Course Point Pathophysiology Ch. 16

The MRA scan of a client with a suspected stroke reports ruptured berry aneurysm. The nurse plans care for a client with:

Subarachnoid hemorrhage

The nurse working in an emergency room is caring for a client who is exhibiting signs and symptoms of a stroke. What does the nurse anticipate that the physician's orders will include?

CT scan

The parent of an infant who developed hydrocephalus while in utero is very concerned that the child will have significant intellectual dysfunction. The best response to the parent would be:

"Because the skull sutures are not fused there may be no brain damage."

The spouse of a client who has been in a long-term care facility for a few months due to a brain injury that caused a vegetative state asks the nurse why the client is still being fed through the gastrostomy tube. What is the nurse's best response?

"To avoid aspiration into the lungs."

Global and focal brain injuries manifest differently. What is almost always a manifestation of a global brain injury?

Altered level of consciousness

A nurse is teaching a client newly diagnosed with a seizure disorder. Which statement is most important for the nurse to provide regarding antiepileptic medications?

Antiepileptic medications should never be discontinued abruptly.

What medication teaching should be done for a woman of childbearing age with a seizure disorder?

Antiseizure drugs increase the risk for congenital abnormalities.

The nurse is caring for a client with a brain tumor when the client begins to vomit. Which intervention should the nurse do first?

Assess for other signs/symptoms of increased intracranial pressure.

A teenager has been in a car accident and experienced an acceleration-deceleration head injury. Initially, the client was stable but then started to develop neurological signs/symptoms. The nurse caring for this client should be assessing for which type of possible complication?

Brain contusions and hematomas

A client has sustained a severe, diffuse brain injury that resulted in seriously compromised brain function. The client is at greatest risk for:

Brain death

Which intracranial volume is most capable of compensating for increasing intracranial pressure?

Cerebrospinal fluid

A client's emergency room report includes the presence of a contrecoup injury. The nurse plans care for a client with which of the following?

Closed head injury opposite the area of impact

The nurse developing a plan of care for a client with a cerebral cortex injury should include assessment for which of the following?

Difficulty concentrating

A child is being seen in the emergency department (ED) after ingesting crayons with lead in them. He is disoriented and having seizures. The provider suspects he has which of the following?

Encephalitis

An adult client is admitted to the emergency department reporting a headache, stiff neck and lethargy. Based on the intake interview, the nurse suspects that the client had a seizure the day before. The client's vital signs are within reference range with the exception of a heart rate of 102 bpm and oral temperature of 38.6°C (101.5°F). Which diagnosis is most likely?

Encephalitis

Excessive activity of the excitatory neurotransmitters and their receptor-mediated effects is the cause of which type of brain injury?

Excitotoxic

An emergency room nurse receives a report that a client's Glasgow Coma Scale (GCS) is 3. The nurse prepares to care for a client with which of the following?

Flaccid motor response

Which would the nurse consider an ischemic stroke?

Lacunar infarct

The nurse reading a client's lumbar puncture results notifies the physician of findings consistent with meningitis when which sign/symptom is noted?

Large number of polymorphonulcear neutrophils

The emergency room doctor suspects a client may have bacterial meningitis. The most important diagnostic test to perform would be:

Lumbar puncture

A client has started having uncontrolled seizures that are not responding to usual medications. Nurses working with the client must pay special attention to which priority aspects of this client's care? Assessment of:

Respiratory status and oxygen saturation

The nurse is caring for an older adult client with hemiplegia following a stroke. While planning the client's care, the nurse knows the client is at risk for developing which condition?

Muscle atrophy

Following a car accident in which the driver did not have his seatbelt on, the client is diagnosed with a traumatic brain injury requiring emergent craniotomy for severe cerebral edema. Which assessments should the nurse report immediately since they correspond to a supratentorial herniation progressing to midbrain involvement? Select all that apply.

Respiration rate of 40 breaths/min Pupils fixed at ~ 5 mm in diameter Decerebrate posturing following painful stimulation of the sternum

The nurse assessing a client with a traumatic brain injury assesses for changes in which neurologic component? Select all that apply.

Sensory function Level of consciousness Cognition Motor function

An adult client has been admitted to a rehabilitation center after hospital treatment for an ischemic stroke. Which aspect of the client's history would be considered to have contributed to his stroke?

The client's blood pressure has historically been in the range of 150/90 to 160/100 mm Hg.

A client suffering a thrombotic stroke is brought into the emergency department by ambulance and the health care team is preparing to administer a synthetic tissue plasminogen activator for which purpose?

Thrombolysis

The most common cause of an ischemic stroke is which of the following?

Thrombosis

A client who is being seen in the outpatient clinic reports a single episode of unilateral arm and leg weakness and blurred vision that lasted approximately 45 minutes. The client is most likely experiencing:

Transient ischemic attack (TIA)

A client is brought to the emergency department and is diagnosed with an ischemic stroke confirmed by CT scan. The most important treatment for this client would be to:

administer IV tissue plasminogen activator (tPA).

The spouse of a client admitted to the hospital after a motor vehicle accident reports to the nurse that the client has become very drowsy. The nurse should:

assess the client for additional signs/symptoms of increased intracranial pressure.

A soccer player has been diagnosed with a brain contusion after being injured in a game. The best explanation of the injury by the nurse would be that:

bruising on the surface of the brain occurred.

A client has suffered a stroke that has affected his speech. The physician has identified the client as having expressive aphasia. Later in the day, the family asks the nurse to explain what this means. The most accurate response would be aphasia that is:

characterized by an inability to communicate spontaneously with ease or translate thoughts or ideas into meaningful speech or writing.

The parents of an infant born with hydrocephalus are concerned about the size of the baby's head. The doctors are telling them that the infant needs the surgical placement of a shunt. The nurse caring for the infant in the neonatal intensive care unit explains that placement of a shunt will:

decrease the likelihood of further neurological deficits.

A client has experienced a pontine stroke which has resulted in severe hemiparesis. What priority assessment should the nurse perform prior to allowing the client to eat or drink from the food tray?

gag reflex assessing for problems with chewing and swallowing

The chart of a client admitted because of seizures notes that the seizure activity began simultaneously in both cerebral hemispheres. The nurse should interpret this to mean that the client experienced:

generalized seizure.

A client has developed global ischemia of the brain. The nurse determines this is:

inadequate to meet the metabolic needs of the entire brain.

As the nurse is performing a physical assessment of a client, the client begins to have seizure activity including loss of consciousness and limb jerking. The nurse's priority is to:

protect the client from injury.

Which pathophysiologic process occurs in cases of bacterial meningitis?

Inflammation allows pathogens to cross into the cerebrospinal fluid.

The nurse taking a report on a client coming into the emergency room plans care for a client with brain dysfunction based on which symptom?

Stupor

A client's recent computed tomography (CT) scan has revealed the presence of hydrocephalus. Which treatment measure is most likely to resolve this health problem?

Placement of a shunt