased ICP is caused by vasodilation and edema from the initial brain insult or necrotic tissue. Blood vessel compression and brainstem compression and herniation occur as a result of increased ICP.

Which components are able to change to adapt to small increases in intracranial pressure (ICP) (select all that apply)? a. Blood d. Scalp tissue b. Skull bone e. Cerebrospinal fluid (CSF) c. Brain tissue

a, c, e. Blood adapts with increased venous outflow, decreased cerebral blood flow (CBF), and collapse of veins and dural sinuses. Brain tissue adapts with distention of the dura, slight compression of tissue, or herniation. Cerebrospinal fluid (CSF) adapts with increased absorption, decreased production, and displacement into the spinal canal. Skull bone and scalp tissue do not adapt to changes in intracranial pressure (ICP).

Common psychosocial reactions of the stroke patient to the stroke include (select all that apply) a. depression. b. disassociation. c. intellectualization. d. sleep disturbances. e. denial of severity of stroke.

a, d, e Rationale: The patient with a stroke may experience many losses, including sensory, intellectual, communicative, functional, role behavior, emotional, social, and vocational losses. Some patients experience long-term depression, manifesting symptoms such as anxiety, weight loss, fatigue, poor appetite, and sleep disturbances. The time and energy required to perform previously simple tasks can result in anger and frustration. Frustration and depression are common in the first year after a stroke. A stroke is usually a sudden, extremely stressful event for the patient, caregiver, family, and significant others. The family is often affected emotionally, socially, and financially as their roles and responsibilities change. Reactions vary considerably but may involve fear, apprehension, denial of the severity of stroke, depression, anger, and sorrow.

The nurse is concerned that a client recovering from a stroke may have parietal lobe damage. Which observations made by the nurse support this concern? (Select all that apply.) a Client did not respond when foot was caught in the side rail. b Client did not respond when hot coffee was spilled on the hand. c Client is unable to move the left hand independently. d Client is unable to speak. e Client did not react when the trash can in the room caught on fire.

a,b Rationale The parietal lobes process sensory information such as shapes, temperature, pain, and two-point discrimination. Speech and spontaneous movement are controlled by the frontal lobe. The temporal lobe interprets smell.

What stimulates the compensatory mechanisms of the cerebral blood vessels to regulate cerebral pressure? (Select all that apply.) a Lactic acid b Carbon dioxide c Carbonic acid d Hypokalemia e Elevated serum uric acid level

a,b,c Lactic acid, carbonic acid, and carbon dioxide are chemicals that stimulate the dilation or contraction of blood vessels within the brain, which aids in regulation of cerebral pressure. Cerebral hemorrhage also regulates dilation or constriction of the cerebral blood vessels in response to the amount of blood flow within the brain. Elevated serum acid levels and reduced potassium levels (hypokalemia) do not affect cerebral pressure.

Which assessments should the nurse include when examining a client with an alteration in intracranial pressure? (Select all that apply.) a Level of consciousness b Motor status and strength c Vital signs d Fluid intake for the past 24 hours e Pupillary responses to light

a,b,c,e Neurologic assessments of a client with a head injury include assessment of the level of consciousness, which will be the first indication of an increase in intracranial pressure. Additional assessments are vital signs, motor status and strength, and pupillary response to light. Previous oral fluid intake is not associated with a head injury, but ongoing fluid monitoring and limitation may be part of the treatment plan.

A nurse in the emergency department is providing care for a client who has increased intracranial pressure (IICP) from a traumatic brain injury from a motor vehicle crash. The nurse anticipates orders for which diagnostic tests in the care of this client? (Select all that apply.) a ABGs b Cardiac monitoring c CT of the head d Electromyogram e Intracranial pressure monitor

a,b,c,e Rationale An intracranial pressure monitor will give information about intracranial pressure. This information can be used to manage the medications and fluids for this client. A CT of the head will give information about possible hemorrhage and diffuse axonal injuries. Cardiac monitoring would be essential to monitor cardiac rate and rhythm. Arterial blood gases give information about oxygen and carbon dioxide levels in the blood. This information is used to manage artificial airways and mechanical ventilation. Electromyography is used to measure skeletal muscle activity. It would not be used in the diagnosis of a client with traumatic brain injury.

After a nursing assessment, the nurse documents that a client is confused. Which behaviors did the nurse assess to determine this client's level of consciousness? (Select all that apply.) a Does not remember home address b Does not know why hospitalization is required c Responds to verbal stimuli but quickly falls back asleep d Uses inappropriate words to describe situations e Moans in response to painful stimuli

a,b,d Rationale Confusion is the inability to think rapidly and clearly. Additional characteristics include easily bewildered, poor memory, short attention span, misinterprets stimuli and impaired judgment. Semicomatose is moaning in response to painful stimuli. Obtundation is responding to verbal stimuli but quickly falling asleep.

The client is being treated for increased intracranial pressure (IICP). Which of these manifestations should indicate to the nurse that the outcomes are being met for this client? (Select all that apply.) a Blood pressure = 118/76 b No redness or drainage at site of intraventricular catheter c Verbalizes need to increase stimuli d Lethargic e Intracranial pressure = 14 mmHg

a,b,e Rationale The client should maintain ICP less than< 20 mmHg. The blood pressure should be normal. Client and significant others will verbalize the reasons for, and how to maintain, a low-stimuli environment, not high stimuli. The client will remain free of infection including redness and drainage at the sites of insertion. The client will maintain adequate cerebral perfusion, and level of consciousness should return to normal and not be lethargic.

The nurse is preparing to conduct a neurologic assessment interview with a client. Which general questions should the nurse use when conducting this assessment? (Select all that apply.) a "Are you experiencing any pain?" b "How many fingers am I holding up at this time?" c "Do you have a history of seizures or fainting?" d "Do you have any problems with balance or coordination?" e "Are you having any problems with your memory?"

a,c,d,e Rationale General questions to include in a neurologic assessment interview include asking about pain, history of seizures or fainting, and asking about problems with memory and coordination or balance. Asking to identify the number of fingers would focus on the client's vision.

A nurse in the intensive care unit is providing care for a client with increased intracranial pressure (IICP). The nurse monitors the client for which manifestations of IICP? (Select all that apply.) a Decreased level of consciousness b Decreased blood pressure c Projectile vomiting d Increased heart rate e Dilated pupils

a,c,e Rationale Projectile vomiting is a manifestation of increased intracranial pressure. This is caused by pressure on the brainstem from swollen brain tissue. Dilated pupils are a manifestation of increased intracranial pressure. This is caused by pressure on the cranial nerves and vision pathways within the brain. A decreased level of consciousness is a manifestation of increased intracranial pressure. This is caused by pressure on the cerebral cortex and decreased oxygenation of the brain tissues. Increased intracranial pressure causes increased blood pressure, especially the systolic blood pressure. This worsens until there is a wide difference between the systolic blood pressure and the diastolic blood pressure. Increased intracranial pressure causes lowered heart rate. This is caused by the body's attempt to compensate for increased blood pressure.

A pediatric client is admitted for a head injury after falling off of a skateboard. The client was at first combative but is now becoming lethargic. Which actions should the nurse take for this client who has increasing intracranial pressure? (Select all that apply.) a Elevate the head of the bed 30 degrees b Install suction equipment at the bedside c Insert a nasogastric tube d Raise the side rails e Pad the side rails

a,d,e Rationale Nursing actions for the client with increasing intracranial pressure include padding and raising the siderails to prevent injury in the event that the client begins to seize. Elevating the head of the bed will help reduce increasing pressure in the head. Inserting a nasogastric tube would cause unnecessary stimulation and further raise intracranial pressure. Suction equipment would be necessary if the client has a seizure disorder or is experiencing status epilepticus.

A client with a minor head injury has a Glasgow Coma score of 15. What does this score indicate to the nurse? (Select all that apply.) a Client is oriented to person, place, and time. b Client withdraws to pain. c Client withdraws to touch. d Client uses appropriate words and phrases. e Client spontaneously opens the eyes.

a,d,e Rationale The maximum Glasgow Coma score is 15. This means that the client uses appropriate words and phrases, spontaneously opens the eyes, and is oriented to person, place, and time. Withdrawing to pain or touch would cause the Glasgow Coma score to be less than 15.

The nurse is assessing a 10-year-old client's level of consciousness in the emergency department because the mother feels her child is disoriented and lethargic. Which questions would the nurse want to ask the parent in assessing possible increased intracranial pressure (IICP) as a cause of her confusion and lethargy? (Select all that apply.) a. "Has your child ever had a shunt, brain hemorrhage, or brain surgery?" b. "Does your family have animals at home?" c. "Could your child been ingesting any household products, drugs, or medications?" d. "Has the child had strep throat recently?" e. "Has your child had any recent head trauma, falls, or accidents that you're aware of?"

a. "Has your child ever had a shunt, brain hemorrhage, or brain surgery?" c. "Could your child been ingesting any household products, drugs, or medications?" e. "Has your child had any recent head trauma, falls, or accidents that you're aware of?" Rationale Health history is important when assessing for altered levels of consciousness. Asking about recent or past head trauma, falls, accidents, shunting, brain hemorrhage, or cranial surgery is useful in discerning possible reasons for altered level of consciousness (LOC). Parents should be asked about intentional or accidental ingestion or exposure to drugs or other substances. There is no particular association between a recent strep throat infection and an altered level of consciousness, although other illnesses such as meningitis or viral syndromes might predispose the client to problems with intracranial regulation. Recent animal exposure usually is not related to altered levels of consciousness.

The father of an adolescent client with a recent head injury asks the nurse to explain what the family can expect in the way of treatment, especially medications, for their son. The nurse should respond with: a. "Head injury clients tend to be agitated, so I expect the doctor will keep him sedated to decrease his movement and brain activity." b. "Even though he has fluid and swelling inside his head from the injury, he probably won't be given diuretics as these are used more in cardiac clients." c. "It's likely he that won't be given anti-fever medications since drugs like acetaminophen are contraindicated in head injury." d. "Even though he might be restless, it's probable that he won't be sedated so that we can more accurately monitor his level of consciousness."

a. "Head injury clients tend to be agitated, so I expect the doctor will keep him sedated to decrease his movement and brain activity." Rationale The best response that the nurse can give is to tell the father that individuals with head injury and increased intracranial pressure are typically sedated due to restlessness and agitation. Such behavior raises blood pressure, intracranial pressure, and cerebral metabolism, and can cause further damage to the brain. Thus, head injury clients are not kept awake for the purpose of better monitoring of their level of consciousness. Diuretics are considered mainstays in treating clients with Increased ICP (IICP). Antipyretics are also an important adjunct to treatment when clients develop fever since hyperthermia increases cerebral metabolic rate and exacerbates an increase in ICP.

14. A 154-pound woman has been prescribed tPA (0.9 mg/kg) for an ischemic stroke. The nurse knows to give how many mg initially? a. 6.3 mg b. 7.5 mg c. 8.3 mg d. 10 mg

a. 6.3 mg - bolus 56.7mg- infusion dose

6. A nurse is assisting with a community screening for people at high risk for stroke. To which of the following clients would the nurse pay most attention? a. A 60-year-old African-American man b. A 40-year-old Caucasian woman c. A 62-year-old Caucasian woman d. A 28-year-old pregnant African-American woman

a. A 60-year-old African-American man

Priority Decision: A patient has ICP monitoring with an intraventricular catheter. What is a priority nursing intervention for the patient? a. Aseptic technique to prevent infection c. Removal of CSF to maintain normal ICP b. Constant monitoring of ICP waveforms d. Sampling CSF to determine abnormalities

a. An intraventricular catheter is a fluid-coupled system that can provide direct access for microorganisms to enter the ventricles of the brain and aseptic technique is a very high nursing priority to decrease the risk for infection. Constant monitoring of ICP waveforms is not usually necessary and removal of CSF for sampling or to maintain normal ICP is done only when specifically ordered.

The nurse notes that a client has muscle fasciculations of both bicep muscles. What additional information should the nurse assess in this client? (Select all that apply.) a. Body temperature b. Last solid food intake c. Urine output d. List of medications taking e. Blood pressure and pulse

a. Body temperature c. Urine output d. List of medications taking Rationale Fasciculations occur in clients with disease or trauma to the lower motor neurons, as a side effect of medications, in fever, in sodium deficiency, and in uremia. Fasciculations are not associated with food intake or blood pressure and pulse measurements.

A client with a minor head injury has a Glasgow Coma score of 15. What does this score indicate to the nurse? (Select all that apply.) a. Client uses appropriate words and phrases. b. Client spontaneously opens the eyes. c. Client is oriented to person, place, and time. d. Client withdraws to pain. e. Client withdraws to touch.

a. Client uses appropriate words and phrases. b. Client spontaneously opens the eyes. c. Client is oriented to person, place, and time. Rationale The maximum Glasgow Coma score is 15. This means that the client uses appropriate words and phrases, spontaneously opens the eyes, and is oriented to person, place, and time. Withdrawing to pain or touch would cause the Glasgow Coma score to be less than 15.

The nurse establishes a diagnosis of Ineffective Tissue Perfusion: Cerebral for a client with increased intracranial pressure (IICP). Which interventions would not be included in the client's plan of care? a. Cluster nursing care. b. Provide a quiet environment, limiting noxious stimuli. c. Preoxygenate the mechanically-ventilated client with 100% oxygen before suctioning. d. Assess for bladder distention and bowel constipation.

a. Cluster nursing care. Rationale Nursing care should be planned so that certain activities are not clustered together. For example, turning the client, getting the client on the bedpan, and suctioning should not be done within the same time period since multiple procedures can increase ICP. Nursing care should be scheduled to provide rest periods between procedures. Providing a quiet environment, preoxygenating before suctioning, and assessing for bowel and bladder fullness are appropriate for the client with IICP.

16. A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? a. Heparin sodium b. Dexamethasone (Decadron) c. Methyldopa (Aldomet) d. Phenytoin (Dilantin)

a. Heparin sodium

Priority Decision: When a patient is admitted to the ED following a head injury, what should be the nurse's first priority in management of the patient once a patent airway is confirmed? a. Maintain cervical spine precautions. c. Determine the presence of increased ICP. b. Monitor for changes in neurologic status. d. Establish IV access with a large-bore catheter

a. In addition to monitoring for a patent airway during emergency care of the patient with a head injury, the nurse must always assume that a patient with a head injury may have a cervical spine injury. Maintaining cervical spine precautions in all assessment and treatment activities with the patient is essential to prevent additional neurologic damage.

The nurse assessing a client with suspected increased intracranial pressure (IICP) should be aware of which physiologic mechanisms related to IICP? (Select all that apply.) a. Interruption of the cerebral blood flow, particularly oxygen and glucose, leads to brain tissue ischemia and disruption of the cerebral metabolism. b. Pressure and metabolic autoregulation mechanisms have an unlimited ability to maintain cerebral blood flow by constricting or dilating cerebral arterioles when ICP changes. c. In pressure autoregulation, high arterial pressure causes stretch receptors in the brain's small blood vessels to dilate to increase cerebral blood flow d. If the volume of the brain, CSF, or blood in the skull increases, the volume of the others must decrease to maintain normal pressures in the cranium. d. Vasodilation refers to the relationship between the volume of the intracranial components and intracranial pressure.

a. Interruption of the cerebral blood flow, particularly oxygen and glucose, leads to brain tissue ischemia and disruption of the cerebral metabolism. d. If the volume of the brain, CSF, or blood in the skull increases, the volume of the others must decrease to maintain normal pressures in the cranium. Rationale Interruption of cerebral blood flow leads to ischemia and disrupted cerebral metabolism. Since the cranial cavity can't expand, and the brain, CSF, and blood fill the entire cranium, if one of these substances increases, the volume of the others must decrease to maintain normal pressures. In pressure autoregulation, if the arterial pressure is high, the stretch receptors in the brain's small blood vessels will cause the vessels to constrict, not dilate. This serves to maintain normal pressure. This ability, however, is limited. The relationship between volume and intracranial pressure is called compliance, not vasodilation.

11. Which of the following is a contraindication for the administration of tissue plasminogen activator (t-PA)? a. Intracranial hemorrhage b. Ischemic stroke c. Age 18 years of age or older d. Systolic blood pressure less than or equal to 185 mm Hg

a. Intracranial hemorrhage

a. Irritability Rationale Irritability may indicate that the client is experiencing an increase in intracranial pressure, especially if associated with additional signs of bradycardia, increased systolic pressure, increased pulse pressure, vomiting, headache, lethargy, and change in mental status. Nausea does not accompany the vomiting associated with increased intracranial pressure. Hypotension and oliguria are not associated with increased intracranial pressure.

15. What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke? a. Left visual field deficit b. Aphasia c. Slow, cautious behavior d. Altered intellectual ability

a. Left visual field deficit

The ICU nurse reviewing an intraventricular pressure reading of a client under care for increased intracranial pressure notes a value of 20 mmHg. This requires what action? a. Notification of the physician and immediate treatment b. Continued monitoring of the intracranial pressure c. No special action as this value is within normal limits d. Periodic observation for seizure activity

a. Notification of the physician and immediate treatment Rationale The normal range for intracranial pressure (ICP) in adults is typically 5-15 mmHg. Sustained elevated pressure is 15 mmHg in adults, and a result of 20 mmHG warrants immediate intervention and treatment. Taking no action is not an option. The nurse should continue to carefully observe the client, including observing for seizure activity, but immediate intervention for a 20 mmHg reading is the most critical action by the nurse with a reading at this level.

A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema. What is an appropriate nursing intervention for the patient? a. Avoid positioning the patient with neck and hip flexion. b. Maintain hyperventilation to a PaCO2 of 15 to 20 mm Hg. c. Cluster nursing activities to provide periods of uninterrupted rest. d. Routinely suction to prevent accumulation of respiratory secretions.

a. Nursing care activities that increase ICP include hip and neck flexion, suctioning, clustering care activities, and noxious stimuli. They should be avoided or performed as little as possible in the patient with increased ICP. Lowering the PaCO2 below 20 mm Hg can cause ischemia and worsening of ICP

A nurse in the intensive care unit is providing care for a client with increased intracranial pressure (IICP). The nurse monitors the client for which manifestations of IICP? (Select all that apply.) a. Projectile vomiting b. Increased heart rate c. Decreased level of consciousness d. Dilated pupils e. Decreased blood pressure

a. Projectile vomiting c. Decreased level of consciousness d. Dilated pupils Rationale Projectile vomiting is a manifestation of increased intracranial pressure. This is caused by pressure on the brainstem from swollen brain tissue. Dilated pupils are a manifestation of increased intracranial pressure. This is caused by pressure on the cranial nerves and vision pathways within the brain. A decreased level of consciousness is a manifestation of increased intracranial pressure. This is caused by pressure on the cerebral cortex and decreased oxygenation of the brain tissues. Increased intracranial pressure causes increased blood pressure, especially the systolic blood pressure. This worsens until there is a wide difference between the systolic blood pressure and the diastolic blood pressure. Increased intracranial pressure causes lowered heart rate. This is caused by the body's attempt to compensate for increased blood pressure.

A nurse in the intensive care unit is providing care for a client with increased intracranial pressure from a traumatic brain injury. The client has a fever of 102 °F. Which interventions will the nurse use to promote normal intracranial pressure? (Select all that apply.) a. Provide supplemental oxygen b. Monitor level of consciousness c. Flex the neck to open the airway d. Suction for no more than 10 seconds per pass e. Administer acetaminophen per order

a. Provide supplemental oxygen b. Monitor level of consciousness d. Suction for no more than 10 seconds per pass e. Administer acetaminophen per order Rationale Hyperthermia increases intracranial pressure. Hyperthermia also affects hypothalamic function in clients with increased intracranial pressure; therefore, administering an antipyretic medication is appropriate. Prolonged suctioning can increase intracranial pressure. It also causes decreased oxygen levels. Increased intracranial pressure can cause irregular and ineffective respirations. Supplemental oxygen helps prevent hypoxia. It also helps prevent excess carbon dioxide, which is a vasodilator. A decreased level of consciousness can be a manifestation of pressure on the cerebral cortex. It can also be a manifestation of decreased oxygen levels in the brain. Flexing the neck increases intracranial pressure by preventing blood return from the brain. The head and neck must be kept in neutral position.

A pediatric client is admitted for a head injury after falling off of a skateboard. The client was at first combative but is now becoming lethargic. Which actions should the nurse take for this client who has increasing intracranial pressure? (Select all that apply.) a. Raise the side rails b. Install suction equipment at the bedside c. Insert a nasogastric tube d. Pad the side rails e. Elevate the head of the bed 30 degrees

a. Raise the side rails d. Pad the side rails e. Elevate the head of the bed 30 degrees Rationale Nursing actions for the client with increasing intracranial pressure include padding and raising the siderails to prevent injury in the event that the client begins to seize. Elevating the head of the bed will help reduce increasing pressure in the head. Inserting a nasogastric tube would cause unnecessary stimulation and further raise intracranial pressure. Suction equipment would be necessary if the client has a seizure disorder or is experiencing status epilepticus.

A 54-year-old man is recovering from a skull fracture with a subacute subdural hematoma that caused unconsciousness. He has return of motor control and orientation but appears apathetic and has reduced awareness of his environment. When planning discharge of the patient, what should the nurse explain to the patient and the family? a. The patient is likely to have long-term emotional and mental changes that may require professional help. b. Continuous improvement in the patient's condition should occur until he has returned to pretrauma status. c. The patient's complete recovery may take years and the family should plan for his long-term dependent care. d. Role changes in family members will be necessary because the patient will be dependent on his family for care and support.

a. Residual mental and emotional changes of brain trauma with personality changes are often the most incapacitating problems following head injury and are common in patients who have been comatose for longer than 6 hours. Families must be prepared for changes in the patient's behavior to avoid family-patient friction and maintain family functioning and professional assistance may be required. There is no indication the patient will be dependent on others for care but he likely will not return to pretrauma status.

9. An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following reasons? a. She is taking coumadin. b. She is not within the treatment time window. c. She is taking digoxin. d. She had surgery 6 weeks ago

a. She is taking coumadin.

The mother of an adolescent daughter wants to know what they should look for in case the daughter gets hit in the head playing soccer. The nurse notes that four areas of functioning should be assessed if a concussion is suspected, including physical, cognitive, and emotional. The fourth area of functioning to assess is: a. Sleep b. School performance c. Musculoskeletal complaints d. Personality

a. Sleep Rationale Sleep is the fourth area of functioning that the mother and daughter should monitor. Individuals experiencing concussion may be drowsy, sleep more or less than usual, or may have trouble falling asleep.

Why is the Glasgow Coma Scale (GCS) used? a. To quickly assess the LOC b. To assess the patient's ability to communicate c. To assess the patient's ability to respond to commands d. To assess the patient's coordination with motor responses

a. The Glasgow Coma Scale (GCS) is used to quickly assess the LOC with a standardized system. The three areas assessed are the patient's ability to speak, obey commands, and open eyes to verbal or painful stimulus. Although best motor response is an indicator, it is not used to assess coordination.

A woman brings in her 82-year-old mother for a check-up at the local clinic. The woman reports that her mother does not respond to her appropriately at times, and that she seems to be forgetful. The nurse wants to do a complete sensory-perceptual functioning assessment. What components would the nurse include in her assessment? (Select all that apply.) a. The whisper test b. Asking the daughter about the client's social support network c. Status of the client's insurance d. Discussing the client's history of wearing hearing aids e. Mental status exam

a. The whisper test b. Asking the daughter about the client's social support network d. Discussing the client's history of wearing hearing aids e. Mental status exam Rationale A complete nursing assessment of the sensory-perceptual functioning includes a client history, a mental exam, a physical exam, social support network, the client's environment, and identifying people at high risk. The whisper test would be included in the physical exam. The client's history of wearing hearing aids would be appropriate in collection of the client's medical history. A mental status exam would help the nurse determine whether the client answering her daughter inappropriately is due to senility or a sensory deficit. Insurance status would not be appropriate during the assessment of the client's sensory function.

For the patient undergoing a craniotomy, when should the nurse provide information about the use of wigs and hairpieces or other methods to disguise hair loss? a. During preoperative teaching b. If the patient asks about their use c. In the immediate postoperative period d. When the patient expresses negative feelings about his or her appearance

a. To prevent undue concern and anxiety about hair loss and postoperative self-esteem disturbances, a patient undergoing cranial surgery should be informed preoperatively that the head is usually shaved in surgery while the patient is anesthetized and that a turban, scarf, or cap may be used after the dressings are removed postoperatively and a wig also may be used after the incision has healed to disguise the hair loss. In the immediate postoperative period the patient is very ill and the focus is on maintaining neurologic function but preoperatively the nurse should anticipate the patient's postoperative need for self-esteem and maintenance of appearance.

A nurse is giving a presentation at the local community center regarding the prevention of vision loss. She wants to discuss modifiable risk factors to help people protect their eyes and vision. What modifiable risk factors would be discussed during this presentation? (Select all that apply.) a. Ultraviolet light exposure b. Smoking c. Annual eye exams d. Isolation e. Eye injuries

a. Ultraviolet light exposure b. Smoking e. Eye injuries Rationale Modifiable risk factors for vision loss include decreasing ultraviolet light exposure, not smoking, and preventing eye injuries by using protective eye wear. Isolation of adults is associated with sensory deprivation in both infants and in adults. Isolation is a modifiable risk factor, but it is not associated with vision loss. Annual eye exams may detect early changes in vision loss, but are not considered a risk factor.

After a nursing assessment, the nurse documents that a client is confused. Which behaviors did the nurse assess to determine this client's level of consciousness? (Select all that apply.) a. Uses inappropriate words to describe situations b. Moans in response to painful stimuli c. Does not know why hospitalization is required d. Responds to verbal stimuli but quickly falls back asleep e. Does not remember home address

a. Uses inappropriate words to describe situations c. Does not know why hospitalization is required e. Does not remember home address Rationale Confusion is the inability to think rapidly and clearly. Additional characteristics include easily bewildered, poor memory, short attention span, misinterprets stimuli and impaired judgment. Semicomatose is moaning in response to painful stimuli. Obtundation is responding to verbal stimuli but quickly falling asleep.

9. Common psychosocial reactions of the stroke patient to the stroke include (select all that apply) a. depression. b. disassociation. c. intellectualization. d. sleep disturbances. e. denial of severity of stroke.

a. depression. d. sleep disturbances. e. denial of severity of stroke.

When providing care to a client with increased intracranial pressure (IICP) requiring mechanical ventilation, the nurse is aware that intracranial pressure can increase due to: a. hypoxemia and hypercapnia. b. hyperventilation. c. oxygenation with a partial pressure of arterial oxygen at about 100 mmHg. d. partial pressure of arterial carbon dioxide of about 35 mmHg.

a. hypoxemia and hypercapnia. Rationale Hypoxemia and hypercapnia can increase intracranial pressure. It is important to maintain adequate oxygenation with a partial pressure of arterial oxygen at about 100 mmHg and a partial pressure of arterial carbon dioxide of about 35 mmHg. Hyperventilation decreases the PaCO2 and would cause the ICP to decrease.

The nurse is preparing to conduct a neurologic assessment interview with a client. Which general questions should the nurse use when conducting this assessment? (Select all that apply.) a. "Are you experiencing any pain?" b. "Are you having any problems with your memory?" c. "How many fingers am I holding up at this time?" d. "Do you have any problems with balance or coordination?" e. "Do you have a history of seizures or fainting?"

a. "Are you experiencing any pain?" b. "Are you having any problems with your memory?" d. "Do you have any problems with balance or coordination?" e. "Do you have a history of seizures or fainting?" Rationale General questions to include in a neurologic assessment interview include asking about pain, history of seizures or fainting, and asking about problems with memory and coordination or balance. Asking to identify the number of fingers would focus on the client's vision.

The nurse instructs the parents of school-age children on ways to prevent head injuries. Which statement made by a participant indicates that additional teaching is required? a. "My son should wear protective shoulder and knee pads when playing football." b. "My daughter needs to wear a helmet when riding the bicycle." c. "Even though he won't like it, I'll make sure my son wears a helmet when skateboarding." d. "I need to get my son a helmet to wear when ice skating."

a. "My son should wear protective shoulder and knee pads when playing football." Rationale The nurse should teach all clients about ways to prevent head injuries or trauma, including wearing helmets when bicycling, skateboarding, and skating and using sports-specific helmets and equipment when participating in contact sports. The son needs to wear a helmet in addition to shoulder and knee pads when playing football. The other participant comments indicate that teaching has been effective.

A client with a head injury is being monitored for increased intracranial pressure (ICP). His mean arterial pressure (MAP) is 70 and the ICP is 18 mmHg; therefore his cerebral perfusion pressure (CPP) is: a.) 52 mm Hg b.) 88 mm Hg c.) 48 mm Hg d.) 68 mm Hg

a.) 52 mm Hg Rationale: CCP=MAP-ICP 70-18=52 CCP=52 CCP is maintained above 60 mm Hg

a.) A positive Brudzinski's sign Rationale: Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is fixed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the knee and thigh are extended from a flexed-right angle position. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glascow Coma Scale of 15 is a perfect score and indicates the client is awake and alert with no neurological deficits.

a.) Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). Rationale: A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Oxygenation is evaluated through PaO2 and oxygen saturation. Alveolar hypoventilation would be reflected in an increased PaCO2.

a.) Evaluate urine specific gravity Rationale: Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce anti-diuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. There's no evidence that the client is experiencing renal failure. Providing emollients to prevent skin breakdown is important, but doesn't need to be performed immediately. Slowing the rate of IV fluid would contribute to dehydration when polyuria is present.

a.) Laceration of the middle meningeal artery Rationale: Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. An embolic stroke is a thromboembolism from a carotid artery that ruptures. Venous bleeding from the arachnoid space is usually observed with subdural hematoma

a.) Normal saline. Rationale: A systolic blood pressure less than 90 mm Hg in a patient with a traumatic brain injury is a predictor of a poor outcome. Initial management usually involves assuring that the patient is hydrated. Isotonic crystalloids such as 0.9% saline or Ringer's solution are most commonly used. Normal Saline is preferred because it is inexpensive, iso-osmolar and has no free water. #2 and #4 are not correct. In general, the use of hypotonic crystalloids, such as D5W or 0.45% normal saline is avoided because of the potential for worsening cerebral edema. #3 is not correct. D51/2 NS is hypertonic and will draw fluid from the cells & interstial tissue into the vascular space. This could worsen cerebral edema.

a.) Urine output increases Rationale: Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. No information is given about abnormal BUN and creatinine levels or that mannitol is being given for renal dysfunction or blood pressure maintenance.

The nurse is caring for a client with a closed head injury. Which of the following would contribute to intracranial hypertension? a.) hypoventilation b.) elevating the head of the bed c.) hypernatremia d.) quiet darkened environnent

a.) hypoventilation Rationale: Hypoventilation leads to vasodilation and increased intracranial pressure.

answer: a Rationale: TIA is often a precursor to CVA and the client who chooses not to make lifestyle changes is at increased risk. There is no particular increased risk for aneurysm, vasovagal syndrome, or myasthenia gravis in a client with TIA.

The nurse is reviewing the orders of a client experiencing a thrombotic stroke and notes an order for the administration of tissue plasminogen within the first 3 hours after the stroke. The nurse concludes that the reason for this order is to: a. Reduce the risk of vasospasm. b. Cause fibrinolysis of the clot. c. Increase platelet aggregation. d. Decrease the risk of infection.

answer: b Rationale: Tissue plasminogen activator (TPA) is given within the first 3 hours after the ischemic stroke to cause fibrinolysis of the clot. It does not affect vasospasm, infection, or platelet aggregation.

Which clinical manifestation would alert the nurse that the client has experienced a transient ischemic attack (TIA)? a. Loss of sensation and reflexes in both legs b. Complete paralysis of the right arm and leg c. Numbness and tingling at the corner of the mouth d. Sudden severe pain over the left eye

answer: c Rationale: Numbness and tingling at the mouth that disappears within minutes or hours is a manifestation of temporary occlusion of the middle cerebral artery. Sudden eye pain, paralysis, and loss of sensation are manifestations of stroke

The nurse is administering oxygen to a client experiencing a stroke in order to prevent hypoxia and hypercapnia. The nurse expects this treatment to decrease the risk for: a. pulmonary emboli. b. fluid accumulation in the lungs. c. increased intracranial pressure (ICP). d. rebleeding.

answer: c Rationale: Preventing hypoxia and hypercapnia through administration of oxygen will prevent further ischemia of cerebral tissues and ICP. Fluid in the lungs and pulmonary emboli are unrelated to stroke. Administering oxygen will not prevent rebleeding.

A 76-year-old client has been brought to the emergency department by ambulance with a suspected stroke. Initial vital signs are BP 150/100, pulse 90, and respirations 20. After 30 minutes, vital signs have changed to BP 170/90, pulse 78 and respirations of 24. Which action should the nurse initiate next? a. Check the client's phenytoin (Dilantin) level. b. Ask how the client feels. c. Get an order to decrease IV fluids. d. Offer the client clear liquids to prevent dehydration.

answer: c Rationale: The client is showing signs of increased intracranial pressure, and infusion of fluids exacerbates the increasing pressure. Asking how the client feels is a psychosocial assessment, and the primary need is physiological integrity. Offering fluids is inappropriate since the client should have fluids restricted. There is no evidence that the client had seizures and was receiving phenytoin.

The nurse concludes that further teaching is needed when visiting the home of a client who has recovered from a cerebrovascular accident (CVA). Which finding indicates the client is at risk of Ineffective Tissue Perfusion? a. Hand weights are next to the couch. b. The commode is at the bedside. c. Metamucil is on the kitchen counter. d. Oxygen canister is in the closet.

answer: d Rationale: Administer oxygen as prescribed. Administration of oxygen decreases the risk for hypoxia and hypercapnia, which can increase cerebral ischemia and intracranial pressure. The commode at the bedside, Metamucil, and hand weights are all appropriate for this client.

The nurse is assigned to care for a client who has had an acute ischemic stroke of a left cerebral vessel. The chart reveals that the client has contralateral deficits. The nurse explains to the family that this means: a. Deficits will be present below the level of the stroke. b. Both sides of the client's body are involved. c. The client will have neurological deficits on the left side. d. The client will have neurological deficits on the right side.

answer: d Rationale: The motor pathways of the nervous system cross at the medulla and spinal cord, so that damage to a cerebral vessel on one side will manifest neurologic deficits in the opposite, or contralateral, side. This client will exhibit deficits on the right side.

Hypertension can often accompany the risk factors for which of the following disease processes

artherosclerosis

A client recovering from a stroke is unable to swallow and has an absent gag reflex. Which cranial nerve should the nurse suspect is affected in this client? a Spinal accessory b Glossopharyngeal c Hypoglossal d Trigeminal

The mother of 2-week-old Miriam Shroeder is concerned when the nurse measures the circumference of the baby's head. Which explanation about the assessment is appropriate to share with the mother? a "The size of the head correlates to the amount of fluid that is within the body organs." b "The head circumference helps determine if there is extra fluid accumulating in the child's brain." c "This measurement helps determine when primitive reflexes are going to disappear." d "The size of the head helps determine if cranial nerves are developing and functioning."

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? A Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. B Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. C Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. D Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

The nurse is drawing an arterial blood sample from Jamal Lemmington, a 22-year-old male diagnosed with a traumatic brain injury. What should the nurse explain to Jamal's father about the purpose of this blood sample? a Estimates the length of time it will take for the client to resume consciousness b Measures the amount of carbon dioxide in the blood to predict the presence of increased intracranial pressure c Determines the response of medications to remove excess fluid from the brain tissue and reduce swelling d Predicts the number and depth of respirations that the client will have during one minute

b Rationale Irritability may indicate that the client is experiencing an increase in intracranial pressure, especially if associated with additional signs of bradycardia, increased systolic pressure, increased pulse pressure, vomiting, headache, lethargy, and change in mental status. Nausea does not accompany the vomiting associated with increased intracranial pressure. Hypotension and oliguria are not associated with increased intracranial pressure.

A client is to be discharged from the hospital first thing in the morning. However, overnight the client developed symptoms of "not being able to see well." The client also cannot move either the left arm or the left leg to get out of bed. What is the priority response by the nurse? a Ask the client if he has a family history of strokes b Assess the client's vital signs c Assist the client to dress for discharge d Instruct the client on the use of assistive devices to assist in mobility

b Rationale The change in assessment should signal the nurse to follow the nursing process and assess the client further. Although family history is important, it is not the priority in this situation. These symptoms are consistent with worsening condition and possible increased intracranial pressure. Continuing with the tasks associated with discharge would not be appropriate.

A client recovering from a stroke has an absent gag reflex and has lost 7 lb over the last 5 days. Which intervention does the nurse anticipate for this client? a Intramuscular injection of a corticosteroid b Placement of a feeding tube c Administration of hypotonic intravenous fluids d Administration of dextrose 50% and water

b Rationale The client is losing fluid and is unable to safely eat or drink. The nurse should prepare for this client to have a feeding tube placed. Dextrose 50% and water is a treatment for status epilepticus. Corticosteroids are indicated to treat inflammation. Hypotonic fluids will increase intracranial pressure. Isotonic or hypertonic fluids would be indicated for this client.

A nurse in the emergency department is providing care for a client diagnosed with increased intracranial pressure (IICP). The client is experiencing a decreasing level of consciousness. Which collaborative treatment would the nurse question for this client? a Place client on mechanical ventilator to increase oxygen and eliminate carbon dioxide b Administer intravenous 0.45% saline infusion c Intubate the client with an endotracheal tube d Administer intravenous mannitol

b Rationale The nurse would not administer hypotonic intravenous fluids for this client. Hypotonic fluids will cause water to move into the brain cells. This will increase intracranial pressure. The other interventions are expected and appropriate for clients with IICP.

The client has an increase in intracranial pressure caused by an increase in capillary permeability. The nurse should recognize this as which type of cerebral edema? a Hormonal b Vasogenic c Bacterial d Cytotoxic

b Rationale Vasogenic cerebral edema is caused by an increase in capillary permeability of cerebral vessels. Retained fluid in the neurons and endothelial cells associated with sodium and water retention is the cause of cytotoxic cerebral edema. Hormonal and bacterial are not types of cerebral edema.

b Rationale: During initial evaluation, the most important point in the patient's history is the time since onset of stroke symptoms. If the stroke is ischemic, recombinant tissue plasminogen activator (tPA) must be administered within 3 to 4.5 hours of the onset of clinical signs of ischemic stroke; tPA reestablishes blood flow through a blocked artery and prevents brain cell death in patients with acute onset of ischemic stroke.

When planning care for a client with a posterior fossa craniotomy which action in contraindicated? a keeping the client flat on one side b elevating the head of the bed 30 degrees c log rolling or turning as a unit d keeping the neck in a neutral position

b client required to lie flat

a client with ICP is placed on mechanical ventilation with hyperventilation. The nurse knows that the purpose of hyperventilation is to: a. prevent the development of acute respiratory failure b. decrease the cerebral blood flow c. increase systemic tissue perfusion d. prevent cerebral anoxia

b hyperventilation reduces swelling and ICP by decreasing cerebral blood flow

What are causes of vasogenic cerebral edema (select all that apply)? a. Hydrocephalus b. Ingested toxins c. Destructive lesions or trauma d. Local disruption of cell membranes e. Fluid flowing from intravascular to extravascular space

b, e. Vasogenic cerebral edema, the most common type of edema, occurs mainly in the white matter and is characterized by leakage of macromolecules from the capillaries into the surrounding extracellular space. This results in an osmotic gradient that favors the flow of fluid from the intravascular to the extravascular space. A variety of insults, such as brain tumors, abscesses, and ingested toxins, may cause an increase in the permeability of the blood-brain barrier and produce an increase in the extracellular fluid volume. Hydrocephalus causes interstitial cerebral edema.

What would be used to provide respiratory support for an alteration in intracranial regulation? (Select all that apply.) a Metered-dose inhaler b Endotracheal intubation c Oropharyngeal airway d Mechanical ventilation e Nebulizer treatments

b,c,d

Which are independent nursing interventions for an alteration in intracranial regulation? (Select all that apply.) a Provide antianxiety medication through intravenous site b Reduce the lights in the room c Shine a light into the client's eyes d Raise the head of the bed e Insert an indwelling urinary catheter

b,c,d

A nurse in the intensive care unit is providing care for a client with increased intracranial pressure from a traumatic brain injury. The client has a fever of 102 °F. Which interventions will the nurse use to promote normal intracranial pressure? (Select all that apply.) a Flex the neck to open the airway b Monitor level of consciousness c Provide supplemental oxygen d Suction for no more than 10 seconds per pass e Administer acetaminophen per order

b,c,d,e Rationale Hyperthermia increases intracranial pressure. Hyperthermia also affects hypothalamic function in clients with increased intracranial pressure; therefore, administering an antipyretic medication is appropriate. Prolonged suctioning can increase intracranial pressure. It also causes decreased oxygen levels. Increased intracranial pressure can cause irregular and ineffective respirations. Supplemental oxygen helps prevent hypoxia. It also helps prevent excess carbon dioxide, which is a vasodilator. A decreased level of consciousness can be a manifestation of pressure on the cerebral cortex. It can also be a manifestation of decreased oxygen levels in the brain. Flexing the neck increases intracranial pressure by preventing blood return from the brain. The head and neck must be kept in neutral position.

A nurse is caring for a client who has a closed head injury with ICP reading ranging from 16-22 mmHg. Which of the following actions should the nurse take to decrease the potential for raising the clients ICP? (SELECT ALL THAT APPLY) a. suction the endo tracheal tube frequently b decrease the noise level in the clients room c elevate the clients head on two pillows d administer a stool softner e keep the client well hydrated

b,d suction increases ICP, flexing neck increases ICP

The nurse admits for observation a 70-year-old client with symptoms of increased intracranial pressure (IICP). What diagnostic tests would the nurse not expect to be performed on this elderly client and why? a. Cranial nerve testing because his age makes it difficult to assess cranial nerve function. b. A lumbar puncture to avoid a sudden release of pressure in the skull which might cause cerebral herniation. c. Computed tomography (CT) scan because of its limited value in determining potential causes of this client's abnormal neurological findings. d. Endoscopy to search for stress gastritis and ulcers which occur more often in this population.

b. A lumbar puncture to avoid a sudden release of pressure in the skull which might cause cerebral herniation. Rationale Clients of any age with suspected increased intracranial pressure (IICP) would not be given a lumbar puncture because of the risk of cerebral herniation. Cranial nerve testing, as part of an overall neurological assessment, would be done in all age groups and adapted accordingly. Computed tomography (CT) scans, as well as MRIs, are typical diagnostic tests used to help determine causes of IICP. An endoscopy would not be done as part of the IICP assessment. IICP places individuals at higher risk for developing stress gastritis and ulcers, not the other way around.

What is the best explanation of stereotactic radiosurgery? a. Radioactive seeds are implanted in the brain. b. Very precisely focused radiation destroys tumor cells. c. Tubes are placed to redirect CSF from one area to another. d. The cranium is opened with removal of a bone flap to open the dura.

b. A stereotactic radiosurgery technique uses precisely focused radiation to destroy tumor cells. The radiation is computer and imagery guided. Radioactive seeds are used to deliver radiation. Ventricular shunts are used to redirect CSF from one area to another. A craniotomy is done by first making burr holes and then opening the cranium by connecting the holes to remove a flap of bone to expose the dura mater

3. 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. Tonic-clonic seizures d. Shortness of breath

b. Alteration in level of consciousness (LOC)

When using intraventricular ICP monitoring, what should the nurse be aware of to prevent inaccurate readings? a. The P2 wave is higher than the P1 wave. b. CSF is leaking around the monitoring device. c. The transducer of the ventriculostomy monitor is at the level of the upper ear. d. The drain of the CSF drainage device was closed for 6 minutes before taking the reading.

b. An inaccurate ICP reading can be caused by CSF leaks around the monitor device, obstruction of the intraventricular catheter, kinks or bubbles in the tubing, and incorrect height of the transducer or drainage system relative to the patient's reference point. The P2 wave being higher than the P1 wave indicates poor ventricular compliance. The transducer height should be at the tragus of the ear. The drain of the CSF drainage device should be closed for 6 minutes preceding the reading.

12. A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the medical treatment to include which of the following? a. Cholesterol-lowering drugs b. Anticoagulant therapy c. Monthly prothrombin levels d. Carotid endarterectomy

b. Anticoagulant therapy

A client with a traumatic brain injury is intubated and placed on mechanical ventilation. What should the nurse use to evaluate the effectiveness of these respiratory interventions? a. Motor and sensory function b. Arterial blood gas results c. Cranial nerve function d. Glasgow Coma score

b. Arterial blood gas results Rationale A client with an alteration in LOC may be unable to maintain an open airway and engage in spontaneous respirations. The client may need endotracheal intubation or mechanical ventilation. Arterial blood gases are used to guide the effectiveness of ventilation. Glasgow Coma score, cranial nerve function, and motor and sensory function are used to determine the effect of intracranial pressure on body functioning.

An older female client is residing in the nursing home. As the nurse walks into the room to assist the client for evening care, the client calls out, wondering who it is. The nurse introduces herself and enters the room. The client is wearing very thick glasses and has visual deficits. After the nurse has finished her care, what interventions does the nurse do to improve the safety of the client? (Select all that apply.) a. Moves chair beside the bed so the client has a place to sit if she gets up in the night Turns off the night light to improve sleep quality b. Asks the client where she would like her glasses placed c. Encourages the client to call for any needs d. Puts the call bell within reach of the client

b. Asks the client where she would like her glasses placed c. Encourages the client to call for any needs d. Puts the call bell within reach of the client Rationale This client in this scenario is consistent with a client who has a visual deficit. Putting the call light beside the client is an appropriate intervention for this client so it is within easy reach. Turning the night light off is not an appropriate intervention for someone with a visual deficit. Areas should be well lit. Turning off the night light increases the risk of the client not being able to see when she gets up. Moving the chair beside the bed is not an appropriate intervention for this client. Clients with visual deficits require a clutter-free environment. Furniture should not be moved without notifying the client. Asking the client where she would like her glasses placed is an appropriate intervention. Orienting the client to her surroundings improves her independence with her vision deficit. Encouraging the client to call if she needs help is always an appropriate nursing intervention.

The nurse is providing teaching to a client who is recovering from increased intracranial pressure (IICP). Which instructions should the nurse plan to give the client prior to discharge? (Select all that apply.) a. Eat a diet high in red meat and chicken. b. Avoid straining with bowel movements. c. Perform isometric or muscle-contracting exercises. d. There is no need to worry about keeping the head and neck in alignment when turning in bed. e. Avoid exposure to people with colds.

b. Avoid straining with bowel movements. e. Avoid exposure to people with colds. Rationale Straining with bowel movements and performing isometric exercises are to be avoided as these actions increase intracranial pressure. The client should be taught to turn in bed while maintaining the head and neck in alignment. Because coughing, sneezing, and nose blowing can all increase ICP, the client should avoid others with respiratory illness. Diet does not have a great deal of effect on ICP, but red meat is considered an unhealthy choice if eaten frequently.

During a physical examination, the nurse assesses the reflexes of an older client. Which reflex would require notification to the healthcare provider? a. Gag b. Babinski c. Corneal d. Achilles

b. Babinski Rationale The presence of the Babinski reflex from age 2 years and on indicates cerebral damage. This is the reflex that the nurse should report to the healthcare provider. The gag, corneal, and Achilles reflexes should be present in the older client.

A nurse in the emergency department is providing care for a client who has increased intracranial pressure (IICP) from a traumatic brain injury from a motor vehicle crash. The nurse anticipates orders for which diagnostic tests in the care of this client? (Select all that apply.) a. Electromyogram b. Cardiac monitoring c. Intracranial pressure monitor d. ABGs e. CT of the head

b. Cardiac monitoring c. Intracranial pressure monitor d. ABGs e. CT of the head Rationale An intracranial pressure monitor will give information about intracranial pressure. This information can be used to manage the medications and fluids for this client. A CT of the head will give information about possible hemorrhage and diffuse axonal injuries. Cardiac monitoring would be essential to monitor cardiac rate and rhythm. Arterial blood gases give information about oxygen and carbon dioxide levels in the blood. This information is used to manage artificial airways and mechanical ventilation. Electromyography is used to measure skeletal muscle activity. It would not be used in the diagnosis of a client with traumatic brain injury.

4. 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. Elevation of the head of the bed

A 78-year-old female client presents for an annual exam. The client admits to smoking a ½ a pack of cigarettes per day for the last 50 years. The nurse would expect that the client would also complain of a deficit in what type of sensory stimuli? a. Visual b. Gustatory c. Tactile d. Auditory

b. Gustatory Rationale The two most common sensory deficits associated with tobacco use are the sense of taste (gustatory) and the sense of smell (olfactory). Visual, auditory, and tactile senses are not affected.

Priority Decision: While the nurse performs range of motion (ROM) on an unconscious patient with increased ICP, the patient experiences severe decerebrate posturing reflexes. What should the nurse do first? a. Use restraints to protect the patient from injury. b. Perform the exercises less frequently because posturing can increase ICP. c. Administer central nervous system (CNS) depressants to lightly sedate the patient. d. Continue the exercises because they are necessary to maintain musculoskeletal function

b. If reflex posturing occurs during range of motion (ROM) or positioning of the patient, these activities should be done less frequently until the patient's condition stabilizes because posturing can cause increases in ICP and may indicate herniation. Neither restraints nor central nervous system (CNS) depressants would be indicated

19. A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem? a. Diphenhydramine (Benadryl) b. Lioresal (Baclofen) c. Heparin d. Pregabalin (Lyrica)

b. Lioresal (Baclofen)

A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. What should the nurse record as the patient's GCS score? a. 6 c. 9 b. 7 d. 11

b. No opening of eyes = 1; incomprehensible words = 2; flexion withdrawal = 4. Total = 7

A client with a stroke is demonstrating signs of increasing intracranial pressure. Which actions should the nurse take at this time? (Select all that apply.) a. Provide hypotonic fluids b. Reduce environmental stimuli c. Assess cranial nerve function d. Monitor pupillary response e. Assess vital signs

b. Reduce environmental stimuli c. Assess cranial nerve function d. Monitor pupillary response e. Assess vital signs Rationale Nursing actions for the client demonstrating signs of increasing intracranial pressure include assessing vital signs, monitoring pupillary response, assessing cranial nerve function, and reducing environmental stimuli. Intravenous fluids administered at this time would be isotonic or hypertonic.

___ are not really considered strokes, but rather precursors to stroke. There's a brief, focal loss of function, but full recovery w/in 24 hrs. a. thromboses b. TIAs c. lacunar strokes d. embolisms

b. TIAs

A patient with a head injury has bloody drainage from the ear. What should the nurse do to determine if CSF is present in the drainage? a. Examine the tympanic membrane for a tear. b. Test the fluid for a halo sign on a white dressing. c. Test the fluid with a glucose-identifying strip or stick. d. Collect 5 mL of fluid in a test tube and send it to the laboratory for analysis.

b. Testing clear drainage for CSF in nasal or ear drainage may be done with a Dextrostik or Tes-Tape strip but if blood is present, the glucose in the blood will produce an unreliable result. To test bloody drainage, the nurse should test the fluid for a "halo" or "ring" that occurs when a yellowish ring encircles blood dripped onto a white pad or towel within a few minutes.

The patient is being monitored long-term with a brain tissue oxygenation catheter. What range for the pressure of oxygen in brain tissue (PbtO2 ) will maintain cerebral oxygen supply and demand? a. 55% to 75% c. 70 to 150 mm Hg b. 20 to 40 mm Hg d. 80 to 100 mm Hg

b. The normal pressure of oxygen in brain tissue (PbtO2 ) is 20 to 40 mm Hg. The normal jugular venous oxygen saturation (SjvO2 ) is 55% to 75% and indicates total venous brain tissue extraction of oxygen; this is used for short-term monitoring. The MAP of 70 to 150 mm Hg is needed for effective autoregulation of CBF. The normal range for PaO2 is 80 to 100 mm Hg.

Which nursing action is a priority when intervening with a client having a seizure? a. Apply physical restraints to protect the client from injury. b. Turn the client on the side to prevent aspiration. c. Use a padded tongue blade to open the client's airway. d. Elevate the head of the bed to promote ventilation.

b. Turn the client on the side to prevent aspiration. Rationale The priority nursing action is to turn the client on the side to prevent aspiration from secretions that can occur when a client is having a seizure. Applying physical restraints, using a padded tongue blade, and elevating the head of the bed can cause further physical injury to the client.

18. 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. White male, age 60, with history of uncontrolled hypertension

Contralateral paralysis & sensory loss of (more) LE, appearance of a grasp or sucking reflex, lack of spontaneous behavior, motor inattention, perseveration, & amnesia are all effects of a stroke in the: a. middle cerebral artery (MCA) b. anterior cerebral artery (ACA) c. posterior cerebral artery (PCA)

b. anterior cerebral artery (ACA)

7. For a patient who is suspected of having a stroke, one of the most important pieces of information that the nurse can obtain is a. time of the patient's last meal. b. time at which stroke symptoms first appeared. c. patient's hypertension history and management. d. family history of stroke and other cardiovascular diseases.

b. time at which stroke symptoms first appeared.

A young adult client is brought to the emergency room with a suspected narcotic overdose. The client is in respiratory acidosis and has an increased CO2 level with resulting increased intracranial pressure (IICP). The physiologic mechanism contributing to the IICP is: a. herniation of the brainstem. b. vasodilation of cerebral vessels. c. altered level of consciousness. d. vasoconstriction of cerebral vessels.

b. vasodilation of cerebral vessels. Rationale A narcotic overdose depresses the respiratory system and leads to elevated levels of carbon dioxide (CO2) in the blood and respiratory acidosis. High levels of CO2 cause vasodilation of cerebral vessels leading to increased intracranial pressure (IICP). Elevated ICP is not caused by vasoconstriction, and herniation occurs as an end result of delayed or inadequately treated IICP. Altered level of consciousness is a sign of IICP rather than the physiologic mechanism contributing to IICP.

A nursing instructor is reviewing sensory perception with the nursing students. The nursing instructor knows that the students have appropriately learned the information when he hears them make what comments regarding the sensory process? (Select all that apply.) a. "A receptor is not always necessary to process a stimulus to the brain." b. "The feeling of my stomach being full after a large meal is an example of a visceral sensation." c. "If a person can perceive stimuli in the environment, and respond, that person is exhibiting awareness." d. "When I am feeling around my purse with my hand trying to find my keys, I am using the process of stereognosis." e. "Kinesthetic is the sensation of touch."

b. "The feeling of my stomach being full after a large meal is an example of a visceral sensation." c. "If a person can perceive stimuli in the environment, and respond, that person is exhibiting awareness." d. "When I am feeling around my purse with my hand trying to find my keys, I am using the process of stereognosis." Rationale Awareness is the ability of an individual to perceive their environment, and to react appropriately. A receptor is one of the four aspects necessary for the sensory process. For an individual to process information, there must be a stimulus, a receptor, an impulse conduction and perception. Kinesthetic is the awareness of the position and movement of the body and its parts. Stereognosis is the ability to understand an object through touch. It is used when individuals feel for an object with their hand. A visceral feeling is related to an organ. Feeling full after a large meal is an example of a visceral feeling.

b.) Elective draining of the hematoma.

b.) Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. Rationale: A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise.

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? a.) Vomiting continues b.) Intracranial pressure (ICP) is increased c.) The client needs mechanical ventilation d.) Blood is anticipated in the cerebralspinal fluid (CSF)

b.) Intracranial pressure (ICP) is increased Rationale: Sudden removal of CSF results in pressures lower in the lumbar area than the brain and favors herniation of the brain; therefore, LP is contraindicated with increased ICP. Vomiting may be caused by reasons other than increased ICP; therefore, LP isn't strictly contraindicated. An LP may be preformed on clients needing mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage and was obtained before signs and symptoms of ICP.

Which of the following MOST accurately describes the cause of an ischemic stroke?

blockage of a cerebral artery

A client with a traumatic brain injury is intubated and placed on mechanical ventilation. What should the nurse use to evaluate the effectiveness of these respiratory interventions? a Cranial nerve function b Motor and sensory function c Arterial blood gas results d Glasgow Coma score

A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? a. Glasgow Coma scale b cranial nerve function c O2 sat d pupillary response

A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, the nurse anticipates that the health care provider will request a a. lumbar puncture b. cerebral angiography c. MRI d. CT scan with contrast

A patient with right hemisphere stroke has unilateral neglect . During the patient's rehabilitation, it is important for the nurse to a. avoid positioning the patient on the affected side b. place all objects for care on the patient's unaffected side c. teach the patient to care consciously for the affected side d. protect the affected side from injury with pillows and supports

The RN caring for a client with CVA who is complaining of being nauseated and is requesting a emesis basin. Which action should the nurse take first? a. admin ordered antiemetic b. obtain ice bag and apply to clients throat c. turn client to one side d notify the provider

The nurse instructs the parents of school-age children on ways to prevent head injuries. Which statement made by a participant indicates that additional teaching is required? a "I need to get my son a helmet to wear when ice skating." b "My daughter needs to wear a helmet when riding the bicycle." c "My son should wear protective shoulder and knee pads when playing football." d "Even though he won't like it, I'll make sure my son wears a helmet when skateboarding."

The nurse is preparing a plan of care for Jimmy Williams, a 30-year-old client recovering from a head injury. Which collaborative action should the nurse perform to help reduce cerebral edema? a Regulate the infusion of a proton pump inhibitor b Apply a cooling blanket c Administer ethacrynic acid (Edecrin) as prescribed d Administer antihypertensive medication as prescribed

The nurse is using the glascow coma scale to assess the clients motor response. The nurse places pressure at the base of the clients fingernail for 20 seconds, The clients only response is withdrawal of his hand. The nurse interprets the clients response as: a. a score of 6 because he follows command b. a score of 5 because he localizes pain c. a score of 4 because he uses flexion d. a score of 3 because he uses extension

What is the purpose of consulting physical therapy services for a client with an alteration in intracranial pressure? a To assess the living accommodations before the client's discharge to home b To determine if transfer to skilled nursing facility is required c To recommend interventions for resulting hemiparesis or hemiplegia d To work with the nutritionist to determine effective methods to meet nutritional needs

Which of the following signs and symptoms of increased ICP after head trauma would appear first? A Bradycardia B Large amounts of very dilute urine C Restlessness and confusion D Widened pulse pressure

While cooking, your client couldn't feel the temperature of a hot oven. Which lobe could be dysfunctional? A Frontal B Occipital C Parietal D Temporal

a client with ICP is receiving Osmitrol (Mannitol) and furosemide (lasix). The nurse recognizes that these two drugs are given to reverse what effect? a energy failure b excessive intracellular calcium c cellular edema d excessive glutamate release

a thrombus that develops in a cerebral artery does not always cause a loss of neurologic function because a. the body can dissolve atherosclerotic plaques as they form b. some tissues of the brain do not require constant blood supply to prevent damage c. circulation via the circle of willis may provide blood supply to the affected area of the brain d. neurologic deficits occur only when major arteries are occluded by thrombus formation around atherosclerotic plaque

the patient has a lack of comprehension of both verbal and written language. which type of communication difficulty does this patient. have? a. dysarthria b. fluent dysphasia c. receptive aphasia d. expressive aphasia

what is an appropriate food for a patient with a stroke who has mild dysphagia? a. fruit juices b. pureed meats c. scrambled eggs d. fortified milkshakes

what primarily determines the neurological functions that are affected by a stroke? a. the amount of tissue area involved b. the rapidity of the onset of symptoms c. the brain area perfused by the affected artery d. the presence or absence of collateral circulation

which intervention can the nurse delegate to the licenses practical nurse when caring for a patient following an acute stroke a. assess the patients neurological status b. assess the patients gag reface before beginning feeding c. administer ordered antihypertensives and platelet inhibitors d. teach the patients caregivers strategies to minimize unilateral neglect

What is the intended action of mannitol in the treatment of a client with increased intracranial pressure? a To enhance renal excretion of retained protein b To create a sodium and potassium balance c To draw fluid from the brain tissue d To prevent tiny stress hemorrhages in the brain

c Mannitol is used in the treatment of increased intracranial pressure to draw fluid out of the brain, reducing intracranial pressure. Mannitol does not establish a sodium and potassium balance. Mannitol does not enhance excretion of serum protein, which is not an intended outcome. The medication does not prevent hemorrhages within the brain.

The nurse assesses a respiratory rate of 8 breaths per minute in a client with a traumatic brain injury. Shortly thereafter the client begins hiccupping. Which part of the brain should the nurse suspect is being affected in this client? a Cerebellum b Occipital lobe c Brainstem d Thalamus

c Rationale The brainstem controls breathing and regulates hiccupping. The thalamus is the relay center for all information coming into the brain. The cerebellum is responsible for muscle movement, balance, and control. The occipital lobe contains the visual cortex to process vision.

During a physical examination, the nurse assesses the reflexes of an older client. Which reflex would require notification to the healthcare provider? a Gag b Achilles c Babinski d Corneal

c Rationale The presence of the Babinski reflex from age 2 years and on indicates cerebral damage. This is the reflex that the nurse should report to the healthcare provider. The gag, corneal, and Achilles reflexes should be present in the older client.

c Rationale: Angiography provides visualization of cerebral blood vessels and can help estimate perfusion and detect filling defects in the cerebral arteries.

A patient with right-sided hemiplegia and aphasia resulting from a stroke most likely has involvement of the a. brainstem. b. vertebral artery. c. left middle cerebral artery. d. right middle cerebral artery.

c Rationale: If the middle cerebral artery is involved in a stroke, the expected clinical manifestations include aphasia, motor and sensory deficit, and hemianopsia on the dominant side and include neglect, motor and sensory deficit, and hemianopsia on the nondominant side.

c Rationale: In a carotid endarterectomy, the atheromatous lesion is removed from the carotid artery to improve blood flow.

Bladder training in a male patient who has urinary incontinence after a stroke includes a. limiting fluid intake. b. keeping a urinal in place at all times. c. assisting the patient to stand to void. d. catheterizing the patient every 4 hours.

c Rationale: In the acute stage of stroke, the primary urinary problem is poor bladder control and incontinence. Nurses should promote normal bladder function and avoid the use of indwelling catheters. A bladder retraining program consists of (1) adequate fluid intake, with most fluids administered between 7:00 am and 7:00 pm; (2) scheduled toileting every 2 hours with the use of a bedpan, commode, or bathroom; and (3) noting signs of restlessness, which may indicate the need for urination. Intermittent catheterization may be used for urinary retention (not urinary incontinence). During the rehabilitation phase after a stroke, nursing interventions focused on urinary continence include (1) assessment for bladder distention by palpation; (2) offering the bedpan, urinal, commode, or toilet every 2 hours during waking hours and every 3 to 4 hours at night; (3) using a direct command to help the patient focus on the need to urinate; (4) assistance with clothing and mobility; (5) scheduling most fluid intake between 7:00 am and 7:00 pm; and (6) encouraging the usual position for urinating (i.e., standing for men and sitting for women).

c Rationale: The extent of the stroke depends on the rapidity of onset, size of the lesion, and presence of collateral circulation.

A nurse is caring for a client with a closed head injury Fluid is assessed leaking from the ear. What is the nurses first action? a irrigate the ear canal gently b notify the physician c test the drainage for glucose d apply an occlusive dressing

c cerebrospinal fluid would indicate positive glucose

A patient with increased ICP is being monitored in the intensive care unit (ICU) with a fiberoptic catheter. Which order is a priority for you? A. Perform hourly neurologic checks. B. Take a complete set of vital signs. C. Administer the prescribed mannitol (Osmitrol). D. Give an H2-receptor blocker.

c he priority is to treat the known existing problem, and mannitol is the only thing that can do that. Because the patient is having the current pressure measured with objective numbers, treating the known problem is a priority over additional assessments. H2-blockers are given when corticosteroids are administered to help prevent gastrointestinal bleeding, but they are not a priority compared with the treatment of ICP.

c ~ A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Vital signs, assessment of the abdomen, and initiation of pulse oximetry are considered part of the secondary survey.

the rehab nurse assesses the patient, caregiver and family before planning the rehab program for this patient. what must be included in this assessment (select all that apply)? a. cognitive status of the family b. patient resources and support c. physical status of all body systems d. rehab potential of patient e. body strength remaining after the stroke f. patient and caregiver expectation of the rehab

c, d, f

Which factors decrease cerebral blood flow (select all that apply)? a. Increased ICP d. Arterial blood pH of 7.3 b. PaO2 of 45 mm Hg e. Decreased mean arterial pressure (MAP) c. PaCO2 of 30 mm Hg

c, e. Cerebral blood flow is decreased when the MAP and the PaCO2 are decreased. The other options increase cerebral blood flow.

Which are functions of the parietal lobe within the cerebrum? (Select all that apply.) a Processes information for memory and interprets smell b Processes actions for speech, thought, and learning c Processes information about two-point discrimination d Processes information about temperature and pain e Processes information about vision

c,d

The healthcare provider ordered diagnostic tests for a client with suspected increased intracranial pressure (IICP). Which tests should the nurse expect to show signs of IICP and help confirm the diagnosis and possible treatment needed? (Select all that apply.) a Stool guaiac test b Chest x-ray c CT scan d Serum osmolality e Arterial blood gases (ABGs)

c,d,e Rationale Some tests taken in clients with an intracranial hematoma will be expected to be normal: a chest x-ray and a stool guaiac test. Other tests, such as a CT, arterial blood gases, and serum osmolality can often produce valuable information about the cause of IICP and the treatment.

The nurse notes that a client has muscle fasciculations of both bicep muscles. What additional information should the nurse assess in this client? (Select all that apply.) a Blood pressure and pulse b Last solid food intake c Body temperature d Urine output e List of medications taking

c,d,e Rationale Fasciculations occur in clients with disease or trauma to the lower motor neurons, as a side effect of medications, in fever, in sodium deficiency, and in uremia. Fasciculations are not associated with food intake or blood pressure and pulse measurements.

The mother of a 10-year old client asks the nurse, "Why does my son seem so dazed after he has a seizure?" How should the nurse respond? a. "The grogginess after a seizure occurs from decreased oxygen getting to the brain during the seizure causing a temporary brain injury." b. "Children's brains are less resistant to the effects of seizure activity so they tend to have more confusion afterwards." c. "Seizure activity exhausts energy production in brain cells and may be producing molecules that negatively affect brain function until balance is restored." d. "He's likely just confused about what's happened to him during the seizure and just needs time to recover from the episode."

c. "Seizure activity exhausts energy production in brain cells and may be producing molecules that negatively affect brain function until balance is restored." Rationale The spontaneous and disordered discharge of activity occurring during a seizure is thought to exhaust energy metabolites or to produce locally toxic molecules. This affects level of consciousness following a seizure episode until metabolic balance is restored.

An unconscious patient with increased ICP is on ventilatory support. The nurse notifies the health care provider when arterial blood gas (ABG) measurement results reveal what? a. pH of 7.43 c. PaO2 of 70 mm Hg b. SaO2 of 94% d. PaCO2 of 35 mm Hg

c. A PaO2 of 70 mm Hg reflects hypoxemia that may lead to further decreased cerebral perfusion. PaO2 should be maintained at greater than or equal to 100 mm Hg. The pH and SaO2 are within normal range and a PaCO2 of 35 mm Hg reflects a normal value.

A client with a traumatic brain injury is diagnosed as being brain dead. Which assessment finding supports this diagnosis? a. Complete unawareness of self b. Aware of environment but unable to communicate c. Absence of spontaneous respirations d. Neck extended and the jaw is clenched

c. Absence of spontaneous respirations Rationale Brain death is the cessation and irreversibility of all brain functions, including the brainstem. Since the brainstem controls respirations, absence of respirations would be a nursing assessment finding in brain death. Complete unawareness of self describes a persistent vegetative state. An extended neck with clenched jaw describes the decerebrate posturing. Aware of the environment but unable to communicate describes locked-in syndrome.

The nurse is caring for the client with increased intracranial pressure (IICP) from a severe head injury. The nurse monitors the client for symptoms of which complication of IICP? a. Hydrocephalus b. Headache c. Brain herniation d. Cerebral edema

c. Brain herniation Rationale The client with increased intracranial pressure (IICP) is at risk for brain herniation. Cerebral edema and hydrocephalus are causes of IICP. Headache is a symptom rather than a complication of IICP.

The nurse recognizes the presence of Cushing's triad in the patient with which vital sign changes? a. Increased pulse, irregular respiration, increased BP b. Decreased pulse, increased respiration, decreased systolic BP c. Decreased pulse, irregular respiration, widened pulse pressure d. Increased pulse, decreased respiration, widened pulse pressure

c. Cushing's triad consists of three vital sign measures that reflect ICP and its effect on the medulla, hypothalamus, pons, and thalamus. Because these structures are very deep, Cushing's triad is usually a late sign of ICP. The signs include an increasing SBP with a widening pulse pressure, a bradycardia with a full and bounding pulse, and irregular respirations.

10. From which direction should a nurse approach a client who is blind in the right eye? a. From directly in front of the client b. From the right side of the client c. From the left side of the client d. From directly behind the client

c. From the left side of the client

A client recovering from a stroke is unable to swallow and has an absent gag reflex. Which cranial nerve should the nurse suspect is affected in this client? a. Hypoglossal b. Trigeminal c. Glossopharyngeal d. Spinal accessory

c. Glossopharyngeal Rationale The glossopharyngeal nerve produces the gag and swallowing reflexes. The trigeminal nerve has three branches. The mandibular branch receives sensory impulses from the tongue, lower teeth, skin of chin, and lower lip. The motor action of this branch includes teeth clenching and movement of the mandible. The hypoglossal nerve moves the tongue for swallowing, movement of food during chewing, and speech. The spinal accessory nerve moves the trapezius and sternocleidomastoid muscles and controls some movement of larynx, pharynx, and soft palate.

When the nurse is assessing a client with suspected increased intracranial pressure, the nurse is aware that which of the following is true in clients with increased intracranial pressure? a. In pressure autoregulation, stretch receptors within small blood vessels of the brain cause smooth muscle of the arterioles to dilate. b. Autoregulatory mechanisms have a great ability to maintain cerebral blood flow. c. Interruption of the cerebral blood flow leads to ischemia and disruption of the cerebral metabolism. d. The relationship between the volume of the intracranial components and intracranial pressure is known as vasodilation.

c. Interruption of the cerebral blood flow leads to ischemia and disruption of the cerebral metabolism. Rationale Interruption of the cerebral blood flow leads to ischemia and disruption of the cerebral metabolism. In pressure autoregulation, the arterioles will contract. Autoregulatory mechanisms have a limited ability to maintain cerebral blood flow. The relationship between volume and intracranial pressure is called compliance.

Which nursing action is a priority when suctioning a client with increased intracranial pressure? a. Suction the client as needed. b. Suction the client every hour. c. Limit suction passes to 10 seconds. d. Schedule suctioning with other nursing care.

c. Limit suction passes to 10 seconds. Rationale The nurse must perform the suctioning gently, limiting suction passes to 10 seconds to prevent further increase in ICP. Suctioning can cause an increase in intracranial pressure and should be used cautiously. The nurse must preoxygenate the client with 100% oxygen before suctioning and closely assess the client during suctioning. Suctioning helps maintain airway patency and prevent hypoxemia.

Which drug treatment helps to decrease ICP by expanding plasma and the osmotic effect to move fluid? a. Oxygen administration c. Mannitol (Osmitrol) (25%) b. Pentobarbital (Nembutal) d. Dexamethasone (Decadron)

c. Mannitol (Osmitrol) (25%) is an osmotic diuretic that expands plasma and causes fluid to move from tissues into the blood vessels. Hypertonic saline reduces brain swelling by moving water out of brain tissue. Oxygen administration is done to maintain brain function. Pentobarbital (Nembutal) and other barbiturates are used to reduce cerebral metabolism. The corticosteroid dexamethasone (Decadron) is used to treat vasogenic edema to stabilize cell membranes and improve neuronal function by improving CBF and restoring autoregulation

The nurse is admitting a 65-year-old client for observation who has symptoms of cognitive dysfunction, gait disruptions, and urinary incontinence. The nurse expects the client to undergo testing for which of the following? a. Renal failure b. Cardiac malfunction c. Normal pressure hydrocephalus d. Gastrointestinal disturbances

c. Normal pressure hydrocephalus Rationale Normal pressure hydrocephalus is most commonly seen in older adults. This may result from trauma, complications from surgery or an unknown cause. Due to the slow, insidious onset, the client may be evaluated for dementia. The symptoms listed are not those of renal failure, cardiac malfunction, or gastrointestinal disorders.

A client recovering from a stroke has an absent gag reflex and has lost 7 lb over the last 5 days. Which intervention does the nurse anticipate for this client? a. Administration of dextrose 50% and water b. Intramuscular injection of a corticosteroid c. Placement of a feeding tube d. Administration of hypotonic intravenous fluids

c. Placement of a feeding tube Rationale The client is losing fluid and is unable to safely eat or drink. The nurse should prepare for this client to have a feeding tube placed. Dextrose 50% and water is a treatment for status epilepticus. Corticosteroids are indicated to treat inflammation. Hypotonic fluids will increase intracranial pressure. Isotonic or hypertonic fluids would be indicated for this client.

13. A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke13% a. Numbness of an arm or leg b. Double vision c. Severe headache d. Dizziness and tinnitus

c. Severe headache

The patient has a depressed skull fracture and scalp lacerations with communication to the intracranial cavity. Which type of injury should the nurse record? a. Linear skull fracture c. Compound skull fracture b. Depressed skull fracture d. Comminuted skull fracture

c. The compound skull fracture is a depressed skull fracture and scalp lacerations with communicating pathway(s) to the intracranial cavity. A linear skull fracture is a straight break in the bone without alteration in the fragments. A depressed skull fracture is an inward indentation of the skull that may cause pressure on the brain. A comminuted skull fracture has multiple linear fractures with bone fragmented into many pieces.

Increased ICP in the left cerebral cortex caused by intracranial bleeding causes displacement of brain tissue to the right hemisphere beneath the falx cerebri. The nurse knows that this is referred to as what? a. Uncal herniation c. Cingulate herniation b. Tentorial herniation d. Temporal lobe herniation

c. The dural structures that separate the two hemispheres and the cerebral hemispheres from the cerebellum influence the patterns of cerebral herniation. A cingulate herniation occurs where there is lateral displacement of brain tissue beneath the falx cerebri. Uncal herniation occurs when there is lateral and downward herniation. Tentorial herniation occurs when the brain herniates down through the opening created by the brainstem. The temporal lobe can be involved in central herniation

A client presumed to be brain dead is being assessed for a response to caloric stimulation, the process of irrigating the ear with ice cold water to test the oculovestibular reflex. What finding would be expected if, in fact, the client is brain dead? a. The eyes would move to the side opposite the irrigated side. b. Dilation of both pupils would occur with the irrigation. c. The eyes would not move toward the irrigated side. d. The eyes would move toward the irrigated side and then return to midline.

c. The eyes would not move toward the irrigated side. Rationale A normal response to the caloric stimulation test is for the client's eyes to move first toward the irrigated side, followed by a return to midline. Thus, in an individual with brain death on whom caloric stimulation is conducted, the eyes will not move first toward the irrigated side and then return to midline. Pupillary dilation is not what is examined with this particular procedure.

5. A patient diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following? a. Clopidogrel b. Extended release dipyridamole c. Tissue plasminogen activator (tPA) d. Atorvastatin

c. Tissue plasminogen activator (tPA)

8. Bladder training in a male patient who has urinary incontinence after a stroke includes a. limiting fluid intake. b. keeping a urinal in place at all times. c. assisting the patient to stand to void. d. catheterizing the patient every 4 hours.

c. assisting the patient to stand to void.

2. The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the a. amount of cardiac output. b. O2 content of the blood. c. degree of collateral circulation. d. level of CO2 in the blood.

c. degree of collateral circulation.

___ strokes occur in smaller penetrating "end" arteries, tend occur in ppl w/ multiple medical dx's in the circulatory system, and are the "best" type of stroke to have. a. thrombotic b. TIA c. lacunar d. embolic e. hemorrhagic

c. lacunar

4. A patient is exhibiting word finding difficulty and weakness in his right arm. What area of the brain is most likely involved? a. brainstem. b. vertebral artery. c. left middle cerebral artery. d. right middle cerebral artery.

c. left middle cerebral artery.

5. The nurse explains to the patient with a stroke who is scheduled for angiography that this test is used to determine the a. presence of increased ICP. b. site and size of the infarction. c. patency of the cerebral blood vessels. d. presence of blood in the cerebrospinal fluid.

c. patency of the cerebral blood vessels.

Cortical blindness of the contralateral visual field, memory deficit, ataxia, & contralateral or ipsilateral hemiparesis are all effects of a stroke in the: a. middle cerebral artery (MCA) b. anterior cerebral artery (ACA) c. posterior cerebral artery (PCA)

c. posterior cerebral artery (PCA)

In strokes of the ___, the limbic system & memory can be greatly involved. If the damage reaches the pons or brainstem, the person usually dies. a. middle cerebral artery (MCA) b. anterior cerebral artery (ACA) c. posterior cerebral artery (PCA)

c. posterior cerebral artery (PCA)

6. A patient experiencing TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to a. decrease cerebral edema. b. reduce the brain damage that occurs during a stroke in evolution. c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow. d. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation.

c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow.

During an assessment of a patient's motor status with the Glasgow Coma scale, the patient assumes a posture of abnormal flexion. The nurse would document this finding as: a.) 5 b.) 4 c.) 3 d.) 2

c.) 3

c.) An intact brainstem Rationale: Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected in the auditory canal. A normal response that indicates intact function of cranial nerves III, IV, and VIII is conjugate eye movements toward the side being irrigated, followed by rapid nystagmus to the opposite side. Absent or dysconjugate eye movements indicate brainstem damage.

While cooking, your client couldn't feel the temperature of a hot oven. Which lobe could be dysfunctional? a.) Frontal b.) Occipital c.) Parietal d.) Temporal

c.) Parietal Rationale: The parietal lobe regulates sensory function, which would include the ability to sense hot or cold objects. The frontal lobe regulates thinking, planning, and judgment, and the occipital lobe is primarily responsible for vision function. The temporal lobe regulates memory.

c.) Promote carbon dioxide elimination. Rationale: The goal in treatment is to prevent acidemia by eliminating carbon dioxide.

c.) Restlessness and confusion Rationale: The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there's damage to the posterior pituitary.

c.) To promote osmotic diuresis to decrease ICP Rationale: Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern.

Muscle control and body coordination are controlled by the:

cerebellum.

A carotid endarterectomy is being considered as a treatment for a patient who has had several TIAs. The nurse explains to the patient that this surgery a. involves intracranial surgery to join a superficial extracranial artery to an intracranial artery b. is used to restore blood to the brain following an obstruction of a cerebral artery c. is used to open a stenosis in a carotid artery with a balloon and stent to restore cerebral circulation d. involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke

How does increased intracranial pressure affect brain tissue? a Transmits sensory and motor impulses to the cerebrum for interpretation b Alters electrical discharges in the brain to cause involuntary movement c Removes fluid from interstitial spaces to reduce excess body fluid d Causes an oxygen deficit that leads to changes in personality, memory, and judgment

Mrs. Boyer is a very active, independent 82-year-old woman who lives alone in an assisted living facility. She is in good health and has been treated for mild hypertension and anxiety in the past. She has come to the emergency department of the community hospital via ambulance after falling from a stool in her kitchen and becoming unconsciousness after the fall. During your assessment, Mrs. Boyer says to you, "The x-rays indicate that I didn't break anything, and I only have this bruise on my arm. Why all the fuss with repeatedly checking my blood pressure, my heart, and my eyes and asking me where I am and what time it is?" Which response by the nurse is the most appropriate? a "Sometimes when a person falls, the person doesn't remember what happened and doesn't know simple things like where they are and what day it is. By asking, it helps you remember." b "It is common practice to neurologically assess anyone who has a head injury frequently to identify any swelling that may become visible as the bruised areas fill with fluid over time. We may then need to complete additional tests if we notice any changes." c "Even if bones are not broken, damage to your head could result in a fractured skull, which may show up on a later x-ray because of swelling of your skin." d "Even if there is no indication of external injuries and no broken bones, head trauma from your fall may cause pressure to build up in your head, which could result in some neurologic damage. We are checking frequently to see if that is happening."

The incidence of ischemic stroke in patients with TIAs and other risk factors is reduced with administration of a. nimodipine (Nimotop) b. furosemide (Lasix) c. warfarin (Coumadin) d. daily low dose aspirin

The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? A Sternal rub B Pressure on the orbital rim C Squeezing the sternocleidomastoid muscle D Nail bed pressure

a patient comes to the ED with numbest of the face and an inability to speak. while the patient awaits examination, the symptoms disappear and the patient requests discharge. why should the nurse emphasize that it is important for the patient to be treated before leaving a. the patient has probably experience an asymptotic lacunar stroke b. the symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours c. neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off d. the patient has probably had a transient ischemic attack (TIA) which is a sign of progressive cerebrovascular disease

a patients wife asks the nurse why her husband did not receive the clot-busting medication (tissue plasminogen activators [tPA]) she has been riding about. her husband is diagnosed with a hemorrhagic stroke. what is the best response by the nurse to the patients wife? a. " he didn't arrive within the time frame for that therapy" b. " not everyone is eligible for this drug. has he had surgery lately?" c. "you should discuss the treatment of your husband with his doctors" d. "the medication you are talking about dissolves clots and could cause more bleeding in your husbands brain"

the nurse can best assist the patient and family in coping with the long-term effects of a stroke by doing what? a. informing family members that the patient will need assistance with almost all ADLs b. explain that the patents prestroke behavior will return as improvement progresses c. encouraging the patient and family members to seek assistance from family therapy or stroke support groups d. helping the patient and family understand the significance of residual stroke damage to promote problem solving and planning

what is a nursing intervention that is indicated for the patient with hemiplegia? a. the use of a footboard to prevent plantar flexion b. immobilization of the affected arm against the chest with a sling c. positioning the patient in bed with each joint lower than the joint proximal to it d. having the patient perform passive rang of motion (ROM) of the affected limb with the unaffected limb

what is the priority intervention in the ED for the patient with a stroke? a. IV fluid replacement b. giving osmotic diuretics to reduce cerebral edema c. starting hypothermia to decrease the oxygen needs of the brain d.maintaining respiratory function with a patent airway and oxygen administration

A client with a traumatic brain injury is diagnosed as being brain dead. Which assessment finding supports this diagnosis? a Aware of environment but unable to communicate b Complete unawareness of self c Neck extended and the jaw is clenched d Absence of spontaneous respirations

d Rationale Brain death is the cessation and irreversibility of all brain functions, including the brainstem. Since the brainstem controls respirations, absence of respirations would be a nursing assessment finding in brain death. Complete unawareness of self describes a persistent vegetative state. An extended neck with clenched jaw describes the decerebrate posturing. Aware of the environment but unable to communicate describes locked-in syndrome

The nurse is assessing a client who leads an active, healthy lifestyle. The client has no history of chronic health conditions, but is seeking health care due to visual changes and occasional headaches over the past few weeks. Upon assessment, which question should the nurse ask the client? a "Do you feel nauseated after eating? b "Are you having trouble moving your bowels? c "Have you noticed an increase in thirst? d "Are your headaches worse upon rising in the morning?

d Rationale With increased intracranial pressure, headaches are noted to be worse in the morning and with position changes. Projectile vomiting may occur, but nausea is not present. Thirst does not increase for clients with IICP. Clients with IICP typically do not experience constipation or trouble with bowel movements.

d Rationale: A hemorrhagic stroke usually causes a sudden onset of symptoms, which include neurologic deficits, headache, nausea, vomiting, decreased level of consciousness, and hypertension. Ischemic stroke symptoms may progress in the first 72 hours as infarction and cerebral edema increase.

Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is a(n) a. obese 45-year-old Native American. b. 35-year-old Asian American woman who smokes. c. 32-year-old white woman taking oral contraceptives. d. 65-year-old African American man with hypertension.

d Rationale: Nonmodifiable risk factors for stroke include age (older than 65 years), male gender, ethnicity or race (incidence is highest in African Americans; next highest in Hispanics, Native Americans/Alaska Natives, and Asian Americans; and next highest in white people), and family history of stroke or personal history of a transient ischemic attack or stroke. Modifiable risk factors for stroke include hypertension (most important), heart disease (especially atrial fibrillation), smoking, excessive alcohol consumption (causes hypertension), abdominal obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet (high in saturated fat and low in fruits and vegetables), and drug abuse (especially cocaine). Other risk factors for stroke include a diagnosis of diabetes mellitus, increased serum levels of cholesterol, birth control pills (high levels of progestin and estrogen), history of migraine headaches, inflammatory conditions, hyperhomocystinemia, and sickle cell disease.

What is the most frequent cause of increased intracranial pressure (IICP)? a Hemorrhage b Tumors c Abscesses d Cerebral edema

d The pressure exerted by cerebral edema, the increase in fluid that is retained in brain tissue, is the most common cause of increased intracranial pressure. Tumors and abscesses are space-taking lesions that increase the pressure within the cranial cavity. Hemorrhage, the pooling of blood within the cranial cavity, also exerts additional intracranial pressure.

A nurse caring for a client with a head injury would recognize which assessment finding as most indicative of increased ICP? a. vomiting b headache c dizziness d papilledema (eyes swell)

d papilledema is a hallmark symptom of ICP

A client with a head injury has ICP monitor in place. Cerebral perfusion pressure calculations are ordered. The clients ICP is 22 and the mean pressure reading is 70, what is the clients cerebral perfusion pressure? a. 92 b. 72 c. 58 d. 48

d subtract ICP from mean pressure

The nurse is assessing a client who leads an active, healthy lifestyle. The client has no history of chronic health conditions, but is seeking health care due to visual changes and occasional headaches over the past few weeks. Upon assessment, which question should the nurse ask the client? a. "Are you having trouble moving your bowels?" b. "Do you feel nauseated after eating?close double quote" c. "Have you noticed an increase in thirst? d. "Are your headaches worse upon rising in the morning?"

d. "Are your headaches worse upon rising in the morning?" Rationale With increased intracranial pressure, headaches are noted to be worse in the morning and with position changes. Projectile vomiting may occur, but nausea is not present. Thirst does not increase for clients with IICP. Clients with IICP typically do not experience constipation or trouble with bowel movements.

2. A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement? a. "I sense that you are happy it was not a stroke". b. "People who experience a TIA will develop a stroke". c. "TIA symptoms are short-lived and resolve within 24 hours". d. "TIA is a warning sign. Let's talk about lowering your risks."

d. "TIA is a warning sign. Let's talk about lowering your risks."

1. Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is a(n) a. obese 45-yr-old Native American. b. 35-yr-old Asian American woman who smokes. c. 32-yr-old white woman taking oral contraceptives. d. 65-yr-old African American man with hypertension.

d. 65-yr-old African American man with hypertension.

The patient has been diagnosed with a cerebral concussion. What should the nurse expect to see in this patient? a. Deafness, loss of taste, and CSF otorrhea b. CSF otorrhea, vertigo, and Battle's sign with a dural tear c. Boggy temporal muscle because of extravasation of blood d. Headache, retrograde amnesia, and transient reduction in LOC

d. A cerebral concussion may include a brief disruption in LOC, retrograde amnesia, and a headache, all of short duration. A basilar skull fracture may have a dural tear with CSF or brain otorrhea, rhinorrhea, hearing difficulty, vertigo, and Battle's sign. A temporal fracture would have a boggy temporal muscle because of extravasation of blood, Battle's sign, or CSF otorrhea.

Which cranial surgery would require the patient to learn how to protect the surgical area from trauma? a. Burr holes c. Cranioplasty b. Craniotomy d. Craniectomy

d. A craniectomy is excision of cranial bone without replacement, so the patient will need to protect the brain from trauma in this surgical area. Burr holes are opened into the cranium with a drill to remove blood and fluid. A craniotomy is opening the cranium with removal of a bone flap to open the dura. The replaced bone flap is wired or sutured after surgery. A cranioplasty replaces part of the cranium with an artificial plate.

How are the metabolic and nutritional needs of the patient with increased ICP best met? a. Enteral feedings that are low in sodium b. Simple glucose available in D5 W IV solutions c. Fluid restriction that promotes a moderate dehydration d. Balanced, essential nutrition in a form that the patient can tolerate

d. A patient with increased ICP is in a hypermetabolic and hypercatabolic state and needs adequate glucose to maintain fuel for the brain and other nutrients to meet metabolic needs. Malnutrition promotes cerebral edema and if a patient cannot take oral nutrition, other means of providing nutrition should be used, such as tube feedings or parenteral nutrition. Glucose alone is not adequate to meet nutritional requirements and 5% dextrose solutions may increase cerebral edema by lowering serum osmolarity. Patients should remain in a normovolemic fluid state with close monitoring of clinical factors such as urine output, fluid intake, serum and urine osmolality, serum electrolytes, and insensible losses.

The nurse suspects the presence of an arterial epidural hematoma in the patient who experiences a. failure to regain consciousness following a head injury. b. a rapid deterioration of neurologic function within 24 to 48 hours following a head injury. c. nonspecific, nonlocalizing progression of alteration in LOC occurring over weeks or months. d. unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC.

d. An arterial epidural hematoma is the most acute neurologic emergency and typical symptoms include unconsciousness at the scene with a brief lucid interval followed by a decrease in LOC. An acute subdural hematoma manifests signs within 48 hours of an injury. A chronic subdural hematoma develops over weeks or months.

A nurse at the public health center is discussing hearing screening guidelines with a 53-year-old client. How often would the nurse recommend the client getting his hearing checked? a. Every 10 years b. Prior to leaving the hospital c. Annually d. Every 3 years

d. Every 3 years Rationale The American Speech-Language-Hearing Association recommendations hearing screenings for individuals over the age of 50 every 3 years. Prior to the age of 50, it is recommended that hearing screens occur every 10 years or for a change in hearing or complaint of hearing loss. Infants are usually screened after their birth, and prior to leaving the hospital. Annual hearing screens for low-risk clients are not recommended.

In conducting a Glasgow Coma Scale Assessment on an infant, the nurse understands that the observation made to assess motor response in this age group differs in what way from the observation used in assessing motor response in an adult? a. The eyes open spontaneously in an infant, but only to noise in adults. b. Response to pain is not part of the assessment of the infant's motor response, while it is assessed in adults. c. The degree of flexion is assessed in infants, but not in adults. d. Infants are observed for spontaneous movement, while adults are asked to follow a command.

d. Infants are observed for spontaneous movement, while adults are asked to follow a command. Rationale Motor response in infants using the Glasgow Coma Scale is assessed by observing spontaneous movement while adults' ability to obey a command to move a body part is used with older children and adults. Observing for spontaneous eye opening is done with both infants and adults, but this assessment is in the category of "Eye opening" rather than "Motor response." Response to pain and degree of flexion are assessments of motor responses conducted on both infants and adults.

17. The nurse is caring for a patient diagnosed with a hemorrhagic stroke. The nurse recognizes that which of the following interventions is most important? a. Elevating the head of the bed at 30 degrees b. Monitoring for seizure activity c. Administering a stool softener d. Maintaining a patent airway

d. Maintaining a patent airway

Priority Decision: When assessing the body functions of a patient with increased ICP, what should the nurse assess first? a. Corneal reflex testing c. Extremity strength testing b. Pupillary reaction to light d. Circulatory and respiratory status

d. Of the body functions that should be assessed in an unconscious patient, cardiopulmonary status is the most vital function and gives priorities to the ABCs (airway, breathing, and circulation).

The patient is suspected of having a new brain tumor. Which test will the nurse expect to be ordered to detect a small tumor? a. CT scan c. Electroencephalography (EEG) b. Angiography d. Positron emission tomography (PET) scan

d. The positron emission tomography (PET) scan or magnetic resonance imaging (MRI) are used to reliably detect very small tumors. The computed tomography (CT) and brain scans are used to identify the location of a lesion. Angiography could be used to determine blood flow to the tumor and further localize it. Electroencephalography (EEG) would be used to rule out seizures.

Successful achievement of patient outcomes for the patient with cranial surgery would best be indicated by what? a. Ability to return home in 6 days c. Acceptance of residual neurologic deficits b. Ability to meet all self-care needs d. Absence of signs and symptoms of increased ICP

d. The primary goal after cranial surgery is prevention of increased ICP and interventions to prevent ICP and infection postoperatively are nursing priorities. The residual deficits, rehabilitation potential, and ultimate function of the patient depend on the reason for surgery, the postoperative course, and the patient's general state of health.

Skull x-rays and a computed tomography (CT) scan provide evidence of a depressed parietal fracture with a subdural hematoma in a patient admitted to the ED following an automobile accident. In planning care for the patient, what should the nurse anticipate? a. The patient will receive life support measures until the condition stabilizes. b. Immediate burr holes will be made to rapidly decompress the intracranial cavity. c. The patient will be treated conservatively with close monitoring for changes in neurologic status. d. The patient will be taken to surgery for a craniotomy for evacuation of blood and decompression of the cranium.

d. When there is a depressed fracture or a fracture with loose fragments, a craniotomy is indicated to elevate the depressed bone and remove free fragments. A craniotomy is also indicated in cases of acute subdural and epidural hematomas to remove the blood and control the bleeding. Burr holes may be used in an extreme emergency for rapid decompression or to aid in removing a bone flap but with a depressed fracture, surgery would be the treatment of choice.

3. Information provided by the patient that would help differentiate a hemorrhagic stroke from a thrombotic stroke includes a. sensory disturbance. b. a history of hypertension. c. presence of motor weakness. d. sudden onset of severe headache.

d. sudden onset of severe headache.

d.) Deceleration Rationale: Deceleration injury occurs when the brain stops rapidly in the cranial vault. As the skull ceases movement, the brain continues to move until it hits the skull. The force of deceleration causes injury at the site of impact. An example of this is a victim of a fall.

d.) Nail bed pressure Rationale: Motor testing on the unconscious client can be done only by testing response to painful stimuli. Nailbed pressure tests a basic peripheral response. Cerebral responses to pain are testing using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

Problems with memory and learning would relate to which of the following lobes? a.) Frontal b.) Occipital c.) Parietal d.) Temporal

d.) Temporal Rationale: The temporal lobe functions to regulate memory and learning problems because of the integration of the hippocampus. The frontal lobe primarily functions to regulate thinking, planning, and judgment. The occipital lobe functions regulate vision. The parietal lobe primarily functions with sensory function.

The initial treatment plan for patients with uncomplicated hypertension includes ___ and beta-blockers

diuretics

A patient whose speech is slurred and difficult to understand is experiencing:

dysarthria.

Which of the following is NOT a risk factor for stroke? a. age b. gender c. race d. heredity e. all are risk factors

e. all are risk factors

Tx for ___ strokes includes lowering arterial BP & surgery to remove the clot & decrease intracranial pressure. a. thrombotic b. TIA c. lacunar d. embolic e. hemorrhagic

e. hemorrhagic

___ strokes are caused by AV malformations, weakness of arterial walls, aneurysms, or head injuries. a. thrombotic b. TIA c. lacunar d. embolic e. hemorrhagic

e. hemorrhagic

22. What assessment finding requires immediate intervention if found while a patient is receiving Mannitol? A. An ICP of 10 mmHg B. Crackles throughout lung fields C. BP 110/72 D. Patient complains of dry mouth and thirst

he answer is B. Mannitol can cause fluid volume overload that leads to heart failure and pulmonary edema. Crackles in the lung fields represent pulmonary edema and requires immediate intervention. Option A is a normal ICP reading and shows the mannitol is being effective. BP is within normal limits, and dry mouth/thirst will occur with this medication because remember we are trying to dehydrate the brain to keep edema and intracranial pressure decreased.

Which of the following is not a clinical manifestation of hypertension

intermittent claudication

Problem with IV-TPA

only 1-3% of patients arrive in time to receive it

With prolonged uncontrolled hypertension, the patient may develop which complication

renal failure

What is the drug classification of Aspirin?

salicylate___

See first? 1. A NAP enters the room of the client diagnosed with Pneumocycstis cariniipnneumoia wearing gown, mask, gloves 2. The client who has just returned from a right pneumonectomy is placed in a room with the client diagnosed with COPD 3. toilet overflowing 4. TB patient ready for discharge

see #2 first because postop clients are considered "clean" and should not be placed with a client that is considered "dirty" #1 the NAP should be counseled for wrong PPE, standard precaution #3 is a problem but not most important #4 psychosocial need; physical needs take priority

stroke

You are caring for a 70-year-old female with signs and symptoms of an acute stroke. She is conscious, has secretions in her mouth, and is breathing at a normal rate with adequate depth. You should:

suction her oropharynx and apply 100% oxygen.

After a stroke, thrombolytic therapy ___ can help control the damage, but it must be given w/in ___ hours of the onset of the stroke to be effective.

t-PA; 3

A transient ischemic attack (TIA) occurs when:

the normal body processes destroy a clot in a cerebral artery.

Which of the following is a clinical manifestation of hypertension

tinnitus, blurred vision, nosebleed

What is Dexamethasone (decadron) used for?

to decrease cerebral edema and pressure;

What is phenytoin (Dilantin) used for?

to prevent seizures.

What is methyldopa (Aldomet) used for?

to reduce blood pressure

Patients with hypertension are often symptom free

true

Primary hypertension has no discernible cause

true

When communicating with a client who has sensory (receptive) aphasia, the nurse should: a) speak loudly and articulate clearly. b) allow time for the client to respond. c) give the client a writing pad. d) use short, simple sentences.

use short, simple sentences. Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.

The principal clinical difference between a stroke and hypoglycemia is that patients with hypoglycemia:

usually have an altered mental status or decreased level of consciousness.

A parent brings a 12-year-old to the clinic after a fall from a bicycle. Which statement by the nurse is a health promotion intervention to minimize future risk of increased intracranial pressure? "Thank goodness your child sustained only a few cuts and bruises." "Let's hope this doesn't happen again." "What will you do in the future to prevent this from happening?" "How do you feel about your child wearing a helmet while riding their bicycle?"

"How do you feel about your child wearing a helmet while riding their bicycle?" Health promotion related to intracranial regulation generally involves anticipatory guidance related to the client's age, development, and activities. It also includes providing information about protective equipment for outdoor activities and vehicle restraint systems. While the other answer options are valid statements, by asking an open-ended question with the suggestion of protective equipment, a conversation can begin.

The nurse is caring for a client with increased intracranial pressure (IICP) from a cervical injury. Which statement by the nurse indicates an understanding of how to position the client? "I will ask the client to assist by pushing on the bed with their feet and hands." "I will ask another nurse to help me lift the client toward the head of the bed." "The head of the bed should be kept flat to make it easier to move the client." "The head of the bed should be kept at 90 degrees to assist with venous drainage from the brain."

"I will ask another nurse to help me lift the client toward the head of the bed." To prevent a further increase in intracranial pressure (ICP), the nurse should ask for assistance from another staff member. This prevents the client from pushing with their hands or feet against the bed, both of which can increase ICP. The prone, or flat, position should be avoided; the head of the bed should be kept at 30 degrees to assist with venous drainage from the brain. It is not necessary to sit the client up at a 90-degree angle.

A client is ready for discharge from the hospital after being treated for increased intracranial pressure. Which statement confirms that the client's spouse understands the discharge instructions? "My spouse should avoid alcohol as it can increase the risk of injury." "My spouse can take any over-the-counter medication." "My spouse can continue to use a nicotine patch." "My spouse does not need to do anything differently when we get home."

"My spouse should avoid alcohol as it can increase the risk of injury." Nurses should instruct clients to avoid alcohol, which can increase the risk of injury, and products that contain nicotine, which increase the heart rate and blood pressure and cause vasoconstriction that can increase the client's risk of stroke. The healthcare provider must review all over-the-counter medications for possible contraindications.

The spouse of a client who has increased intracranial pressure (IICP) asks the nurse what is happening in her husband's brain. Based on the pathophysiology, which is the best response by the nurse? "There must be a tumor causing the increase in pressure we are seeing." "Your husband's low blood pressure is causing the brain to have too much fluid in it." "The blood flow to the brain has increased and is causing an increased pressure." "Something in the brain, its blood, or surrounding fluid is off balance and has caused an increased pressure."

"Something in the brain, its blood, or surrounding fluid is off balance and has caused an increased pressure." Rationale Three components make up the pressure-volume equilibrium, the brain, the blood, and the cerebrospinal fluid. Any of these components can change and affect the other two and cause an imbalance and resulting increase in pressure. Low blood pressure and increased blood flow to the brain would not affect the pressure in the brain and cause it to increase. Tumors may be involved but without knowing the facts, the nurse should not mention this.

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." "The occupational therapist will assist you in learning to walk using a walker." "Use the left arm to bathe, brush teeth, comb hair, and eat." "The occupational therapist will teach you how to promote upper extremity strength."

"When getting dressed, first put clothing on the left side."

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.

Which action by the nurse can help to avoid pitfalls that can result in client harm? (Select all that apply.) A. Incorporating client preferences as possible when prioritizing care B. Knowing client healthcare concerns C. Prioritizing client care appropriately D. Following ethical care practices E. Delegating care only when absolutely necessary

A. Incorporating client preferences as possible when prioritizing care B. Knowing client healthcare concerns C. Prioritizing client care appropriately D. Following ethical care practices Rationale: To avoid common pitfalls when providing care, the nurse should follow ethical care practices, know client healthcare concerns, prioritize care appropriately, and incorporate client preferences as possible when prioritizing client care. Appropriate delegation can be helpful to the nurse when prioritizing care, so it should not be avoided but used appropriately.

The nurse is organizing care for the day for the assigned clients. Which client should the nurse give highest prioritization to ensure appropriate medication administration? A. A client who is receiving daily dialysis B. A client receiving several intravenous antibiotics, each to be infused over 30-60 minutes C. A client with unstable vital signs receiving multiple blood pressure medications D. A client with diabetes requiring insulin coverage QID

B. A client receiving several intravenous antibiotics, each to be infused over 30-60 minutes Rationale: When the nurse is caring for multiple clients, setting of priorities is determined by the significance of the interventions for the clients. In this situation, the client receiving several intravenous antibiotics, each of which need to be infused over a specific time frame, would need to be prioritized to ensure adequate medication administration. QID insulin coverage, regularly scheduled blood pressure medications, and daily scheduled dialysis would not have higher prioritization than would the client receiving multiple intravenous antibiotics that must be administered in the correct order over the appropriate time frame.

The nurse in an emergency department (ED) shares with a fellow nurse that, due to the busy pace of the day, he has not even been able to go to the bathroom since he arrived for his shift 6 hours ago. Which response by the fellow nurse should best address this situation? A. Encouraging the nurse to let the supervisor know so that appropriate actions can be taken B. Offering to oversee the nurse's clients so that a 15-minute break can be taken C. Listening to the nurse's concerns and offering verbal encouragement to make it through the rest of the shift D. Discussing better ways to prioritize and manage time with the nurse so that in the future he will be able to take needed breaks

B. Offering to oversee the nurse's clients so that a 15-minute break can be taken Rationale: It is important that nurses take quick 15-minute breaks to refresh, reenergize, and take care of bodily functions, so the best response by the fellow nurse would be to cover for the nurse to allow this break to occur. Encouraging the nurse to let the supervisor know, listening to the nurse's concerns, and discussing better ways to manage time and prioritize would not provide the much-needed break for the nurse.

The nurse is assessing a client's peripheral circulation after cardiac catheterization. Which finding is the highest priority? A. Pulses are palpable and bounding. B. The femoral site is soft and free of hematoma or bleeding. C. The client's toes are warm and pink. D. The client is experiencing numbness in the toes.

Rationale: After cardiac catheterization, a finding that the client is experiencing numbness may indicate a complication of the procedure, thus it would be the highest priority. Warm and pink toes, palpable, bounding pulses, and a femoral site free of hematoma and bleeding are all normal findings.

Name three modifiable risk factors for an Ischemic Stroke.

• Asymptomatic carotid stenosis • Atrial fibrillation • Diabetes (associated with accelerated atherogenesis) • Dyslipidemia • Excessive alcohol consumption • Hypercoagulable states • Hypertension (controlling hypertension, the major risk factor, is the key to preventing stroke) • Migraine • Obesity • Sedentary lifestyle • Sleep apnea • Smoking

Unit 7

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