Exam 6: Ch. 41 & 42 Neuro

The nurse has completed discharge instructions for a client with application of a halo device who sustained a cervical spinal cord injury. Which statement indicates that the client needs further clarification of the instructions? 1. "I will use a straw for drinking." 2. "I will drive only during the daytime." 3. "I will be careful because the device alters balance." 4. I will wash the skin daily under the lamb's wool liner of the vest."

2. "I will drive only during the daytime."

A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit? 1. Is disoriented to person, place, and time. 2. Affect is flat, with periods of emotional lability. 3. Cannot recall what was eaten for breakfast today. 4. Demonstrates inability to add and subtract; does not know who is the president of the United States.

2. Affect is flat, with periods of emotional lability.

The nurse is caring for the client with increased intracranial pressure as a result of a head injury? The nurse would note which trend in vital signs if the intracranial pressure is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse should use which technique to test the client's peripheral response to pain? 1. Sternal rub 2. Nailbed pressure 3. Pressure on the orbital rim 4. Squeezing of the sternocleidomastoid muscle

2. Nailbed pressure

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? 1. A negative Kernig's sign 2. Absence of nuchal rigidity 3. A positive Brudzinski's sign 4. A Glasgow Coma Scale score of 15

3. A positive Brudzinski's sign

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? 1. Hyperreflexia 2. Positive reflexes 3. Flaccid paralysis 4. Reflex emptying of the bladder

3. Flaccid paralysis

A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? 1. Giving client full control over care decisions and restricting visitors 2. Providing positive feedback and encouraging active range of motion 3. Providing information, giving positive feedback, and encouraging relaxation 4. Providing intravenously administered sedatives, reducing distractions, and limiting visitors

3. Providing information, giving positive feedback, and encouraging relaxation

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? 1. "I can sit down to put on my pants and shoes." 2. "I try to exercise every day and rest when I'm tired." 3. "My son removed all loose rugs from my bedroom." 4. "I don't need to use my walker to get to the bathroom."

4. "I don't need to use my walker to get to the bathroom."

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement? 1. "I will wash my face with cotton pads." 2. "I'll have to start chewing on my unaffected side." 3. "I should rinse my mouth if toothbrushing is painful." 4. "I'll try to eat my food either very warm or very cold."

4. "I'll try to eat my food either very warm or very cold."

is able to feed and bathe herself or himself without assistance. The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? 1. "We need to discourage him from wearing eyeglasses." 2. "We need to place objects in his impaired field of vision." 3. "We need to approach him from the impaired field of vision." 4. "We need to remind him to turn his head to scan the lost visual field."

4. "We need to remind him to turn his head to scan the lost visual field."

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? 1. Gets angry with family if they interrupt a task 2. Experiences bouts of depression and irritability 3. Has difficulty with using modified feeding utensils 4. Consistently uses adaptive equipment in dressing self

4. Consistently uses adaptive equipment in dressing self

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has complaints of inability to move both legs and reports a tingling sensation above the waistline. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room? 1. Nebulizer and pulse oximeter 2. Blood pressure cuff and flashlight 3. Nasal cannula and incentive spirometer 4. Electrocardiographic monitoring electrodes and intubation tray

4. Electrocardiographic monitoring electrodes and intubation tray

A client recovering from a head injury is 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 activity? 1. Blowing the nose 2. Isometric exercises 3. Coughing vigorously 4. Exhaling during repositioning

4. Exhaling during repositioning

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1. Fluid is clear and tests negative for glucose. 2. Fluid is grossly bloody in appearance and has a pH of 6. 3. Fluid clumps together on the dressing and has a pH of 7. 4. Fluid separates into concentric rings and tests positive for glucose.

4. Fluid separates into concentric rings and tests positive for glucose.

The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease? 1. Meningitis or encephalitis during the last 5 years 2. Seizures or trauma to the brain within the last year 3. Back injury or trauma to the spinal cord during the last 2 years 4. Respiratory or gastrointestinal infection during the previous month

4. Respiratory or gastrointestinal infection during the previous month

The nurse is teaching a patient about a carotid endarterectomy. Which explanation should the nurse use to describe the procedure? A carotid endarterectomy removes atherosclerotic plaque from the carotid arteries. 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 shoots pulses of water through the artery to widen the blood vessel.

A carotid endarterectomy removes atherosclerotic plaque from the carotid arteries.

The nurse notes that an older patient is developing parkinsonian symptoms. Which should the nurse suspect as the reason for these new symptoms? Abrupt discontinuation of an anticholinergic medication Reduction in oral fluid intake Change in renal function Inability to sleep during the night

Abrupt discontinuation of an anticholinergic medication

A patient with a traumatic brain injury is diagnosed as being brain dead. Which assessment finding supports this diagnosis? Absence of spontaneous respirations Complete unawareness of self Neck extended and the jaw clenched Awareness of environment but unable to communicate

Absence of spontaneous respirations

The nurse is preparing a plan of care for a patient recovering from an injury that has caused increased intracranial pressure (IICP). Which action should the nurse plan to include to help reduce cerebral edema? Administering prescribed loop diruetic Applying a cooling blanket Regulating the infusion of a proton pump inhibitor Raising the head of the bed 30°

Administering prescribed loop diruetic

The nurse reviews a list of diagnostic tests prescribed for a patient. For which health problem should a magnetic resonance spectroscopy (MRS) be prescribed? Alzheimer disease Brain tumor Brain abscess Multiple sclerosis

Alzheimer disease

A patient with a traumatic brain injury (TBI) is intubated and placed on mechanical ventilation. Which information should the nurse use to evaluate the effectiveness of this respiratory intervention? Arterial blood gas results Glasgow Coma Scale score Cranial nerve function Motor and sensory function

Arterial blood gas results

The nurse is assessing a patient's neurologic system. Which direction should the nurse provide to complete a Romberg test? Ask the patient to stand with feet together and arms at the side, first with the eyes open and then with the eyes closed. Ask the patient to walk on the toes. With eyes closed, ask the patient to alternately touch the nose with an index finger. Ask the patient to walk on the heels.

Ask the patient to stand with feet together and arms at the side, first with the eyes open and then with the eyes closed.

The nurse is preparing to assess a patient's neurologic system. Which technique should the nurse use to assess memory? Ask to state date of birth Instruct to calculate a simple problem Quote a proverb and ask to explain its meaning Ask about future plans related to employment

Ask to state date of birth

The nurse is caring for a patient poststroke. Which action is most important prior to feeding the patient? Assessing the results of the swallowing studies Sitting the patient upright Placing the food in the unaffected side of the mouth Ordering a soft or pureed diet

Assessing the results of the swallowing studies

An anticholinergic medication has been discontinued for an older patient. For which reason should this medication be tapered before completely discontinuing it? Avoid parkinsonian symptoms Prevent a fluid imbalance Enhance kidney function Promote rest and sleep

Avoid parkinsonian symptoms

Laboratory tests are being prescribed for a patient with altered level of consciousness. Which tests should the nurse expect to be prescribed for this patient? (Select all that apply.) Blood glucose Urine for WBCs Serum electrolytes Liver function tests Blood and urine toxicology

Blood glucose Serum electrolytes Liver function tests Blood and urine toxicology

A patient has a systemic illness but demonstrates no signs of neurologic involvement. Which physiologic mechanism should the nurse recall that protects the brain from harmful substances? Blood-brain barrier Structure of neurons Large oxygen demand Circulation of cerebrospinal fluid

Blood-brain barrier

A patient is demonstrating signs of reduced blood flow through the carotid arteries. Which diagnostic test should the nurse expect to be prescribed for this patient? Carotid duplex study CT scan of the brain Electroencephalogram (EEG) Magnetoencephalogram (MEG)

Carotid duplex study

A patient is being prepared for a diagnostic test. For which reason should the nurse withhold providing a morning dose of an oral hypoglycemic agent? Contrast medium will be used during the test Serum enzymes will be drawn during the test Client is prescribed a clear liquid diet Client is prescribed bedrest

Contrast medium will be used during the test

The nurse is assessing a patient's cranial nerve function. What equipment should the nurse use to assess function of cranial nerve V, the trigeminal nerve? Cotton ball and safety pin Measuring tape and pencil Scents such as coffee and vanilla Stethoscope with bell and diaphragm

Cotton ball and safety pin

The nurse is preparing a teaching session on the neurologic system for a group of nursing students. What should the nurse include about the purpose and function of cerebrospinal fluid? (Select all that apply.) Cushions the brain Helps nourish the brain Prevents glucose from entering brain cells Protects the brain and spinal cord from trauma Removes waste products of cellular metabolism

Cushions the brain Helps nourish the brain Protects the brain and spinal cord from trauma Removes waste products of cellular metabolism

The nurse is assessing an older patient's neurologic function. Which should the nurse recognize as an age-related change? Decreased sense of taste Difficulty with speech Diminished sense of touch Difficulty with swallowing

Decreased sense of taste

The nurse is instructing a patient on ways to prevent a stroke. What should the nurse emphasize as being the greatest risks for a stroke? (Select all that apply.) Diabetes History of head trauma Heart disease Hypertension Hyperlipidemia

Diabetes Heart disease Hypertension Hyperlipidemia

The nurse is assessing an older patient. Which finding should indicate to the nurse a potential alteration in cranial nerve VIII functioning? Difficulty with balance Lateral deviation of the tongue Unequal eye movements Coughing when swallowing food

Difficulty with balance

A patient is scheduled for a myelogram. Which teaching should the nurse provide to the patient to prepare for this diagnostic test? Do not eat or drink anything for 4 hours before the test. Do not smoke for 8 hours before the test. Drink a liter of fluid before the test. Consume a clear liquid diet the evening before the test.

Do not eat or drink anything for 4 hours before the test.

A patient is experiencing a fine motor tremor. Which neurotransmitter should the nurse suspect is deficient in this patient? Dopamine Acetylcholine Serotonin Gamma aminobutyric acid (GABA)

Dopamine

The nurse is caring for a patient with a suspected seizure disorder. Which diagnostic test should the nurse anticipate to be ordered? Electroencephalogram (EEG) Electrocardiogram (ECG) Electromyogram (EMG) Erythrocyte sedimentation rate (ESR)

Electroencephalogram (EEG)

Upon entering the room of a patient hospitalized for increased intracranial pressure (IICP) secondary to head trauma from a motor vehicle crash, the nurse notes that the patient has been placed in a supine position by the family. What is the nurse's initial response to this situation? Elevate the head of the bed to 30o and explain to the family the importance of this position. Turn the patient to the left side, using pillows to align the body properly. Maintain the current patient position and reinforce with the family the need to remain in this position. Ask the family if they placed the patient in this position or if the patient did so independently.

Elevate the head of the bed to 30o and explain to the family the importance of this position.

The nurse is completing a health history for a patient with a suspected neurologic issue. Which alteration(s) should the nurse observe for to ensure that any deviations from normal are addressed? Facial movements, speech patterns, and alertness Patient willingness to answer questions Level of eye contact with nurse during assessment Emotional response to questions asked

Facial movements, speech patterns, and alertness

A patient is diagnosed with a disease that affects the amount of dopamine in the nervous system. Which symptom should the nurse expect to assess in this patient? Fine motor tremor Fatigue Hunger Hyperactive reflexes

Fine motor tremor

The nurse is documenting that a patient is demonstrating decorticate posturing. What does this statement indicate about the patient's physical posture? (Select all that apply.) Arms extended Fingers flexed Feet plantar flexed Legs internally rotated Wrists extended

Fingers flexed Feet plantar flexed Legs internally rotated

The nurse is caring for a patient admitted for a postopioid overdose who has suspected brain death. Which criterion would be most appropriate for the healthcare provider to independently use to establish the absence of brain activity for this patient? Flat electroencephalogram (EEG) No spontaneous respiration Fixed and dilated pupils Absent ocular responses to head turning

Flat electroencephalogram (EEG)

A patient 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 patient? Glossopharyngeal Trigeminal Hypoglossal Spinal accessory

Glossopharyngeal

The nurse is discussing neurologic disorders during a staff education program. Which neurologic disorder should the nurse explain is genetically transferred? Huntington disease Multiple sclerosis Alzheimer disease Myasthenia gravis

Huntington disease

A patient has an injury to the cerebellum. Which assessment finding should the nurse associate with the injury? Inability to maintain balance Impaired sleep pattern Impaired vision Inability to exercise judgement

Inability to maintain balance

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 Dysphagia Problems with gait Homonymous hemianopia

Inability to make decisions

The nurse assesses a depressed gag reflex in an unconscious patient. The nurse's priority interventions will relate to which patient problem? Increased risk of aspiration Ineffectiveness of breathing pattern Risk for increased intracranial pressure Risk for poor nutrition

Increased risk of aspiration

The nurse is assessing a patient with damage to the lower motor neurons. Which findings should the nurse expect to assess in this patient? (Select all that apply.) Loss of reflexes Increased muscle tone Decreased coordination Fasciculations Muscle atrophy

Loss of reflexes Decreased coordination Fasciculations Muscle atrophy

The nurse is assessing the breathing pattern of a patient with a head injury who has a change in level of consciousness. Which pathophysiologic event causes an irregular respiratory pattern as level of consciousness decreases? Pressure on the meninges Reflexive motor responses Loss of the oculocephalic reflex Lower brainstem responses to changes in PaCO2

Lower brainstem responses to changes in PaCO2

A patient is recovering from a diagnostic test. For which test should the patient be instructed to lie flat in bed for 4 to 8 hours after the test? Lumbar puncture Cerebral angiogram Myelogram Spinal x-rays

Lumbar puncture

A patient with an alteration in intracranial regulation is exhibiting status epilepticus. Which intervention is the priority for the nurse?Managing the airway Establishing an IV line Administering antiseizure medication Delivering glucose

Managing the airway

The nurse is caring for a patient who was transported to the emergency department after having a seizure. Which nursing actions are critical during the postictal period of seizure activity? Monitoring vital signs, performing neurological checks, and ensuring safety Monitoring vital signs, inserting an intravenous line, and performing cardiopulmonary resuscitation Performing neurologic checks and suctioning every 15 minutes Ensuring safety and drawing blood for ordered tests

Monitoring vital signs, performing neurological checks, and ensuring safety

A patient has a documented alteration in reflex responses. Which should the nurse expect when assessing the patient's somatic reflex? Muscle contraction Change in heart rate Change in bowel sounds Alteration in hormone production

Muscle contraction

A patient is diagnosed with a disease that slows nerve conduction. Which part of the nervous system should the nurse suspect is being affected in this patient? Myelin sheath Gray matter Axons Dendrites

Myelin sheath

A patient's assessment reveals lack of movement of the left eye. The nurse will conduct additional assessment of which cranial nerves that control this movement? (Select all that apply.) Olfactory Optic Oculomotor Trochlear Trigeminal

Oculomotor Trochlear

A patient is prescribed a diagnostic test that will be using a contrast medium. Which medication should be withheld in preparation for this test? Oral hypoglycemic agent Anticoagulant Antibiotic Intravenous vasodilator

Oral hypoglycemic agent

The nurse is preparing to assess a patient's neurologic system. The nurse will prepare to use which assessment techniques in this assessment? (Select all that apply.) Palpation Percussion Inspection Auscultation History review

Palpation Percussion Inspection History review

A patient is being admitted for recurrent seizure activity. What assessment data is most important for the nurse to obtain? Past seizure activity Surgical history Menopause status Occupational history

Past seizure activity

The shift charge nurse is reviewing charts for patients with traumatic brain injury (TBI). Which patient should the shift charge nurse identify as having an acceleration-deceleration injury? Patient whose head struck the dashboard of the vehicle in a high-speed crash Patient whose head was struck by a metal object in a construction accident Patient with a gunshot wound to the head Patient who is a victim of violence whose head was punched repeatedly

Patient whose head struck the dashboard of the vehicle in a high-speed crash

The nurse is reviewing the history of a patient admitted for an altered level of consciousness (LOC). Which systemic condition noted in the patient's history should the nurse consider to be a contributing factor to this alteration? Poorly controlled diabetes Increased intracranial pressure Exposure to heavy metals Demyelinating disorders

Poorly controlled diabetes

The nurse prepares an educational program to promote nervous system health for a community health fair. Which should the nurse identify as the health promotion goal for this body system? Prevent injury Avoid over activity Prevent the development of psychotic disorders Early diagnosis of health problems

Prevent injury

An older patient is demonstrating signs of psychologic dysfunction. Which should the nurse identify as a goal for this patient? Protect from injury Assist with coping Enhance rest and sleep Improve perfusion

Protect from injury

The nurse reviews the results of a patient's cerebrospinal fluid analysis. For which value should the nurse notify the healthcare provider? Protein 80 mg/dL pH 7.35 Glucose 55 mg/dL Chloride 125 mmol/L

Protein 80 mg/dL

A patient has a disease that affects the myelin sheath. Which change should be expected in the patient's the nervous system? Reduction in nerve conduction Increased white matter Reduction in gray matter Increased number of axons

Reduction in nerve conduction

A patient is standing with feet together, arms at the side, and eyes closed. Which test should the nurse complete at this time? Romberg Heel-to-shin Stereognosis Two-point discrimination

Romberg

An older patient demonstrates signs of a neurological disorder. Which should the nurse anticipate being prescribed for this patient? Screening Medication management Admission to a rehabilitation facility Surgical intervention

Screening

The nurse is assessing a patient's cranial nerves. For which function should cranial nerve I be assessed? Sense of smell Ability to sense pressure applied to the face Motor activity of facial muscles Ability to swallow

Sense of smell

The nurse is caring for a patient with altered level of consciousness. On which laboratory value should the nurse focus as the most accurate indicator of hydration status in the patient? CBC Urinalysis Blood culture Serum osmolality

Serum osmolality

During a home visit the nurse notes that an older patient has a list of items on the kitchen counter. For which reason should the nurse suspect the patient has a list? Serve as a memory aid for forgetfulness Document oral intake for the day Track the number of activities completed during the day Write down personal feelings throughout the day

Serve as a memory aid for forgetfulness

A patient has had a carotid endarterectomy. The nurse plans which care for this patient? (Select all that apply.) Position on the operative side. Support the head during position changes. Keep the head of bed elevated at least 45 degrees. Maintain head and neck alignment. Keep a tracheostomy tray at the bedside.

Support the head during position changes. Maintain head and neck alignment. Keep a tracheostomy tray at the bedside.

A patient reports narrowly missing having an automobile crash when merging onto the freeway. Which division of the autonomic nervous system should the nurse recall as causing body responses to stress? Adrenergic Cholinergic Sympathetic Parasympathetic

Sympathetic

A nurse is explaining the steps of the ischemic cascade that occurs during a stroke. Which should the nurse include as the first step? The blood supply is cut off to part of the brain. Brain cells are damaged when the cell membranes allow water to enter the cells. Leukocytes enter the area of damage, causing more 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 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 has a 20-year history of smoking two packs of cigarettes per day. The patient's father died of a stroke. 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 has experienced minimal complications from reduced mobility and dysphagia. The patient is sipping water with meals to help with swallowing. The patient is participating in range of motion exercises each day. The patient's family is at the bedside daily assisting the patient with all activities of daily living.

The patient has experienced minimal complications from reduced mobility and dysphagia.

The nurse is caring for a patient immediately after a seizure. Which assessment finding should the nurse expect? The patient is sleepy but arousable. The patient is cyanotic. The patient is unconscious. The patient is experiencing muscular contractions.

The patient is sleepy but arousable.

The nurse is providing care for a patient who has had an acute ischemic stroke of a left cerebral vessel. The medical record includes information that the patient has contralateral deficits. What does this information suggest to the nurse? Both sides of the body are involved. Deficits will be present below the level of the stroke. The patient will have neurologic deficits on the left side of the body. The patient will have neurologic deficits on the right side of the body.

The patient will have neurologic deficits on the right side of the body.

A patient with an L5 spinal injury is confused about losing bowel and bladder control but can walk without difficulty. Which information should the nurse provide the patient? The spinal nerves are a mix of motor and sensory. The spinal nerves are primarily associated with motor function. The spinal nerves are primarily associated with sensory function. The spinal nerves transmit impulses to a cranial nerve responsible for bladder and bowel control.

The spinal nerves are a mix of motor and sensory.

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? Time of onset of symptoms Family history of stroke Patient history of stroke Smoking history

Time of onset of symptoms

Which is the most frequent cause of increased intracranial pressure (IICP)? Tissue ischemia Tumors Abscesses Hemorrhage

Tissue ischemia

For which purpose would a serum osmolality test be implemented for a patient with increased intracranial pressure?To determine hydration status To assess serum pH To identify serum lactic acid levels To indicate adequacy of serum protein levels

To determine hydration status

The nurse is planning to assess a patient's gag reflex. What equipment should the nurse use to test this reflex? Safety pin Cotton ball Stethoscope Tongue depressor

Tongue depressor

The nurse is caring for a patient with a closed head injury. The nurse evaluates that the prescribed hyper-osmotic agents are having their intended effects when which assessment is made? (Select all that apply.) Body temperature decreases Patient is seizure-free Stools for occult blood are negative Urine output increases Intracranial pressure decreases

Urine output increases Intracranial pressure decreases

An older patient reports having occasional difficulty with balance. On which cranial nerve should the nurse focus an assessment? VIII X VI XII

VIII

The nurse is concerned that a patient is experiencing a transient ischemic attack. What did the nurse most likely assess in this patient? (Select all that apply.) Sudden severe pain over the left eye Visual disturbance of one or both eyes Loss of sensation and reflexes in both legs Complete paralysis of the right arm and leg Numbness and tingling in the corner of the mouth

Visual disturbance of one or both eyes Numbness and tingling in the corner of the mouth

The nurse assesses decreased corneal reflex in a newly admitted patient. This reflex may normally be decreased due to which history? Over age 50 Wears contact lenses Takes diuretic medications Wears dentures

Wears contact lenses

The nurse is planning care for a patient with a diagnosis of increased intracranial pressure (IICP). Which intervention should the nurse include? Implementing seizure precautions Increasing stimuli Placing the patient in the Trendelenburg position Monitoring creatinine level

implementing seizure precautions

The nurse is caring for a patient who was diagnosed with thrombotic stroke 4 hours ago. The family asks about the plan for treatment. Which statement should be included in the teaching to the family about the treatment plan? "Drugs that break up clots, such as tPA, must be given within 3 to 4.5 hours of symptom onset." "Heparin is given initially followed by an infusion of drugs such as tPA to finish breaking up the clot." "IV heparin will be started immediately after the tPA administration to prevent stroke recurrence." "Because the patient has a history of stroke, IV tPA will be administered."

"Drugs that break up clots, such as tPA, must be given within 3 to 4.5 hours of symptom onset."

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? "I have to make all the decisions for my mother." "I have to really watch her when she's eating." "She has difficulty walking." "She doesn't seem to see the food on her plate."

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

An older patient is diagnosed with a seizure disorder. Which should the nurse instruct the patient about this disorder? "It is usually better controlled with antiepileptic medication." "It indicates another health problem in the body." "It is a warning sign of a stroke." "Medications to treat the disorder do not affect other medications."

"It is usually better controlled with antiepileptic medication."

The patient asks the nurse how a carotid endarterectomy increases the blood supply to the brain. Which response by the nurse is accurate? "Plaque from your carotid artery is removed to improve perfusion to the brain." "A bypass is established around the plaque buildup in your carotid artery." "The clot in your carotid artery is removed either manually or by suctioning." "A balloon will be inserted into your carotid artery to make it wider and place a stent."

"Plaque from your carotid artery is removed to improve perfusion to the brain."

The nurse is caring for a patient who experienced a seizure. The patient indicates that they were watching television when the seizure occurred and asks why they had the seizure. Which response from the nurse indicates a correct understanding of the cause of seizures? "Seizures are caused by abnormal electrical impulses in the brain." "Seizures are often caused by watching television." "Seizures are caused by having a fever." "Seizures are caused by low blood sugar."

"Seizures are caused by abnormal electrical impulses in the brain."

The nurse is monitoring the neurologic status of a patient in a coma. Which command should the nurse use to accurately identify changes in mental status? "Squeeze my hand." "Tell me your name." "Are you having trouble breathing?" "Look at this light when I shine it in your eyes."

"Squeeze my hand."

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 is the best drug on the market to break up clots that are causing stroke." "Heparin is given initially followed by an infusion tPA to finish breaking up the clot." "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."

The nurse is teaching the emergency care of the patient with status epilepticus to a colleague. Which statement by the colleague indicates that teaching about airway management was effective? "The airway may be compromised by muscle rigidity and secretions." "The airway is managed after an IV is established." "Antiseizure medication must be delivered before the airway is managed." "Oxygen should be delivered only if the pulse oximeter is below 90%"

"The airway may be compromised by muscle rigidity and secretions."

The nurse caring for a patient who has been intubated and placed on a ventilator for increased intracranial pressure (IICP) is describing the patient's treatment to a family member. Which statement by the nurse is correct? "This treatment is for airway protection and respiratory management." "Your dad is very ill and may not recover so the machine is doing the breathing for him." "The pressure in your dad's brain is low, and the ventilator will help him breathe." "The tube in your dad's airway provides extra carbon dioxide to decrease the pressure in his brain."

"This treatment is for airway protection and respiratory management."

The nurse is caring for a patient with a diagnosis of increased intracranial pressure (IICP). The unlicensed assistive personnel (UAP) asks, "Are special precautions to be taken when caring for a patient with IICP?" Which response by the nurse is accurate? "Yes, raise the pads and bedrails." "No, there are no special precautions." "Yes, be sure to leave the TV on at all times." "Yes, keep the bed flat."

"Yes, raise the pads and bedrails."

The nurse cares for a patient recovering from a lumbar puncture. Which teaching should the nurse provide to this patient after the test? "You will need to lie flat in bed for 4 to 8 hours." "You will be on bedrest for 12 to 24 hours." "You will need to lie in bed with the head slightly elevated for several hours." "You can get up and use the bathroom anytime that you need to."

"You will need to lie flat in bed for 4 to 8 hours."

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. 1. Keeping the linens wrinkle-free under the client 2. Preventing unnecessary pressure on the lower limbs 3. Limiting bladder catheterization to once every 12 hours 4. Turning and repositioning the client at least every 2 hours 5. Ensuring that the client has a bowel movement at least once a week

1. Keeping the linens wrinkle-free under the client 2. Preventing unnecessary pressure on the lower limbs 4. Turning and repositioning the client at least every 2 hours

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. 1. Loosening restrictive clothing. 2. Restraining the client's limbs. 3. Removing the pillow and raising padded side rails. 4. Positioning the client to the side, if possible, with the head flexed forward. 5. Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist.

1. Loosening restrictive clothing. 3. Removing the pillow and raising padded side rails. 4. Positioning the client to the side, if possible, with the head flexed forward.

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1. Padding the side rails of the bed. 2. Placing an airway at the bedside. 3. Placing the bed in the high position. 4. Putting a padded tongue blade at the head of the bed. 5. Placing oxygen and suction equipment at the bedside. 6. Flushing the intravenous catheter to ensure that the site is patent.

1. Padding the side rails of the bed. 2. Placing an airway at the bedside. 5. Placing oxygen and suction equipment at the bedside. 6. Flushing the intravenous catheter to ensure that the site is patent.

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? 1. Taking medications as scheduled 2. Eating large, well-balanced meals 3. Doing muscle-strengthening exercises 4. Doing all chores early in the day while less fatigued

1. Taking medications as scheduled

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. 1. The client is aphasic. 2. The client has weakness on the right side of the body. 3. The client has complete bilateral paralysis of the arms and legs. 4. The client has weakness on the right side of the face and tongue. 5. The client has lost the ability to move the right arm but is able to walk independently. 6. The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself without assistance.

1. The client is aphasic. 2. The client has weakness on the right side of the body. 4. The client has weakness on the right side of the face and tongue.