Med Surg II Chapter 61 & 62

A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements?

"A secondary headache is associated with an organic cause, such as a brain tumor."

A client has experienced an ischemic stroke that has damaged the temporal (lateral and superior portions) lobe. Which of the following deficits would the nurse expect during assessment of this client?

Auditory agnosia

Which is the earliest sign of increasing intracranial pressure?

Changes level of consciousness

A transcranial Doppler ultrasonography detects cerebral vasospasms in a client experiencing lethargy 8 days following a subarachnoid hemorrhage. The nurse anticipates which therapeutic intervention?

Nimodipine PO

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)?

administering stool softeners as ordered

Which term refers to the failure to recognize familiar objects perceived by the senses?

agnosia

Classification of seizures: Unknown

epilepsy spasms

A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To confirm that this drug is producing its therapeutic effect, the nurse should consider which finding most significant?

increased urine output

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)?

intracranial hemorrhage

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?

left visual filed deficient

Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere?

neglect of left side

Classification of seizures: Generalized

occur and engage bilaterally

Classification of seizures: Focal:

originates in one hemisphere

Classification of seizures: "Provoked"

related to acute, reversible condition

The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see:

right sided paralysis

A client admitted to the emergency department is being evaluated for the possibility of a stroke. Which assessment finding would lead the nurse to suspect that the client is experiencing a hemorrhagic stroke?

severe exploding headache

A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke?

severe headache

The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the

supine position with the head slightly elevated.

Tonic seizure

sustained muscle contraction

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke?

the day the patient had the stroke

The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention?

Administer corticosteroids

A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis?

Chewing

A patient has been diagnosed with myasthenia gravis. The nurse documents the initial and most common manifestation of:

Diplopia

Which term will the nurse use when referring to blindness in the right or left half of the visual field in both eyes?

Homonymous hemianopsia

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms?

Impaired cerebral circulation

A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication?

Lamictal

Which of the following antiseizure medication has been found to be effective for post-stroke pain?

Lamotrigine Lamictal

Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?

apraxia

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?

Lethargy and stupor

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?

Lioresal (Baclofen)

A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following?

Monro-Kellie

Which of the following is the most common side effect of tissue plasminogen activator (tPA)?

bleeding

Absent seizure

brief; lasts seconds; pt may or may not lose consciousness No loss of change in muscle tone May occur several times during the day Appears to be daydreaming More common in children

When the nurse observes that the client has extension and external rotation of the arms and wrists and plantar flexion of the feet, the nurse records the client's posture as

decerebrate

tonic-clonic seizure

generalized seizure in which the patient loses consciousness and has jerking movements of paired muscle groups

A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation?

cardio embolic

clonic seizure (generalized)

causes repeated jerking movements of muscles on both sides of the body

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?

weakness on one side of body and difficulty with speech

The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client?

Establish eye contact