chapter 42
30) A patient recovering from a stroke has agnosia. What should the nurse do when caring for this patient? 1. Frequently repeat the names of familiar persons and objects in the patient's room when providing care. 2. Help the patient move hands and arms through the motions of combing hair and getting dressed. 3. Speak with a normal tone of voice near the ear on the unaffected side. 4. Talk normally to the patient but allow adequate time for the patient's short responses.
Answer: 1 Explanation: Agnosia is the inability to recognize one or more subjects that were previously familiar, which can be visual, tactile, or auditory. The nurse can assist the patient by frequently repeating names of familiar persons and objects in the patient's room when providing care.
25) The nurse is caring for a patient with transient ischemic attack (TIA). Which medication should the nurse expect to be prescribed for this patient? 1. Antiplatelet agents 2. Fibrinolytic therapy 3. Anticoagulant therapy 4. Corticosteroids
Answer: 1 Explanation: Antiplatelet agents are often used to prevent TIAs and strokes in patients who have had previous strokes. These drugs prevent clot formation and blood vessel occlusion. They include aspirin, clopidogrel (Plavix), dipyridamole (Persantine), and ticlopidine (Ticlid).
2) The nurse notes that a patient with damage to the diencephalon region of the cerebrum is demonstrating a breathing pattern where regular periods of deep, rapid breathing are followed by periods of apnea. How should the nurse document this breathing pattern? 1. Cheyne-Stokes respirations 2. Apneustic respirations 3. Neurogenic hyperventilation 4. Ataxic respirations
Answer: 1 Explanation: Cheyne-Stokes respirations are a change in breathing pattern, alternating regular periods of deep, rapid breathing with periods of apnea, and are seen in many patient conditions in the clinical setting.
35) A patient is brought for medical care with symptoms of a ruptured cerebral aneurysm. Which should the nurse expect to assess in this patient? Select all that apply. 1. Photophobia 2. Muscle cramps 3. Severe neck pain 4. Nausea and vomiting 5. Sudden excruciating headache
Answer: 1, 3, 4, 5 Explanation: 1. The manifestations of a ruptured intracranial aneurysm include photophobia due to meningeal irritation. 3. The manifestations of a ruptured intracranial aneurysm include severe neck pain. 4. The manifestations of a ruptured intracranial aneurysm include nausea and vomiting. 5. The manifestations of a ruptured intracranial aneurysm include a sudden explosive headache.
20) A patient is diagnosed with doll's-eye movements. What should the nurse expect to assess in this patient? 1. The eyes remain fixed as the head is turned. 2. The eyes appear to move in the direction opposite to the motion of the head, when the head is gently rotated. 3. The eyes open and close when the neck is flexed and extended. 4. The pupils remain fixed and dilated.
Answer: 2 Explanation: 1. If doll's-eye movements are absent, the eyes will remain fixed as the head is turned.
13) While riding in a car that hit a tree, a patient's head hit the windshield (coup) and then the brain rebounded within the skull toward the opposite side (contrecoup). For which type of traumatic brain injury should the nurse plan care for this patient? 1. Acceleration-deceleration 2. Rotational 3. Contact 4. Stationary
Answer: 1 Explanation: 1. Acceleration-deceleration injury (linear injury) occurs when the head hits an object and the brain rebounds within the skull.
14) Following a fall, a patient experiences a brief loss of consciousness but is now complaining of a headache, has vomited twice, has a dilated pupil on the same side as a hematoma over the temporal area, and is currently having a seizure. What should the nurse anticipate regarding the care of this patient? 1. This is an emergency situation that is likely due to an epidural hematoma and requires surgery. 2. This is a controlled situation once the seizure stops. 3. This is a serious situation in which a subdural hematoma is developing and requires surgery. 4. This is a typical situation seen with most patients who fall and will subside with observation.
Answer: 1 Explanation: 1. Classic signs of an epidural hematoma include a loss of consciousness followed by a brief lucid period before rapid deterioration.
19) The nurse is caring for a patient with a head injury involving cerebral edema and increased intracranial pressure (IICP). To prevent further transient increases from occurring, the nurse should implement what intervention? 1. Implement measures to help the patient avoid coughing and straining. 2. Position the patient in the supine position with the head of the bed at 30 degrees. 3. Initiate oxygen administration. 4. Initiate and monitor an IV with normal saline.
Answer: 1 Explanation: 1. Coughing and straining can cause transient increases in ICP and should be avoided in this situation.
6) The nurse is caring for a patient recovering from a craniotomy. How should the nurse position this patient? 1. Low Fowler's (head of bed up 30 degrees) 2. Flat 3. High 4. High Fowler's (head of bed up 45 degrees)
Answer: 1 Explanation: 1. Place the patient's head at 30 degrees for optimal draining of cerebrospinal fluid and to prevent increased intracranial pressure.
27) The nurse is caring for a patient in the postoperative unit following carotid endarterectomy. How should the nurse position the patient? 1. On the unoperated side, either in a flat position or with the head of the bed elevated 30 degrees. 2. On the operated side with the head of the bed in semi-Fowler's position. 3. On the unoperated side with a small towel placed directly against the operative site. 4. On the operated side with a pressure dressing over the operative site.
Answer: 1 Explanation: 1. Position the patient on the unoperated side and either maintain a flat position or elevate the head of the bed 30 degrees as prescribed.
11) The nurse is identifying problems for a patient with a seizure disorder. Which problem should the nurse identify as being this patient's greatest psychosocial need? 1. Anxiety 2. Self-Care Deficit 3. Altered Activity: Exercise 4. Altered Body Image
Answer: 1 Explanation: 1. The patient will exhibit anxiety, manifested in questions about the ability to work, drive a car, and feelings of embarrassment about having a seizure in public.
18) The nurse is planning a seminar about headaches for a community group. What type of headache should the nurse describe as having a strong familial connection, affects females three to one over males, and results in lost productivity? 1. Migraine 2. Cluster 3. Stress 4. Sinus
Answer: 1 Explanation: 1. Twenty million people experience migraines, which can last from a few hours to several days. Many require emergency department treatment.
28) The nurse is completing discharge teaching to a patient following hospitalization for a seizure disorder who is being prescribed phenytoin (Dilantin). What should the nurse include in these instructions? 1. "Maintain good oral hygiene, use a soft toothbrush, massage the gums, and floss daily." 2. "Carry identification indicating the type of seizures for which you are being treated." 3. "You will need to have your sodium level monitored." 4. "If you skip a dose, make sure you double the dose the next day."
Answer: 1 Explanation: Phenytoin causes gingival hyperplasia, which results in soft, enlarged gums that are prone to bleeding. Oral hygiene using a soft toothbrush, massaging the gums, flossing daily, and scheduling regular dental checkups are included in discharge teaching.
21) The nurse is caring for a patient who had a craniotomy for a brain tumor and has developed postoperative leakage of cerebrospinal fluid (CSF) from the nose. Which action should the nurse take when caring for this patient? Select all that apply. 1. Keep patient turned on side of leakage and keep the head of the bed elevated 20 degrees. 2. Assess the patient for constant swallowing. 3. Observe for thick, yellow, odorous drainage. 4. Insert sterile packing into the area. 5. Encourage the patient to blow the nose frequently.
Answer: 1, 2 Explanation: 1. Appropriate interventions include positioning the patient on the side of leakage if it is from the ear and keeping the head of the bed elevated to 20 degrees if the leak is from the nose. 2. Assess the patient for constant swallowing.
3) The nurse is caring for a patient who will be evaluated for brain death. What should the nurse expect to be evaluated in this patient? Select all that apply. 1. Absent motor and reflex movements 2. Flat electroencephalogram (EEG) on successive EEGs 3. No spontaneous respiration 4. Pupils are equal and responsive to light 5. Criteria present for at least 15 minutes
Answer: 1, 2, 3 Explanation: 1. Absent motor and reflex movements are part of brain death criteria. 2. Flat electroencephalogram (EEG) on successive EEGs is part of brain death criteria. 3. Lack of spontaneous respiration is part of brain death criteria.
33) The nurse is instructing a patient with a brain tumor about a scheduled craniotomy. What should the nurse include in this teaching? Select all that apply. 1. The tumor is excised. 2. The bone is cut between the burr holes. 3. The bone flap is returned to the opening. 4. A series of burr holes is made in the skull. 5. Plastic material is placed over the opening.
Answer: 1, 2, 3, 4 Explanation: 1. A craniotomy is a surgical opening into the cranial cavity. The tumor is excised. 2. A craniotomy is a surgical opening into the cranial cavity. The bone between burr holes is cut. 3. A craniotomy is a surgical opening into the cranial cavity. The bone flap is returned to the opening. 4. A craniotomy is a surgical opening into the cranial cavity. A series of burr holes is made in the skull.
1) A patient without a history of previous seizures experiences two tonic‒clonic seizures in succession while the nurse is in the patient's room. List in priority order the actions the nurse should take. Choice 1. Turn the patient on his or her side. Choice 2. Reorientation of the patient to time, person, and place. Choice 3. Start oxygen via face mask. Choice 4. Protect patient from environmental harm.
Answer: 1, 2, 3, 4 Explanation: Choice 1. Nursing care of patients during a seizure should first focus on maintaining a patent airway. During a seizure, the tongue may fall back and obstruct the airway, the gag reflex may be depressed, and secretions may pool at the back of the throat. To open and maintain a patent airway, the patient should be turned on his or her side. Choice 2. After ensuring the airway is patent, the nurse should protect the patient from harm. Tonic‒clonic seizures occur without warning, and the patient will have alternating contraction and relaxation of the muscles of all extremities. During the clonic phrase of the seizure, patients are at risk for head injury and fractures of the extremities. Choice 3. After the clonic phase of seizure activity, if needed, oxygen can be administered by face mask. Choice 4. Consciousness returns gradually; it may take hours before the patient is fully aware and alert, and reorientation to person, place, and time can be achieved.
23) A patient with increased intracranial pressure is prescribed mannitol (Osmitrol). What should the nurse do when providing this medication? Select all that apply. 1. Use an in-line filter for IV administration. 2. Do not administer the medication if crystals are noted in the solution. 3.Assess patient for signs of fluid retention. 4. Monitor central venous pressure (CVP) and pulmonary artery pressures (PAP) before and every hour throughout administration. 5. Discontinue the drug immediately if the patient complains of a headache.
Answer: 1, 2, 4 Explanation: 1. Mannitol should be administered with an in-line filter. 2. The solution should be checked for presence of crystals. If observed, do not administer the solution. 4. Monitoring of CVP and PAP, vital signs, and urinary output should be done before and hourly during administration.
34) While reviewing newly prescribed orders, the nurse begins to prepare a patient to receive plasminogen activator alteplase (tPA). What should the nurse realize about this patient's health problem? Select all that apply. 1. The patient had an ischemic stroke. 2. The patient had a hemorrhagic stroke. 3. The patient has uncontrollable seizure activity. 4. The patient had a stroke less than 3 hours ago. 5. The patient's systolic blood pressure is greater than 200 mmHg.
Answer: 1, 4 Explanation: 1. Fibrinolytic therapy, using a tissue plasminogen activator such as recombinant tissue-type plasminogen activator alteplase (tPA), is used to treat ischemic stroke. The drug converts plasminogen to plasmin, resulting in fibrinolysis of the clot. To be effective, it must be given after confirming (with a CT scan) that the patient has not had a hemorrhagic stroke. 4. Fibrinolytic therapy, using a tissue plasminogen activator such as recombinant tissue-type plasminogen activator alteplase (tPA), is used to treat ischemic stroke. The drug converts plasminogen to plasmin, resulting in fibrinolysis of the clot. To be effective, it must be given IV within 3 hours of the onset of manifestations.
15) A patient has a seizure that involves a blank stare, unresponsiveness to questions, and smacking of the lips that lasts less than a minute. How should the nurse categorize this seizure? 1. Partial 2.Absence 3. Tonic‒clonic 4. Status epilepticus
Answer: 2 Explanation: Absence (or petit mal) seizures involve a blank stare, unresponsiveness to questions, and smacking of the lips.
8) A patient is described as having decerebrate posturing after a motor vehicle crash. Which position should the nurse expect to assess in this patient? 1. The arms are folded over the chest and spasms are rhythmic. 2. The arms and legs are hyperextended and arms are hyperpronated. 3. The arms are pulled inward and the head is turned to the side. 4. The arms and legs have tonic‒clonic seizure activity.
Answer: 2 Explanation: Decerebrate posture is displayed by hyperextension of the arms and legs and hyperpronation of the arms. Decerebration is considered a sign that the patient has a serious injury with a poor prognosis.
9) A patient being treated for a fall has a dilated pupil on the right and a hematoma in the right temporal area. What should these findings indicate to the nurse? 1. The process affecting the pupil is occurring on the opposite side and is unrelated to the right temporal hematoma. 2.The process affecting the pupil is occurring locally on the right side (ipsilateral pupil dilation). 3. The process affecting the right pupil is temporary and soon both pupils will be equal in size. 4. The process causing the right pupil to dilate is a result of a metabolic process.
Answer: 2 Explanation: Generally, when a process is occurring locally, the pupil on the same side (ipsilateral) is affected.
31) The nurse is caring for a patient with a seizure disorder who is scheduled for surgery to remove the epileptogenic focus within the cerebral cortex. Which criteria did the patient meet to be a candidate for this type of surgery? Select all that apply. 1. The patient desires to have a family. 2. There is one focal point located within the patient's brain. 3. The patient cannot afford antiseizure medication prescribed. 4. Medications have not been successful to control seizure activity. 5. The patient is unable to hold a fulltime job because of seizure activity.
Answer: 2, 4, 5 Explanation: 2. Resective surgery, with removal of the epileptogenic focus, is an option for patients whose seizures are not well controlled with AEDs. Candidates for this type of surgery include those who have a unilateral focus. 4. Resective surgery, with removal of the epileptogenic focus, is an option for patients whose seizures are not well controlled with AEDs. Candidates for this type of surgery include those who are unresponsive to medical management. 5. Resective surgery, with removal of the epileptogenic focus, is an option for patients whose seizures are not well controlled with AEDs. Candidates for this type of surgery include those who have impaired quality of life from seizures.
26) The nurse is teaching a community education class on warning signs of stroke and transient ischemic attacks (TIAs). What should be included in this presentation? Select all that apply. 1.African Americans are a high-risk group for strokes 2. Sudden confusion, difficulty speaking, or difficulty understanding speech 3. Sudden trouble walking, dizziness, or loss of coordination 4. Arrival time at the hospital should be within three hours of onset for drugs to be effective 5. Sudden weakness or numbness of the face, arm, or leg, especially on one side of the body
Answer: 2,3,5 Explanation: 5. Warning signs of stroke and TIAs include sudden weakness or numbness of the face, arm, or leg, especially on one side of the body. 2. Warning signs of stroke and TIAs include sudden confusion, difficulty speaking, or difficulty understanding speech. 3. Warning signs of stroke and TIAs include sudden trouble walking, dizziness, or loss of coordination
12) A patient has a head injury caused by a swinging bat. For which type of injury should the nurse plan care for this patient? 1. An acceleration-deceleration injury 2. A deceleration 3. Contact 4. Rotational
Answer: 3 Explanation: Contact phenomena injury is sustained when the head is struck by a moving object, such as a swinging bat.
29) The nurse is caring for a patient with an intracranial pressure monitoring device. For which potential problem should the nurse plan care for this patient? 1.Changes in skin integrity 2. Confusion 3. Possible infection 4. Changes in mobility status
Answer: 3 Explanation: Intracranial monitoring is more invasive than other monitoring devices and disrupts skin and skeletal barriers. It is often used on patients with impaired immune defenses. It necessitates frequent flushing and monitoring and may be an open system, which offers increased opportunity for pathogens to enter and grow.
4) The nurse is caring for a patient with an altered level of consciousness (LOC). Which intravenous fluid should the nurse expect to be prescribed for this patient? 1. Dextrose 5% in water 2. 0.45% normal saline 3. Isotonic or hypertonic 4. Dextrose 5% in 0.45% normal saline
Answer: 3 Explanation: Isotonic (0.9% normal saline) or slightly hypertonic (lactated Ringer's) IV solutions are used in the patient with altered LOC.
17) The nurse is caring for a patient with migraine headaches. Which medication should the nurse expect to be prescribed prophylactically for this patient? 1. Zolmitriptan (Zomig) 2. Acetaminophen (Tylenol) 3. Propranolol hydrochloride (Inderal) 4. Sumatriptan (Imitrex)
Answer: 3 Explanation: Propranolol hydrochloride (Inderal) is a beta-blocker that prevents dilation of vessels in the pia mater and inhibits serotonin uptake.
24) The nurse instructs a patient on actions to help reduce the onset of migraine headaches. Which patient statement indicates that additional teaching is required? 1. "I will need to drink caffeine-free soft drinks and coffee from now on." 2. "Reading food labels is important since I have to avoid tyramine." 3."I will switch to red wine rather than continuing to drink white wine." 4. "Stress management classes will be a good approach to take."
Answer: 3 Explanation: Suggestions to decrease the incidence of migraine headaches includes reducing or eliminating red wine.
7) A patient is in the emergency department following a head injury. What should the nurse realize as being the most accurate sign of developing increased intracranial pressure (IICP)? 1.Decreasing respiratory rate 2. Elevated diastolic blood pressure 3. Decreasing level of consciousness 4. Pupils are equal
Answer: 3 Explanation: The brain is very sensitive to the level of oxygenation. As hypoxia develops, it will negatively affect the level of consciousness.
36) A patient is diagnosed with a stable arteriovenous malformation of the right parietal lobe. What teaching should the nurse provide to this patient? Select all that apply. 1. Engage in regular exercise. 2. Limit sodium and water intake. 3. Engage in stress-reduction activities. 4. Take antiseizure medication as prescribed. 5. Take antihypertensive medication as prescribed.
Answer: 3, 4, 5 Explanation: 3. Nursing care depends on the condition of the malformation. If hemorrhage has not occurred, teach the patient to avoid activities that raise blood pressure or could cause injury. 4. Nursing care depends on the condition of the malformation. If hemorrhage has not occurred, the patient is usually given medications to prevent seizures. 5. Nursing care depends on the condition of the malformation. If hemorrhage has not occurred, the patient is usually given medications to control blood pressure.
32) The nurse notes on the surgical schedule that a patient is scheduled for cranial burr holes. For which health problem does the nurse realize this type of surgical approach is indicated? Select all that apply. 1. Ischemic stroke 2. Migraine headache 3. Epidural hematoma 4. Hemorrhagic stroke 5. Acute subdural hematoma
Answer: 3, 5 3. The treatment of choice for epidural hematomas and large acute subdural hematomas is surgical evacuation of the clot. This can often be performed through burr holes made into the skull. 5. The treatment of choice for epidural hematomas and large acute subdural hematomas is surgical evacuation of the clot. This can often be performed through burr holes made into the skull.
5) The nurse is caring for an unconscious patient. What should the nurse expect to be prescribed for this patient when the cough reflex disappears? 1. Continuous pulse oximetry instead of intubation 2. Frequent suctioning with a tonsil-tip suction device 3. Close observation as the patient is fed 4. Intubation and mechanical ventilation
Answer: 4 4. This patient is at risk for impaired airway and aspiration. Oximetry would be done in addition to intubation and mechanical ventilation.
16) A patient is having a tonic‒clonic seizure. What should the nurse make a priority when caring for this patient? 1.Obtain vital signs 2. Insert a bite block to prevent the patient from swallowing the tongue. 3. Ask the staff to hold the patient tightly. 4. Protect the patient from injury. .
Answer: 4 Explanation: Because of the lack of warning with tonic-clonic seizures, head injury, fractures, burns, or motor vehicle crashes may occur secondarily to seizure activity.
10) A patient is experiencing status epilepticus. Which medication should the nurse expect to be prescribed for this patient? 1. Gabapentin (Neurontin) and lamotrigine (Lamictal) 2. Oral glucose 3. Phenytoin (Dilantin) orally 4. Lorazepam (Ativan) IV
Answer: 4 Explanation: Lorazepam (Ativan) can be used IV to stop the seizure and is an appropriate treatment order.
22) A patient with a brain tumor asks why a chest x-ray is needed when the tumor is in the head. What is the nurse's most appropriate response? 1."The escort is here to take you to radiology, so we'll discuss this when you return." 2. "This is just a precautionary measure. The physician often prescribes chest x-rays." 3. "Don't get so upset about this! It's routine. The doctor will talk to you later." 4. "The physician may be trying to determine if this is a metastatic brain tumor, as the most common source of these tumors is cancer of the lung."
Answer: 4 Explanation: The most common source of metastatic brain tumors is cancer of the lung.
