Neuro prep u exam
A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized?
Maintain and improve cerebral tissue perfusion. Explanation: Each of the listed goals is appropriate in the care of a client recovering from a stroke. However, promoting cerebral perfusion is a priority physiologic need, on which the client's survival depends.
After having a stroke, a patient has cognitive deficits. What are the cognitive deficits the nurse recognizes the patient has as a result of the stroke? Select all that apply.
Poor abstract reasoning Decreased attention span Short- and long-term memory loss Explanation: Cognitive deficits associated with stroke include short- and long-term memory loss, decreased attention span, and poor abstract reasoning. Expressive aphasia is a verbal deficit, not a cognitive deficit. Paresthesias are sensory deficits, not cognitive deficits.
A male client presents to the clinic reporting a headache. The nurse notes that the client is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the client may have meningitis. What is another well-recognized sign of this infection?
Positive Kernig sign Explanation: Meningeal irritation results in a number of well-recognized signs commonly seen in meningitis, such as a positive Kernig sign, a positive Brudzinski sign, and photophobia. Hyperpatellar reflex and a sluggish pupil reaction are not commonly recognized signs of meningitis.
A college student goes to the infirmary with a fever, headache, and a stiff neck. The nurse suspects the student may have meningitis and has the student transferred to the hospital. If the diagnosis is confirmed, what should the nurse institute for those who have been in contact with this student? Select all that apply.
-Administration of rifampin (Rifadin) -Administration of ciprofloxacin hydrochloride (Cipro) -Administration of ceftriaxone sodium (Rocephin) Explanation: People in close contact with patients with meningococcal meningitis should be treated with antimicrobial chemoprophylaxis using rifampin (Rifadin), ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin).
A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions?
-Renal Explanation: Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. Complications with the integumentary system will can be observed by the nurse; it is not necessary to review laboratory results or urine output for integumentary reactions. Urine output is not monitored for musculoskeletal or hepatic adverse reactions.
A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school?
Absence seizure Explanation: Staring episodes characterize an absence seizure, whereas focal seizures, generalized seizures, and unclassified seizures involve uncontrolled motor activity.
The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop?
Damage to the optic nerve Explanation: Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing. Sequelae to meningitis do not include damage to the vagal nerve, the olfactory nerve or the facial nerve.
A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with a severe head injury. Upon entering the room, the nurse observes that the patient is positioned like part A of the accompanying image. Which posturing is the patient exhibiting?
Decorticate Explanation: An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. Decorticate posture is the flexion and internal rotation of forearms and hands. Decerebrate posture is extension and external rotation. Flaccidity is the absence of motor response; tonic clonic movements are seen with seizures.
A nursing student is writing a care plan for a newly admitted client who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the client's plan of care?
Disturbed sensory perception Explanation: The client who has experienced a stroke is at a high risk for disturbed sensory perception. Stroke is associated with multiple other nursing diagnoses, but hyperthermia, adult failure to thrive, and post-trauma syndrome are not among these.
A nurse is providing education to a community group about ischemic strokes. One group member asks if there are ways to reduce the risk for stroke. Which of the following is a risk factor that can be modified?
Hypertension Explanation: Modifiable risk factors for ischemic stroke include hypertension, atrial fibrillation, hyperlipidemia, diabetes mellitus, smoking, asymptomatic carotid stenosis, obesity, and excessive alcohol consumption. Non-modifiable risk factors include advanced age, gender, and race.
Which diagnostic test is used for early diagnosis of HSV-1 encephalitis?
Polymerase chain reaction (PCR) Explanation: PCR is the standard test for early diagnosis of HSV-1 encephalitis. An LP often reveals a high opening pressure and low glucose and high protein levels in CSF samples. EEG is used to diagnose seizures. An MRI is used to detect lesions in the brain.
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:
Severe headache and early change in level of consciousness Explanation: 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.
A client is having a tonic-clonic seizure. What should the nurse do first?
Take measures to prevent injury. Explanation: Protecting the client from injury is the immediate priority during a seizure. Elevating the head of the bed would have no effect on the client's condition or safety. Restraining the client's arms and legs could cause injury. Placing a tongue blade or other object in the client's mouth could damage the teeth.
The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four clients who might be at risk for a stroke. Which client is likely at the highest risk for a hemorrhagic stroke?
White male, age 60, with history of uncontrolled hypertension Explanation: Uncontrolled hypertension is the primary cause of a hemorrhagic stroke. Control of hypertension, especially in individuals over 55 years of age, clearly reduces the risk for hemorrhagic stroke. Additional risk factors are increased age, male gender, and excessive alcohol intake. Another high-risk group includes blacks, where the incidence of first stroke is almost twice that as in Caucasians.
A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:
carefully move the client to a flat surface and turn him on his side. Explanation: When caring for a client experiencing a tonic-clonic seizure, the nurse should help the client to a flat nonelevated surface and then position him on his side to ensure that he doesn't aspirate and to protect him from injury. These steps help reduce the risk of injury from falling or hitting surrounding objects and help establish an open airway. The client shouldn't be restrained during the seizure. Also, nothing should be placed in his mouth; anything in the mouth could impair ventilation and damage the inside of the mouth.
The nurse is caring for a client admitted with a diagnosis of septic meningitis. The nurse is aware that this infection is caused by which of the following?
Bacteria Explanation: Septic meningitis is caused by bacteria. In aseptic meningitis, the cause is viral or secondary to lymphoma, leukemia, or human immunodeficiency virus.
The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe?
Headache and nuchal rigidity Explanation: Headache and fever are the initial symptoms of meningitis. Nuchal rigidity can be an early sign. Photophobia is also a well-recognized sign in meningitis. Ptosis and diplopia are usually seen with myasthenia gravis. Hyporeflexia in the legs is seen with Guillain-Barre syndrome.
An emergency department nurse is caring for a 7-year-old child suspected of having meningitis. The client is to have a lumbar puncture performed, and the nurse is doing preprocedure teaching with the child and the mother. The nurse's action is an example of which therapeutic communication technique?
Informing Explanation: Informing involves providing information to the client regarding his or her care. Suggesting is the presentation of an alternative idea for the client's consideration relative to problem-solving. This action is not characterized as expectation setting or enlightening.
A client has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse perform to best prevent joint deformities?
Place a pillow in the axilla when there is limited external rotation. Explanation: A pillow in the axilla prevents adduction of the affected shoulder and keeps the arm away from the chest. The prone position with a pillow under the pelvis, not flat, promotes hyperextension of the hip joints, essential for normal gait. To promote venous return and prevent edema, the upper thigh should not be flexed acutely. The hand is placed in slight supination, not pronation, which is its most functional position.
After a seizure, the nurse should place the patient in which of the following positions to prevent complications?
Side-lying, to facilitate drainage of oral secretions Explanation: To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions, and suctioning is performed, if needed, to maintain a patent airway and prevent aspiration.
When reviewing the results of a client's lumbar puncture, a nurse notes a glucose level of 32 mg/dl. What does this result suggest to the nurse?
The client may have bacterial meningitis. Explanation: The normal glucose level for CSF ranges from 50 mg/dl to 75 mg/dl. The client's reduced glucose level may indicate a condition such as bacterial meningitis. The client's glucose level doesn't indicate diabetes mellitus. A decreased serum (not CSF) glucose level indicates hypoglycemia.
A client with meningitis has a history of seizures. Which activity should the nurse do while the client is actively seizing?
Turn the client to the side during a seizure and do not restrain movements Explanation: When a client is in a seizure, the nurse should turn the client to the side and not restrain his or her movements. This helps reduce the potential for aspiration of saliva or stomach contents. The nurse should suction the mouth and pharynx after a seizure has occurred, not during the seizure. Anticonvulsants may be administered to reduce the chances of seizure. Oxygen should not be given to clients with seizures. Clients with respiratory distress are given oxygen. Finally, a cooling blanket is placed beneath the client when hyperthermia occurs, not a seizure.
The student nurse is completing a simulation where a client is the victim of nerve gas. The instructions are for the student to set up the room and have all needed supplies available. Which medication does the student nurse ensure is in the medication administration system to control seizures?
Valium intravenous injection Explanation: The students nurse is correct to have Valium intravenously on hand for seizure activity. When seizure activity occurs, the intravenous route is the best option to deliver the medication safely and rapidly into the system.
To meet the sensory needs of a client with viral meningitis, the nurse should:
minimize exposure to bright lights and noise. Explanation: Photophobia and hypersensitivity to environmental stimuli are the common clinical manifestations of meningeal irritation and infection. Therefore, the nurse should provide a calm environment with less stressful stimuli. Physical activity may worsen symptoms; therefore, physical activity should be reduced. Family members do not need to be avoided. People diagnosed with viral meningitis should be instructed to thoroughly wash hands frequently.
A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure?
Generalized Explanation: A generalized seizure causes generalized electrical abnormality in the brain. The client typically falls to the ground, losing consciousness. The body stiffens (tonic phase) and then alternates between episodes of muscle spasm and relaxation (clonic phase). Tongue biting, incontinence, labored breathing, apnea, and cyanosis may also occur. A Jacksonian seizure begins as a localized motor seizure. The client experiences a stiffening or jerking in one extremity, accompanied by a tingling sensation in the same area. Absence seizures occur most commonly in children. They usually begin with a brief change in the level of consciousness, signaled by blinking or rolling of the eyes, a blank stare, and slight mouth movements. Symptoms of a sensory seizure include hallucinations, flashing lights, tingling sensations, vertigo, déjà vu, and smelling a foul odor.
A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?
Heparin sodium Explanation: 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 healthcare provider may use dexamethasone (Decadron) to decrease cerebral edema and pressure, methyldopa (Aldomet) to reduce blood pressure, and phenytoin (Dilantin) to prevent seizures.
Which is the most common cause of acute encephalitis in the United States?
Herpes simplex virus (HSV) Explanation: HSV-1 ( herpes simplex virus) is the most common cause of acute encephalitis in the United States. Fungal infections of the central nervous system occur rarely in healthy people. The Western equine encephalitis virus is one of four types of arboviral encephalitis that occur in North America is one of several fungi that may cause fungal encephalitis. Lyme disease leads to flu like symptoms and starts as a local infection which can systematically spread causing organ issues, however the incidence is rate, HIV leads to autoimmune disorders.
A client diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the client and family needs to begin as soon as the client is settled on the unit and will continue until the client is discharged. What will family education need to include?
How to correctly modify the home environment Explanation: For a client with a hemorrhagic stroke, teaching addresses the use of assistive devices or modification of the home environment to help the client live with the disability. This is more important to the client's needs than knowing about risk factors for ischemic stroke. It is not necessary for the family to differentiate between different types of strokes. Medication regimens should never be altered without consultation.
A client with epilepsy is having a seizure. What intervention should the nurse do after the seizure?
Keep the client on one side. Explanation: The nurse will need to keep the client on one side to prevent aspiration. Make sure the airway is patent. On awakening, reorient the client to the environment. If the client is confused or wandering, guide the client gently to a bed or chair. If the client becomes agitated after a seizure (postictal), stay a distance away, but close enough to prevent injury until the client is fully aware. The client does not need a cooling blanket after a seizure. The client's temperature should not be elevated from the seizure. The nurse should not pry the client's mouth open after a seizure so that the airway remains open.
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?
Lack of deep tendon reflexes Explanation: 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.
A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication?
Lamictal Explanation: Lamictal is an antiseizure medication. Its packaging was recently changed in an attempt to reduce medication errors, because this medication has been confused with Lamisil (an antifungal), labetalol (an antihypertensive), and Lomotil (an antidiarrheal).
What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?
Left visual field deficit Explanation: A left visual field deficit is a common clinical manifestation of a right hemispheric stroke. Aphasia, slow, cautious behavior, and altered intellectual ability are all clinical manifestations of a left hemispheric stroke.
A client presents to the emergency department status post-seizure. The physician wants to know what the pressure is in the client's head. What test might be ordered on this client?
Lumbar puncture Explanation: Changes in CSF occur in many neurologic disorders. A lumbar puncture (spinal tap) is performed to obtain samples of CSF from the subarachnoid space for laboratory examination and to measure CSF pressure.
When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women?
Osteoporosis Explanation: Because of bone loss associated with the long-term use of antiseizure medications, patients receiving antiseizure agents should be assessed for low bone mass and osteoporosis. They should be instructed about strategies to reduce their risks of osteoporosis (AANN, 2009).
A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety?
Place the client in a side-lying position. Explanation: To prevent complications, the client is placed in the side-lying position to facilitate drainage of oral secretions. Suctioning is performed, if needed, to maintain a patent airway and prevent aspiration. None of the other listed actions promotes safety during the immediate recovery period.
A nurse is providing care to a client with a brain tumor. The client has experienced seizures as a result of the tumor. Which area would be a priority for this client?
Safety Explanation: Clients who have seizures are carefully monitored and protected from injury. Therefore, safety is the priority.
A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is:
190 mm Hg/120 mm Hg Explanation: Elevated blood pressure (systolic >185; diastolic >110 mm Hg) is a contraindication to tPA.
A client has meningitis and cultures are being done to determine the cause. Which of the following is most likely to be identified as the causative factor?
Streptococcus pneumoniae Explanation: The bacteria Steptococcus pneumoniae and Nesseria meningitides are responsible for 80% of cases of meningitis in adults.
Cerebrospinal fluid (CSF) studies would indicate which of the following in a patient suspected of having meningitis? Select all that apply.
-Decreased glucose -Increased protein -Increased white blood cells Explanation: CSF studies demonstrate decreased glucose, increased protein levels, and increased white blood cells.
Which well-recognized sign of meningitis is exhibited when the client's neck is flexed and flexion of the knees and hips is produced?
Positive Brudzinski sign Explanation: A positive Brudzinski sign occurs when the client's neck is flexed (after ruling out cervical trauma or injury), and flexion of the knees and hips is produced. Photophobia is sensitivity to light. A positive Kerning sign occurs when the client is lying with the thigh flexed on the abdomen and the leg cannot be completely extended. Nuchal rigidity is neck stiffness.
The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration?
Alteration in level of consciousness (LOC) Explanation: Alteration in LOC is the earliest sign of deterioration in a client after a hemorrhagic stroke, such as mild drowsiness, slight slurring of speech, and sluggish papillary reaction. Sudden headache may occur, but generalized pain is less common. Seizures and shortness of breath are not identified as early signs of hemorrhagic stroke.
During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect?
Gingival hyperplasia Explanation: Side-effects of dilantin include visual problems, hirsutism, gingival hyperplasia, arrhythmias, dysarthria, and nystagmus.
A health care provider asks a nurse to assess a patient being evaluated for aseptic meningitis for a positive Brudzinski sign. Which of the following actions should the nurse take?
Help the patient flex his neck and observe for flexion of the hips and knees. Explanation: A positive Brudzinski sign: When the patient's neck is flexed (after ruling out cervical trauma or injury), flexion of the knees and hips is produced; when the lower extremity of one side is passively flexed, a similar movement is seen in the opposite extremity.
When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke?
The day the patient has the stroke Explanation: Although rehabilitation begins on the day the patient has the stroke, the process is intensified during convalescence and requires a coordinated team effort.
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?
"TIA is a warning sign. Let's talk about lowering your risks." Explanation: TIA is a warning sign and can be used to empower clients to make life changes to lower the risks. Sensing the client is happy is a psychotherapeutic response but does not lead to teaching and learning for health promotion. TIAs can lead to a stroke for approximately one third of the clients but is not a definitive result and presents as a frightening statement without empowering change. TIA symptoms are shortlived, but this is a factual statement that does not provide additional information to the client.
The nurse is administering the IV antiviral medication ganciclovir (Cytovene) to the patient with HSV-1 encephalitis. What is the best way for the nurse to administer the medication to avoid crystallization of the medication in the urine?
Administer via slow IV over 1 hour. Explanation: Antiviral agents, either acyclovir (Zovirax) or ganciclovir (Cytovene), are the medications of choice in the treatment for HSV (Karch, 2012). Early administration of antiviral agents (usually well tolerated) improves the prognosis associated with HSV-1 encephalitis. Slow IV administration over 1 hour prevents crystallization of the medication in the urine.
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 the body and difficulty with speech Explanation: 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.
A client with epilepsy is having a seizure. During the active seizure phase, the nurse should:
place the client on his side, remove dangerous objects, and protect his head. Explanation: During the active seizure phase, the nurse should initiate precautions by placing the client on his side, removing dangerous objects, and protecting his head from injury. A bite block should never be inserted during the active seizure phase. Insertion can break the teeth and lead to aspiration. Placing the client on his back and holding down the arms could cause injury to the client ad the nurse.
The client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. The nurse monitors blood chemistry test results and urinary output for
renal complications related to acyclovir therapy. Explanation: Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. To prevent relapse, treatment with acyclovir should continue for up to 3 weeks.
The nurse receives a phone call at the clinic from the family of a client with AIDS. They state that the client started "acting funny" and reported headache, tiredness, and a stiff neck. Checking the temperature resulted in a fever of 103.2°F. What should the nurse inform the family member?
"The client may have cryptococcal meningitis and will need to be evaluated by the health care provider." Explanation: A fungal infection, Cryptococcus neoformans is another common opportunistic infection among clients with AIDS, and it causes neurologic disease. Cryptococcal meningitis is characterized by symptoms such as fever, headache, malaise, stiff neck, nausea, vomiting, mental status changes, and seizures.
A client with herpes simplex virus encephalitis (HSV) has been admitted to the ICU. What medication would the nurse expect the health care provider to order for the treatment of this disease process?
Acyclovir Explanation: Antiviral agents, acyclovir or ganciclovir, are the medications of choice in the treatment of HSV. The mode of action is the inhibition of viral DNA replication. To prevent relapse, treatment would continue for up to 3 weeks. Cyclosporine is an immunosuppressant and antirheumatic. Cyclobenzaprine is a centrally acting skeletal muscle relaxant. Ampicillin, an antibiotic, is ineffective against viruses.
A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What should the nurse do?
Provide close supervision because of the client's impulsiveness and poor judgment. Explanation: The primary symptoms of a client who experiences a right-sided stroke are left-sided weakness, impulsiveness, and poor judgment. Aphasia is more commonly present when the dominant or left hemisphere is damaged. When a client has one-sided weakness, the nurse should place the wheelchair on the client's unaffected side. Because a right-sided stroke causes left-sided paralysis, the right side of the body should remain unaffected.
The causes of acquired seizures include what? (Mark all that apply.)
-Cerebrovascular disease -Metabolic and toxic conditions -Brain tumor -Drug and alcohol withdrawal Explanation: The specific causes of seizures are varied and can be categorized as idiopathic (genetic, developmental defects) and acquired. Causes of acquired seizures include cerebrovascular disease; hypoxemia of any cause, including vascular insufficiency; fever (childhood); head injury; hypertension; central nervous system infections; metabolic and toxic conditions (eg, renal failure, hyponatremia, hypocalcemia, hypoglycemia, pesticide exposure); brain tumor; drug and alcohol withdrawal; and allergies.
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?
6.3 mg Explanation: A person who weighs 154 lbs weighs 70 kg. To calculate total dosage, multiply 70 × 0.9 mg/kg = 63 mg. Ten percent of the calculated dose is given as an IV bolus over 1 minute. The remaining dose (90%) is given IV over 1 hour via an infusion pump. So initially the nurse gives 10% (6.3 mg) over 1 minute.
A neurologic nurse is reviewing seizures with a group of staff nurses. How should this nurse best describe the cause of a seizure?
A dysrhythmia in the nerve cells in one section of the brain Explanation: The underlying cause of a seizure is an electrical disturbance (dysrhythmia) in the nerve cells in one section of the brain; these cells emit abnormal, recurring, uncontrolled electrical discharges. Seizures are not caused by changes in blood flow or electrolytes.
A client with a metastatic brain tumor of the frontal lobe experiences a generalized seizure for the first time. The nurse should prepare for what action?
Administration of anticonvulsants Explanation: Seizure activity necessitates anticonvulsants. In most cases, the development of seizure activity does not require immediate diagnostic imaging. Intubation is unnecessary except in cases of respiratory failure.
A client is admitted through the ED with suspected St. Louis encephalitis. The unique clinical feature of St. Louis encephalitis will make what nursing action a priority?
Close monitoring of fluid balance Explanation: A unique clinical feature of St. Louis encephalitis is SIADH with hyponatremia. As such, it is important to monitor the client's intake and output closely.
While completing a health history on a client who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state?
Confusion Explanation: In the postictal state (after the seizure), the client is often confused and hard to arouse and may sleep for hours. The epileptic cry occurs from the simultaneous contractions of the diaphragm and chest muscles that occur during the seizure. Urinary incontinence and intense rigidity of the entire body are followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction) during the seizure.
A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment?
Limited attention span and forgetfulness Explanation: Damage to the frontal lobe may impair learning capacity, memory, or other higher cortical intellectual functions. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation. Damage to the motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes. Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia.
When developing a care plan for a client who has recently suffered a stroke, a nurse includes the nursing diagnosis Risk for imbalanced body temperature. What is the rationale for this diagnosis?
The stroke may have impacted the body's thermoregulation centers. Explanation: The body's thermoregulation centers are located in the hypothalamus. A stroke may impair their functioning. A decreased body temperature isn't necessarily an indication to cover the client. Although an elevated temperature may indicate cerebellum malfunction or infection, these factors aren't the focus of the risk described in the nursing diagnosis.
A client is diagnosed with meningococcal meningitis. The 22-year-old client shares an apartment with one other person. What would the nurse expect as appropriate care for the client's roommate?
Treatment with antimicrobial prophylaxis as soon as possible Explanation: People in close contact with clients who have meningococcal meningitis should be treated with antimicrobial chemoprophylaxis, ideally within 24 hours after exposure.
A client diagnosed with a stroke is ordered to receive warfarin. 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
aspirin. Explanation: If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.
Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply.
-Cloudy cerebral spinal fluid -Purpura of hands and feet Explanation: The cerebral spinal fluid (CSF) will be cloudy if bacterial meningitis is the causative agent. Purpura indicates a serious complication of bacterial meningitis (disseminated intravascular coagulation) is occurring and may place the client at risk for amputation of those parts. Pain and stiffness of the extremities is not indicative of meningitis. A rise in RBCs, WBCs, and ADH would be expected.
Nursing assessment of hearing loss in an older adult client includes evaluation of age-related changes, as well as a history of current illnesses and medications. Which of the following factors are associated with ototoxic effects? Select all that apply.
-Diabetes mellitus -Loop diuretics (e.g., Lasix) -Bacterial meningitis -Gentamicin Explanation: Certain medications (eg, aminoglycerides, gentamicin, loop diuretics, aspirin) have ototoxic effects, especially when renal changes with aging decrease medication excretion. Coronary artery disease and asthma do not predispose a person to hearing loss.
A client is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the client's complaints of headache?
-Dimming the lights and reducing stimulation Explanation: Comfort measures to reduce headache include dimming the lights, limiting noise and visitors, grouping nursing interventions, and administering analgesic agents. Opioid analgesic medications may mask neurologic symptoms; therefore, they are used cautiously. Nonopioid analgesics may be preferred. Distraction is unlikely to be effective, and may exacerbate the patient's pain.
The nurse is reviewing the medication administration record of a female client who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke?
Aspirin 81 mg PO o.d. Explanation: Research findings suggest that low-dose aspirin may lower the risk of stroke in women who are at risk. Naproxen, lorazepam, and calcium supplements do not have this effect.
A nurse is caring for an older client who has had a hemorrhagic stroke. The client has exhibited impulsive behavior and, despite reminders from the nurse, doesn't recognize his limitations. Which priority measure should the nurse implement to prevent injury?
Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed. Explanation: The bed alarm will alert staff that the client is attempting to transfer, so they can come to assist. The nurse shouldn't encourage the family to reprimand the client. Instead, the nurse should ask the family to encourage the client to request assistance. The nurse should encourage the client to use the call light in all situations, not just emergencies. A vest and wrist restraints aren't appropriate unless less-restrictive measures have failed and the client is a danger to himself or others.
A nurse in the ICU is providing care for a client who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the client is becoming progressively more drowsy over the course of the day. What is the nurse's best response to this assessment finding?
Report this to the health care provider as a possible sign of clinical deterioration. Explanation: Alteration in LOC often is the earliest sign of deterioration in a client with a hemorrhagic stroke. Drowsiness and slight slurring of speech may be early signs that the LOC is deteriorating. This finding is unlikely to be the result of metabolic changes and it is not expected. Stimulating a client with an acute stroke is usually contraindicated.
A patient diagnosed with meningitis would be expected to exhibit which of the following clinical manifestations? Select all that apply.
-Nuchal rigidity -Positive Kernig's sign -Positive Brudzinski's sign -Photophobia Explanation: Signs of meningeal irritation include nuchal rigidity (neck stiffness), a positive Kernig's sign, a positive Brudzinski's sign, and photophobia. Patients may have a fever.
An emergency department nurse understands that a 110-lb (50-kg) recent stroke victim will receive at least the minimum dose of recombinant tissue plasminogen activator (t-PA). What minimum dose will the client receive?
45 mg Explanation: The client is weighed to determine the dose of t-PA. Typically, two or more IV sites are established prior to administration of t-PA (one for the t-PA and the other for administration of IV fluids). The dosage for t-PA is 0.9 mg/kg, with a maximum dose of 90 mg. 50 kg X 0.9 mg= 45 mg dose
A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take?
Face the client and establish eye contact. Explanation: When speaking with a client who has aphasia, the nurse should face the client and establish eye contact. The nurse should use short phrases, not one long sentence, and give the client time between phrases to understand what is being said. Keeping extraneous and background noise such as the television to a minimum helps the client concentrate on what is being said. It isn't necessary to speak in a louder or softer voice than normal.
The nurse is caring for a client with recurrent ear infections. The nurse assesses the client for further infectious processes traveling deeper into the tissue and becoming more lethal. Which infection, originated in the ear, is of most concern?
Meningitis Explanation: The infection stemming for the ear may extend to the meninges, causing meningitis, or a brain abscess could occur. This could be life threatening. The other options are also potential complications of an ear infection.
Nursing care during the immediate recovery period from an ischemic stroke should include which of the following?
Positioning to avoid hypoxia Explanation: Interventions during this period include measures to reduce ICP, such as administering an osmotic diuretic (e.g., mannitol) and positioning to avoid hypoxia. Hypertonic IV solutions are not used unless sodium depletion is evident. PaCO2 must remain within an acceptable range, not maximized. Mobilization would take place after the immediate threat of increased ICP has past.
The nurse is assessing a newly admitted client with a diagnosis of meningitis. On assessment, the nurse expects to find which of the following?
Positive Kernig's sign Explanation: A positive Kernig's sign is a common finding in the client with meningitis. When the client is lying with the thigh flexed on the abdomen, the leg cannot be completly extended. A positive Brudzinski's sign is usual with meningitis. The Romberg sign would not be tested in this client. The client will develop lethargy as the illness progresses, not hyper-alertness.
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.
Recent intracranial pathology Current anticoagulation therapy Symptom onset greater than 3 hours prior to admission Explanation: Some of the absolute contraindications for thrombolytic therapy include symptom onset greater than 3 hours before admission, a client who is anticoagulated (with an INR above 1.7), or a client who has recently had any type of intracranial pathology (e.g., previous stroke, head injury, trauma).
A client admitted with meningitis is to receive Vancocin (vancomycin) 250 mg in 100 mL intravenously over 60 minutes twice a day. The IV tubing set is calibrated at 15 drops per/mL. At how many drops per minute will the nurse run this solution? Enter the correct number ONLY.
25 Explanation: (100 mL/60 minutes) X 15 = 25. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies.
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?
Left-sided cerebrovascular accident (CVA) Explanation: 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 scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction?
"Avoid stimulants and alcohol for 24 to 48 hours before the test." Explanation: For 24 to 48 hours before an EEG, the client should avoid coffee, cola, tea, alcohol, and cigarettes because these may interfere with the accuracy of test results. (For the same reason, the client also should avoid antidepressants, sedatives, and anticonvulsants.) To avoid a reduced serum glucose level, which may alter test results, the client should eat normal meals before the test. The hair should be washed before an EEG because the electrodes must be applied to a clean scalp. The client's thoughts don't affect the test results.
A client with newly diagnosed seizures asks about stigma associated with epilepsy. The nurse will respond with which of the following statements?
"Many people with developmental disabilities resulting from neurologic damage also have epilepsy." Explanation: Many people who have developmental disabilities because of serious neurologic damage also have epilepsy. Epilepsy is not associated with intellectual level. It is not synonymous with intellectual disability or illness.
A family member brings the client 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?
"Stop smoking as soon as possible." Explanation: Smoking is a modifiable and highly significant risk factor for stroke. The significance of smoking, and the potential benefits of quitting, exceed the roles of sodium, diet, and regular medical assessments.
A rehabilitation nurse caring for a client who has had a stroke is approached by the client's family and asked why the client has to do so much for herself when she is obviously struggling. What would be the nurse's best answer?
"The focus on care in a rehabilitation facility is to help the client to resume as much self-care as possible." Explanation: In both acute care and rehabilitation facilities, the focus is on teaching the client to resume as much self-care as possible. The goal of rehabilitation is not to be "useful," nor is it to return clients to their prestroke level of functioning, which may be unrealistic.
The nurse plays a critical role in the initial work-up of a patient with acute stroke symptoms. An immediate decision is to determine if the stroke is ischemic or hemorrhagic. Although there is overlap in some motor, sensory, and cognitive changes, hemorrhagic strokes can be identified by some specific signs. Which of the following signs are consistent with a hemorrhagic stroke? Select all that apply.
-Vomiting -Sudden, severe headache -Seizures Explanation: These three signs are usually diagnostic of a hemorrhagic stroke. The other signs can occur with both hemorrhagic and ischemic stroke.
A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last?
1 to 3 days Explanation: 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.
A client is suspected to have bacterial meningitis. What is the priority nursing intervention?
Administer prescribed antibiotics. Explanation: A client with suspected bacterial meningitis should receive antibiotic therapy within 30 minutes of arrival. Outcomes are usually better with early administration of antibiotics. Although the nurse should assess the CSF laboratory test results, antibiotic therapy should not be delayed waiting for the results. Encouraging oral fluids and preparing for a CT scan are appropriate interventions depending on the client, but the priority intervention is the early administration of antibiotics.
The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child?
An absence seizure Explanation: Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. Both myoclonic and tonic-clonic seizures involve jerking movements.
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 Explanation: 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 motor neurons may cause hemiparesis, hemaplegia, and a change in reflexes.
A patient suffering a stroke is having a difficult time swallowing. What would the nurse document this finding as?
Dysphagia Explanation: Stroke can result in dysphagia (difficulty swallowing) due to impaired function of the mouth, tongue, palate, larynx, pharynx, or upper esophagus. Patients must be observed for paroxysms of coughing, food dribbling out of or pooling in one side of the mouth, food retained for long periods in the mouth, or nasal regurgitation when swallowing liquids. Swallowing difficulties place the patient at risk for aspiration, pneumonia, dehydration, and malnutrition.
After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client?
Elevating the head of the bed to 30 degrees Explanation: Because the client's gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the client's risk of aspiration. Checking the stools, performing ROM exercises, and keeping the skin clean and dry are important, but preventing aspiration through positioning is the priority.
The nurse is expecting to admit a client with a diagnosis of meningitis. While preparing the client's room, which of the following would the nurse most likely have available?
Equipment to maintain infection control precautions Explanation: An important component of nursing care for the client with meningits is instituting infection control precautions until 24 hours after initiation of antibiotic therapy. Oral and nasal discharge is considered infectious. This client may well experience photophobia, so the lighting should be kept dim. IV Tensilon is used to diagnose myasthenia gravis.
The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke?
Facial droop Explanation: Facial drooping or asymmetry is a classic abnormal finding on a physical assessment that may be associated with a stroke. Facial edema is not suggestive of a stroke and clients less commonly experience dysrhythmias or vomiting.
During assessment of cognitive impairment, post-stroke, the nurse documents that the patient was experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?
Frontal Explanation: Frontal lobe damage results in impaired learning capacity, memory, and other higher cortical intellectual functions.
A client the nurse is caring for experiences a seizure. What would be a priority nursing action?
Protect the client from injury. Explanation: The nursing action for a client experiencing a seizure should be to protect the client from being injured. To ensure this, the nurse should turn the client to one side and not restrain client's movements. Inserting a tongue blade between the teeth is not as important as protecting the client from injury. The mouth and the pharynx of the client should be suctioned only after the seizure.
A nurse is completing discharge teaching for the client who has left-sided hemiparesis following a stroke. When investigating the client's home environment, the nurse should focus on which nursing diagnosis?
Risk for injury Explanation: Because of decreased physical mobility, a client with recent left-sided hemiparesis is at risk for falls in the home setting. His ability to cope with the stroke is important, but investigating the home environment doesn't provide information about this nursing diagnosis. Diarrhea and Noncompliance aren't related to the client's home environment.
A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client?
The client should be approached on the side where visual perception is intact. Explanation: Clients with decreased field of vision should first be approached on the side where visual perception is intact. All visual stimuli should be placed on this side. The client can and should be taught to turn the head in the direction of the defective visual field to compensate for this loss. The nurse should constantly remind the client of the other side of the body and should later stand at a position that encourages the client to move or turn to visualize who and what is in the room.
A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose?
To remove atherosclerotic plaques blocking cerebral flow Explanation: The main surgical procedure for select clients with TIAs is carotid endarterectomy, the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in clients with occlusive disease of the extracranial arteries. An endarterectomy does not decrease cerebral edema, prevent seizure activity, or determine the cause of a TIA.
Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at
controlling seizures and increased intracranial pressure. Explanation: There is no specific medication for arbovirus encephalitis; therefore symptom management is key. Medical management is aimed at controlling seizures and increased intracranial pressure.
The primary arthropod vector in North America that transmits encephalitis is the
mosquito. Explanation: Arthropod-borne viruses, or arboviruses, are maintained in nature through biologic transmission between susceptible vertebrate hosts by blood feeding arthropods (mosquitoes, psychodids, ceratopogonids, and ticks). Arthropod vectors transmit several types of viruses that cause encephalitis. The primary vector in North America is the mosquito.
A client 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 client's cardiac and neurologic status, the nurse monitors the client for signs of what complication?
Bleeding Explanation: Bleeding is the most common side effect of t-PA administration, and the client is closely monitored for any bleeding. Septicemia, pain, and seizures are much less likely to result from thrombolytic therapy.
The nurse is caring for a client following a head injury. The nurse understands that the client is at risk for posttraumatic seizures. A seizure classified as early occurs within which time frame?
1 to 7 days of injury Explanation: Posttraumatic seizures are classified as immediate (within 24 hours after injury), early (within 1 to 7 days after injury), or late (more than 7 days after injury). Seizures are classified according to time after injury, not after surgery. Seizure prophylaxis is the practice of administering antiseizure medications to clients with head injury to prevent seizures. It is important to prevent posttraumatic seizures, especially in the immediate and early phases of recovery, because seizures may increase intracranial pressure and decrease oxygenation.
What should be included in the client's care plan when establishing an exercise program for a client affected by a stroke?
Exercise the affected extremities passively four or five times a day. Explanation: The affected extremities are exercised passively and put through a full ROM four or five times a day to maintain joint mobility, regain motor control, prevent development of a contracture in the paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. Active ROM exercises should ideally be performed more than once per day.
A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis?
Neck flexion produces flexion of knees and hips Explanation: Clinical manifestations of bacterial meningitis include a positive Brudzinski sign. Neck flexion producing flexion of knees and hips correlates with a positive Brudzinski sign. Positive Homan sign (pain upon dorsiflexion of the foot) and negative Romberg sign (inability to stand with eyes closed and arms extended) are not expected assessment findings for the client with bacterial meningitis. Peripheral neuropathy manifests as numbness and tingling in the lower extremities. Again, this would not be an initial assessment to rule out bacterial meningitis.
The nurse is providing care for a client who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the client has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following?
The client's activities immediately prior to the seizure. Explanation: Before and during a seizure, the nurse observes the circumstances before the seizure, including visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; and hyperventilation. Communication with the client is not possible during a seizure and physical restraint is not attempted. The client's ability to explain the seizure is not clinically relevant.
A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like the person in part B of the accompanying image. Which posturing is the patient exhibiting?
Decerebrate Explanation: An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. Decorticate posture is the flexion and internal rotation of forearms and hands. Decerebrate posture is extension and external rotation. Flaccidity is the absence of motor response; tonic clonic movements are seen with seizures.
A client experiences a seizure while hospitalized for appendicitis. During the postictal phase, the client is yelling and swings a closed fist at the nurse. Which is the appropriate action by the nurse?
Reorient the client while gently holding their arms. Explanation: Some clients during the postictal phase will become confused and agitated. This reaction is not intentional and most clients do not remember becoming agitated. The nurse should attempt to calm and reorient the client, but also should gently hold the arms to prevent the client from hitting. The nurse should always use restraints as a last resort; therefore, the nurse should try to reorient the client before applying wrist restraints. Lorazepam is not indicated for postictal agitation. It may be administered to prevent future seizures. Oxygen is not indicated for this client
Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event?
Seizure was 1 minute in duration including tonic-clonic activity. Explanation: Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and their skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity.
The nurse caring for a patient with bacterial meningitis is administering dexamethasone (Decadron) that has been ordered as an adjunct to antibiotic therapy. When does the nurse know is the appropriate time to administer this medication?
15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days Explanation: Dexamethasone (Decadron) has been shown to be beneficial as adjunct therapy in the treatment of acute bacterial meningitis and in pneumococcal meningitis if it is administered 15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days. Research suggests that dexamethasone improves the outcome in adults and does not increase the risk of gastrointestinal bleeding (Bader & Littlejohns, 2010).
A client admitted with bacterial meningitis must be transported to the radiology department for a repeat computed tomography scan of the head. His level of consciousness is decreased, and he requires nasopharyngeal suctioning before transport. Which infection control measures are best when caring for this client?
Put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport. Explanation: Bacterial meningitis is spread through contact with infected droplets. The nurse should wear gloves, a mask, and eye protection when suctioning the client. Additionally, the client should wear a mask when out of the isolation room for diagnostic testing. Standard precautions don't adequately protect staff and other clients from bacterial meningitis.
A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what?
Evidence of hemorrhagic stroke Explanation: Thrombolytic therapy would exacerbate a hemorrhagic stroke with potentially fatal consequences. Stroke evolution, high BP, or previous thrombolytic therapy does not contraindicate its safe and effective use.
A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize?
Generalized seizure Explanation: Generalized seizures often involve both hemispheres of the brain, causing both sides of the body to react. Intense rigidity of the entire body may occur, followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction). This pattern of rigidity does not occur in clients who experience unclassified, absence, or focal seizures.
Which is the most common cause of acute encephalitis in the United States?
Herpes simplex virus Explanation: Viral infection is the most common cause of encephalitis. Herpes simplex virus is the most common cause of acute encephalitis in the United States. The Western equine encephalitis virus, West Nile virus, and St. Louis virus are types of arboviral encephalitis that occur in North America, but they are not the most common causes of acute encephalitis.
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?
Semi-Fowler's Explanation: The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.
The nurse is caring for a client diagnosed with an ischemic stroke and knows that effective positioning of the client is important. Which of the following should be integrated into the client's plan of care?
The client should be placed in a prone position for 15 to 30 minutes several times a day. Explanation: If possible, the clientis placed in a prone position for 15 to 30 minutes several times a day. A small pillow or a support is placed under the pelvis, extending from the level of the umbilicus to the upper third of the thigh. This helps to promote hyperextension of the hip joints, which is essential for normal gait, and helps prevent knee and hip flexion contractures. The hip joints should not be maintained in flexion and the Trendelenburg position is not indicated.
A client with meningitis has a history of seizures. Which should the nurse do to safely manage the client during a seizure? Select all that apply.
-Turn the client to the side. -Provide verbal reassurance. Explanation: Turning client to the side will allow accumulated saliva to drain from the mouth. The person may not be able to hear you while unconscious, but verbal assurances will help as the person is regaining consciousness. Physically restraining a client during a seizure increases the potential for injuries. Inspection of oral cavity occurs after a generalized seizure and not during a seizure.
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 60-year-old African-American man Explanation: The 60-year-old African-American man has three risk factors: gender, age, and race. African Americans have almost twice the incidence of first stroke compared with Caucasians.
A patient has had a large ischemic stroke and is hospitalized in the neurologic intensive care unit. What interventions will be provided for this patient to decrease intracranial pressure? Select all that apply.
Administering mannitol Maintaining the partial pressure of carbon dioxide (PaCO2) within a range of 30 to 35 mm Hg Elevating the head of the bed 30 degrees Explanation: Increased intracranial pressure (ICP) from brain edema and associated complications may occur after a large ischemic stroke. Interventions during this period include measures to reduce ICP, such as administering an osmotic diuretic (e.g., mannitol), and maintaining the partial pressure of arterial carbon dioxide (PaCO2) within a slightly lower range of 30 to 35 mm Hg. The nurse should provide supplemental oxygen if oxygen saturation is below 92%, not below 88%. The head of the bed should be elevated to 25 to 30 degrees to assist the patient in handling oral secretions and decrease intracranial pressure. Because of the risks associated with anticoagulants (such as heparin), their general use is no longer recommended for patients with acute ischemic stroke.
A client is diagnosed with a brain tumor. As the nurse assists the client from the bed to a chair, the client begins having a generalized seizure. Which action should the nurse take first?
Assist the client to the floor, in a side-lying position, and protect him with linens. Explanation: The nurse should protect the client from injury by assisting him to the floor, in a side-lying position, and protect him from harm by padding the floor with bed linens. Initiating a response from the code team isn't necessary because seizures are self-limiting. As long as the client's airway is protected, his cardiopulmonary status isn't affected. The nurse shouldn't force anything into the client's mouth during a seizure; doing so may cause injury. Documenting seizure activity is important, but it doesn't take priority over client safety.
A client who just experienced a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus?
Cardiac and respiratory status Explanation: Acute care begins with managing ABCs. Clients may have difficulty keeping an open and clear airway secondary to decreased LOC. Neurologic assessment with close monitoring for signs of increased neurologic deficit and seizure activity occurs next. Fluid and electrolyte balance must be controlled carefully with the goal of adequate hydration to promote perfusion and decrease further brain activity.
When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal?
Elevation of the head of the bed Explanation: Elevation of the head of the bed promotes venous drainage and lowers ICP; the nurse should avoid flexing or extending the neck or turning the head side to side. The head should be in a neutral midline position. Excessively frequent position changes are unnecessary.
Which of the following antiseizure medication has been found to be effective for post-stroke pain?
Lamotrigine (Lamictal) Explanation: The antiseizure medication lamotrigine (Lamictal) has been found to be effective for post-stroke pain.
A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?
Loosen the client's restrictive clothing. Explanation: An appropriate nursing intervention would include loosening any restrictive clothing on the client. No attempt should be made to restrain the client during the seizure because muscular contractions are strong and restraint can produce injury. Do not attempt to pry open jaws that are clenched in a spasm to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. If possible, place the client on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus
A nurse is teaching about ischemic stroke prevention to a community group and emphasizes that control of hypertension, which is the major risk factor for stroke, is key to prevention. Ways to control hypertension include the Dietary Approaches to Stop Hypertension (DASH) diet. This diet includes which of the following?
Moderate amounts of low-fat dairy products Explanation: The DASH diet is high in fruits and vegetables, moderate in low-fat dairy products, and low in animal protein.
Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere?
Neglect of the left side Explanation: This client would have deficits on the left side. Expressive aphasia typically occurs with left-hemisphere stroke.
The nurse is caring for a client who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this client?
Phenytoin Explanation: Anticonvulsant medication (phenytoin, diazepam) is often prescribed prophylactically for clients who have undergone supratentorial craniotomy because of the high risk of seizures after this procedure. Prednisone and dexamethasone are steroids and do not prevent seizures. Cafergot is used in the treatment of migraines.
Which well-recognized sign of meningitis is exhibited when the client's neck is flexed and flexion of the knees and hips is produced?
Positive Brudzinski sign Explanation: A positive Brudzinski sign occurs when the client's neck is flexed (after ruling out cervical trauma or injury) and flexion of the knees and hips is produced. Photophobia is sensitivity to light. A positive Kerning sign occurs when the client is lying with the thigh flexed on the abdomen and the leg cannot be completely extended. Nuchal rigidity is neck stiffness.
A nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely?
Positive Brudzinski's sign Explanation: A positive Brudzinski's sign is a common finding in the client with meningitis. When the client's neck is flexed, flexion of the knees and hips is produced. A positive Kernig's sign is usual with meningitis. The client will develop lethargy as the illness progresses, not increased intake or hyper-alertness.
Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?
The client will remain free of injury if a seizure does occur. Explanation: All of the goals are appropriate, but the most important goal is the long-term goal to remain free of injury if a seizure occurs. Nursing interventions associated can include notifying someone of not feeling well, lowering self to a safe position, protecting head, turning on a side, etc. Also, the client may be at a risk for injury because, once a seizure begins, the client cannot implement self-protective behaviors. An established plan is important in the care of a seizure client. The other options are acceptable goals for nursing care.
A client with hypertension comes to the outpatient department for a routine checkup. Because hypertension is a risk factor for cerebral hemorrhage, the nurse questions the client closely about warning signs and symptoms of hemorrhage. Which complaint is a possible indicator of cerebral hemorrhage in this client?
Tinnitus Explanation: Tinnitus is commonly a warning sign of cerebral hemorrhage. Other warning signs include vomiting (without nausea), a change in level of consciousness, and localized seizures. Vertigo isn't a common indicator of cerebral hemorrhage.
The client presents to the walk-in clinic with fever, nuchal rigidity, and headache. Which of the following assessment findings would be most significant in the diagnosis of this client?
Vector bites Explanation: Possible exposure to mosquito bites can be beneficial in the diagnosing of encephalitis secondary to West Nile virus. Change in level of consciousness (LOC), vomiting, and seizures are all symptoms of increased intracranial pressure (ICP) and do not assist in the differentiating of cause, diagnosis, or establishing nursing care.
A client is scheduled for standard EEG testing to evaluate a possible seizure disorder. Which nursing intervention should the nurse perform before the procedure?
Withhold anticonvulsant medications for 24 to 48 hours before the exam Explanation: Anticonvulsant agents, tranquilizers, stimulants, and depressants should be withheld 24 to 48 hours before an EEG because these medications can alter EEG wave patterns or mask the abnormal wave patterns of seizure disorders. To increase the chances of recording seizure activity, it is sometimes recommended that the client be deprived of sleep on the night before the EEG. Coffee, tea, chocolate, and cola drinks are omitted in the meal before the test because of their stimulating effect. However, meals are not omitted, because an altered blood glucose concentration can cause changes in brain wave patterns. The client is informed that a standard EEG takes 45 to 60 minutes; a sleep EEG requires 12 hours.
Cryptococcus meningitis is suspected in a client with HIV. Which manifestations would be consistent with cryptococcus meningitis? Select all that apply.
-Stiff neck -Seizures Explanation: Manifestations of cryptococcal meningitis include fever, headache, malaise, stiff neck, nausea, vomiting, mental status changes, and seizures. Psychomotor slowing, a vacant stare, and hyperreflexia suggest HIV encephalopathy.
Which medication classification is used preoperatively to decrease the risk of postoperative seizures?
Anticonvulsants Explanation: Anticonvulsants are used to decrease the risk of postoperative seizures following cranial surgery. Diuretics, corticosteroids, and antianxiety medications may be used for the client with increased intracranial pressure.
Which of the following drugs may be used after a seizure to maintain a seizure-free state?
Phenobarbital Explanation: IV diazepam (Valium), lorazepam (Ativan), or fosphenytoin (Cerebyx) are administered slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are administered later to maintain a seizure-free state. In general, a single drug is used to control the seizures.
A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse?
Turn client to side-lying position. Explanation: When a client begins to convulse, the highest priority is to maintain airway. This can best be accomplished by turning client to side-lying position, which allows saliva and emesis to drain from the mouth. Turning the client also allows the tongue to fall forward opening the airway. More damage can occur if a bite block is inserted after the seizure has begun. Manually restraining extremities is not recommended. Attempting to take blood pressure is not recommended and pulse rate and respirations during the event will not be beneficial. Monitor vital signs during the postictal phase.
A client has been on the unit for 3 weeks receiving treatment for bacterial meningitis. The client is being discharged, and the nurse is discussing the disease process and future prevention. As part of teaching, the nurse must:
respect the client's beliefs about the cause of illness. Explanation: A person's beliefs about health and illness and how illness is treated are strongly influenced by culture. Nurses may disagree with a client's health or illness beliefs. However, they must appreciate these beliefs to assist the client in achieving health goals. Trying to change the client's beliefs is not an appropriate part of teaching. Although certain written information may be helpful, a large quantity of scholarly information is not appropriate.
Which of the following is the medication of choice in the treatment of herpes simplex virus (HSV)?
Acyclovir (Zovirax) Explanation: Acyclovir, an antiviral agent, is the medication of choice in the treatment of HSV. Decadron, vancomycin, and Dilantin may be used in the treatment of meningitis.
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?
Cerebral aneurysm Explanation: A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache.
A 45-year-old client presents to the ED reporting trouble speaking and numbness of the right arm and leg. The nurse suspects an ischemic stroke. Which insult or abnormality can cause an ischemic stroke?
Cocaine use Explanation: Two classifications of ischemic strokes are cryptogenic strokes, which have no known cause, and strokes from other causes, such as illicit drug use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries. 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, trauma, and intracerebral aneurysm are associated with hemorrhagic strokes.
A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?
Frontal Explanation: 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 a lack of motivation.
A client is experiencing dysphagia following a stroke. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing?
Help the client sit upright when eating and feed slowly. Explanation: Having the client sit upright, preferably out of bed in a chair, and instructing him or her to tuck the chin toward the chest when swallowing will help prevent aspiration. The client may be started on a thick liquid or puréed diet, because these foods are easier to swallow than thin liquids. The diet may be advanced as the client becomes more proficient at swallowing. If the client cannot resume oral intake, a gastrointestinal feeding tube is placed for ongoing tube feedings and medication administration. The client should be allowed to rest before meals because fatigue may interfere with coordination and following instructions.
The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication?
Provide a board of commonly used needs and phrases. Explanation: The inability to talk on the telephone or answer a question or exclusion from conversation causes anger, frustration, fear of the future, and hopelessness. A common pitfall is for the nurse or other health care team member to complete the thoughts or sentences of the client. This should be avoided because it may cause the client to feel more frustrated at not being allowed to speak and may deter efforts to practice putting thoughts together and completing a sentence. The client may also benefit from a communication board, which has pictures of commonly requested needs and phrases. The board may be translated into several languages.
A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is 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?
The client should mobilize as soon as she is physically able . Explanation: As soon as possible, the client is assisted out of bed and an active rehabilitation program is started. Delaying mobility causes complications, but not necessarily stroke recurrence. Mobility should not be withheld until the client initiates.
An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following?
Three hours Explanation: Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in clients with ischemic stroke leads to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months.
A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client?
An isolation room three doors from the nurses' station Explanation: A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other's disease. Immunity to bacterial meningitis can't be acquired; therefore, a client who previously had bacterial meningitis shouldn't be put at risk by rooming with a client who has just been diagnosed with this disease.
The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important?
Maintaining a patent airway Explanation: Maintaining the airway is the most important nursing intervention. Immediate complications of a hemorrhagic stroke include cerebral hypoxia, decreased cerebral blood flow, and extension of the area of injury. Providing adequate oxygenation of blood to the brain minimizes cerebral hypoxia. Brain function depends on delivery of oxygen to the tissues. Administering supplemental oxygen and maintaining hemoglobin and hematocrit at acceptable levels will assist in maintaining tissue oxygenation. All other interventions are appropriate, but the airway takes priority. The head of the bed should be elevated to 30 degrees, monitoring the client because of the risk for seizures, and stool softeners are recommended to prevent constipation and straining, but these are not the most important interventions.
A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient?
Within 24 hours after exposure Explanation: People in close contact with patients with meningococcal meningitis should be treated with antimicrobial chemoprophylaxis using rifampin (Rifadin), ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin). Therapy should be started within 24 hours after exposure because a delay in the initiation of therapy limits the effectiveness of the prophylaxis.
A client with fungal encephalitis receiving amphotericin B reports fever, chills, and body aches. The nurse knows that these symptoms
may be controlled by the administration of diphenhydramine and acetaminophen approximately 30 minutes before administration of the amphotericin. Explanation: Administration of amphotericin B may cause fever, chills, and body aches. The administration of diphenhydramine and acetaminophen approximately 30 minutes before the administration of amphotericin B may prevent these side effects. Renal toxicity due to amphotericin B is dose limiting. Monitoring serum creatinine and blood urea nitrogen levels may alert the nurse to the development of renal insufficiency and the need to address the clients' renal status. Vascular changes are associated with C. immitis and Aspergillus. Manifestations of vascular change may include arteritis or cerebral infarction. Blood and CSF cultures help diagnosis fungal encephalitis.
The statements presented here match nursing interventions with nursing diagnoses. Which statements are true for a client with a stroke? Select all that apply.
Impaired swallowing: Provide a pureed diet. Disturbed sensory perception: Stand on the client's unaffected side. Impaired verbal communication: Repeat words and instructions. Explanation: A pureed diet is often prescribed for a client with impaired swallowing. Other interventions for this client may include a thickened liquid diet, use of the chin tuck technique, and sitting upright. The client may have disturbed sensory perception related to visual disturbances, so standing on the client's unaffected side will allow him or her to see the nurse. The client with impaired verbal communication may benefit from repetition of words or instructions. Other interventions include facing the client, establishing eye contact, using short phrases, using communication boards, decreasing background noise, and allowing the client time between phrases to understand the information. For impaired physical mobility, instruct the client on the use of a walker to improve mobility. The client may experience weakness and the use of the walker will assist with ambulation. For self-care deficit, wide-grip utensils help the client to eat independently, addressing the self-care deficit related to nutrition and self-feeding.
A client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How might the nurse help the client manage her potential sensory and perceptional difficulties?
Place the client's extremities where she can see them. Explanation: The client with homonymous hemianopsia (loss of half of the visual field) turns away from the affected side of the body and tends to neglect that side and the space on that side; this is called amorphosynthesis. In such instances, the client cannot see food on half of the tray, and only half of the room is visible. It is important for the nurse to remind the client constantly of the other side of the body, to maintain alignment of the extremities, and if possible, to place the extremities where the client can see them. Clients with a decreased field of vision should be approached on the side where visual perception is intact. All visual stimuli (clock, calendar, and television) should be placed on this side. The client can be taught to turn the head in the direction of the defective visual field to compensate for this loss. Increasing the natural or artificial lighting in the room and providing eyeglasses are important in increasing vision. There is no reason to keep the lights dim
A client recovering from a stroke has severe shoulder pain from subluxation of the shoulder. To prevent further injury and pain, the nurse caring for this client is aware of what principle of care?
The client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder. Explanation: To prevent shoulder pain, the nurse should never lift a client by the flaccid shoulder or pull on the affected arm or shoulder. The client is taught how to move and exercise the affected arm/shoulder through proper movement and positioning. The client is instructed to interlace the fingers, place the palms together, and push the clasped hands slowly forward to bring the scapulae forward; he or she then raises both hands above the head. This is repeated throughout the day. The use of a properly worn sling when the client is out of bed prevents the paralyzed upper extremity from dangling without support. Range-of-motion exercises are still vitally important in preventing a frozen shoulder and ultimately atrophy of subcutaneous tissues, which can cause more pain. Elevation of the arm and hand is also important in preventing dependent edema of the hand.
A client with meningitis has a history of seizures. Which action by the nurse is appropriate while the client is actively seizing?
Turn the client to the side Explanation: When a client is seizing, the nurse should turn the client to the side and not restrain his or her movements. This helps reduce the potential for aspiration of saliva or stomach contents. An oral airway should not be inserted while the client is actively seizing. An oral airway may be inserted during the aura phase. Anticonvulsants may be administered, but mannitol is an osmotic diuretic, not an anticonvulsant. Applying a cooling blanket while the client is actively seizing could cause harm to the client and is not indicated for seizure activity.
The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipated administering to halt the seizure immediately?
Intravenous diazepam Explanation: Medical management of status epilepticus includes IV diazepam and IV lorazepam given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state. Oral medications are not given during status epilepticus.
Which reflects basic nursing measures in the care of the client with viral encephalitis?
Providing comfort measures Explanation: Providing comfort measures to reduce headache, including dimmed lights, limited noise, and analgesics, are the basic nursing measures in the care of the client with viral encephalitis. Narcotic analgesics may mask neurologic symptoms; therefore, they are used cautiously. Acyclovir therapy is commonly prescribed for viral encephalitis. Amphotericin B is used in the treatment of fungal encephalitis. Nursing management of the client with viral encephalitis includes monitoring of blood chemistry test results and urinary output to alert the nurse to the presence of renal complications related to acyclovir therapy.
The nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education?
Take antihypertensive medication as prescribed. Explanation: The client and family are provided with information that will enable them to cooperate with the care and restrictions required during the acute phase of hemorrhagic stroke and to prepare the client to return home. Client and family teaching includes information about the causes of hemorrhagic stroke and its possible consequences. Symptoms of hydrocephalus include gradual onset of drowsiness and behavioral changes. Hypertension is the most serious risk factor, suggesting that appropriate antihypertensive treatment is essential for a client being discharged. Seizure activity is not normal; complaints of a serious headache should be reported to the health care provider before any medication is taken. Drowsiness is not normal or expected.
