Neuro Questions

A client with a neurologic deficit is feeling frustrated because it is very difficult to pronounce words since having a stroke. The client is struggling with: A) Dysphagia B) Dysarthria C) Dysphasia D) Ataxia

B Dysarthria is characterized by poor articulation of words due to muscle weakness or loss of muscle control. Dysphasia is characterized by the compromised ability to put words together meaningfully. Ataxia is a dysfunction of the parts of the nervous system that coordinate movement. Dysphagia is difficulty with swallowing.

Which disturbance results in loss of half of the visual field? A) Diplopia B) Homonymous hemianopsia C) Nystagmus D) Anisocoria

B Homonymous hemianopsia (loss of half of the visual field) may occur from stroke and may be temporary or permanent. Double vision is documented as diplopia. Nystagmus is ocular bobbing and may be seen in multiple sclerosis. Anisocoria is unequal pupils.

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? A) 6.3 mg B) 7.5 mg C) 9 mg D) 10 mg

A 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.

The nurse is creating a plan of care for a client who has a recent diagnosis of MS. Which of the following should the nurse include in the client's care plan? A) Instruct the client on daily muscle stretching B) Order a low-residue diet C) Assist the client with all ADLs D) Encourage the client to void every hour.

A A client diagnosed with MS should be encouraged to increase the fiber in his or her diet and void 30 minutes after drinking to help train the bladder. The client should participate in daily muscle stretching to help alleviate and relax muscle spasms.

A client with a neurological disorder has difficulty swallowing. The nurse should take special care with the client's diet because of a potential risk of imbalanced nutrition. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing? A) Help the client sit upright and feed slowly B) Enable exercise before their meal C) Offer liquids frequently, in large quantities D) Instruct the client to lie in bed to eat

A A client who has impaired swallowing should be helped to eat foods with texture. The nurse should help such a client sit upright, flex the client's chin toward the chest, and feed slowly. These measures promote easy swallowing of food and reduce the risk of aspiration or airway obstruction. The client should be allowed to rest before meals because fatigue may interfere with coordination and following instructions. Liquids should be offered frequently but in small quantities

A nurse practitioner provides health teaching to a patient who has difficulty managing hypertension. This patient is at an increased risk of which type of stroke? A) Intracerebral hemorrhage B) Subarachnoid hemorrhage C) Hemorrhage due to an aneurysm D) Arteriovenous malformation

A About 80% of hemorrhagic strokes are intracerebral, and they are caused primarily by uncontrolled hypertension.

Which term refers to the failure to recognize familiar objects perceived by the senses? A) Agnosia B) Agraphia C) Apraxia D) Perseveration

A Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to disturbances in writing intelligible words. Apraxia refers to an inability to perform previously learned purposeful motor acts on a voluntary basis. Perseveration is the continued and automatic repetition of an activity, word, or phrase that is no longer appropriate.

A nurse working on a medical-surgical floor walks into a patient's room to find a patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority? A) Maintenance of a patent airway B) Positioning to prevent complications C) Assessment of pupillary light reflexes D) Determination of the cause

A The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.

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. A) Poor abstract reasoning B) Expressive aphasia C) Paresthesias D) Decreased attention span E) Short and long term memory loss

A, D, E 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.

Which are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply. A) Hemorrhagic stroke B) Age 18 or older C) Ischemic stroke D) Systolic BP less than or equal to 185 E) Major surgery in 10 days

A, E Intracranial hemorrhage, neoplasm, aneurysm, and major surgical procedures within 14 days are contraindications to t-PA. Clinical diagnosis of ischemic stroke, being 18 years of age or older, and a systolic BP less than or equal to 185 mm Hg are eligibility criteria.

A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is higher than: A) 170/105 B) 175/100 C) 185/110 D) 190/120

C Elevated blood pressure (systolic >185; diastolic >110 mm Hg) is a contraindication to tPA.

Which is a nonmodifiable risk factor for ischemic stroke? A) Smoking B) Hyperlipidemia C) Gender D) Atrial fibrillation

C Nonmodifiable risk factors include gender, age, and race. Modifiable risk factors include atrial fibrillation, hyperlipidemia, and smoking.

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? A) Supine B) Trendelburg C) Semi Fowler's D) High Fowler's

C The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.

After the patient has received tPA, the nurse knows to check vital signs every 30 minutes for 6 hours. Which of the following readings would require calling the provider? A) Heart rate of 100 B) Respiration of 22 C) Systolic pressure of 130 mm Hg D) Diastolic pressure of 110 mm Hg

D A diastolic pressure reading of over 105 mm Hg warrants notifying the health care provider. The other choices are within the normal range.

The nurse knows that symptoms associated with a TIA, usually a precursor of a future stroke, usually subside in what period of time? A) 12 hr B) 3-6 hr C) 24 hr D) 1 hr

D A transient ischemic attack (TIA) is a neurologic deficit typically lasting less than 1 hour. A TIA is manifested by a sudden loss of motor, sensory, or visual function. The symptoms result from temporary ischemia (impairment of blood flow) to a specific region of the brain; however, when brain imaging is performed, there is no evidence of ischemia.

The client with a cerebral aneurysm asks the nurse, "What's the big fuss over a headache?" Which is the best response from the nurse regarding to a cerebral aneurysm? A) "Don't worry. The aneurysm has probably been there since birth." B) "The headache can be an indication that the aneurysm is growing." C) "A headache means your aneurysm is leaking blood into the brain." D) "Your physician wants to evaluate the location and condition of the aneurysm."

D Keeping the client calm and quiet is an important aspect of care. Explaining the need for further evaluation is factual. The nurse should avoid saying "don't worry" or telling a client how to feel—this is not a therapeutic response. The aneurysm is growing or leaking are both inappropriate responses from a nurse and can lead to increased concern and anxiety for the client.

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? A) Elevating the head of the bed to 30 degrees B) Checking stools for occult blood C) Performing range-of-motion (ROM) exercises on the left sid D) Keeping skin clean and dry

A 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.

A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin? A) immediately B) in 2 to 3 days C) after 1 week D) upon transfer to a rehabilitation unit

A Beginning basic rehabilitation during the acute phase is an important nursing function. Measures such as position changes and prevention of skin breakdown and contractures are essential aspects of care during the early phase of rehabilitation. The nursing goal is to prevent complications that may interfere with the client's potential to recover function.

A male patient with cerebrovascular accident (CVA) is prescribed medication to treat the disorder. The patient wants to know what other measures may help reduce CVA. Which of the following is an accurate suggestion for the patient? A) Reduce hypertension and high blood cholesterol levels. B) Increase body weight moderately C) Increase fluid intake and hydration D) Increase intake of carbohydrates and proteins

A CVAs are prevented by reducing certain risk factors, such as hypertension, overweight, cardiac dysrhythmias (such as atrial fibrillation), and high blood cholesterol levels. Patients should not gain body weight. In addition, the increased intake of proteins, carbohydrates, or fluids does not help in reducing the risk of CVAs.

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 the assessment? A) Lack of deep tendon reflexes B) Visual agnosia C) Limited attention span D) Auditory agnosia

A 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 76-year-old client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? A) Carotid endarterectomy B) Stent placement C) Removal of the carotid artery D) Percutaneous transluminal coronary artery angioplasty

A If the narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a carotid endarterectomy (surgical removal of atherosclerotic plaque) is a treatment option. A balloon angioplasty, a procedure similar to a percutaneous transluminal coronary artery angioplasty, is performed to dilate the carotid artery and increase blood flow to the brain. Options A, B, and C are not surgical options to increase blood flow through the carotid artery to the brain

A nurse is providing care to a client who has had a stroke. Which symptoms are consistent with left-sided stroke? A) impulsive behavior, poor judgment, deficits in left visual fields B) expressive aphasia, defects in the right visual fields, problems with abstract thinking C) problems with abstract thinking, impairment of short-term memory, poor judgment D) cautious behavior, deficits in left visual fields, misjudgment of distances

A Impulsive behavior, poor judgment, deficits in left visual fields are symptoms of right hemispheric stroke. Expressive aphasia, defects in the right visual fields, problems with abstract thinking are symptoms of left hemispheric stroke. Problems with abstract thinking, impairment of short-term memory, poor judgment are symptoms inconsistent with each other as some indicate left and others indicate right hemispheric stroke. Cautious behavior, deficits in left visual fields, misjudgment of distances are symptoms inconsistent with each other as some indicate left and others indicate right hemispheric stroke.

A client with a recent stroke history is admitted to a rehabilitation unit and placed on high fall risk precautions. The client is impulsive, easily distracted, frequently forgets his/her cane when walking, and the location of his/her room. What stroke conditions do these signs best indicate A) Right hemispheric stroke B) Left hemispheric stroke C) Ischemic stroke D) Hemorrhagic stroke

A In right hemispheric stroke, signs include a client that is easily distracted and has impulsive behavior and poor judgment. The client can be unaware of deficits like motor weakness, as demonstrated by the client forgetting the cane. Clients can also have spatial or perceptual deficits. This means they can get lost in familiar and unfamiliar places. This client was unable to find his/her room. The client who has a right hemisphere stroke demonstrates weakness on the left side of the body. The client with left hemispheric stroke has signs such as paralysis or weakness in the right side of the body, right-sided visual deficits, and slow cautious behaviors. Ischemic and hemorrhagic strokes describe what caused the stroke rather than what side of the brain was affected. Signs and symptoms differ for each type of stroke. Ischemic strokes can include numbness to one side of the face. Headache, decreased level of consciousness, and seizures typically are signs of a hemorrhagic stroke.

Which statement reflects nursing management of the client with expressive aphasia? A) Encourage the client to repeat sounds of the alphabet B) Speak slowly and clearly to assist the client in forming the sounds C) Frequently reorient the patient to time and place D) Speak clearly to the client in simple sentences, and use gestures or pictures when able

A Nursing management of the client with expressive aphasia includes encouraging the client to repeat sounds of the alphabet. Nursing management of the client with global aphasia includes speaking clearly to the client in simple sentences and using gestures or pictures when able. Nursing management of the client with receptive aphasia includes speaking slowing and clearly to assist the client in forming the sounds. Nursing management of the client with cognitive deficits, such as memory loss, includes frequently reorienting the client to time, place, and situation.

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) A 60-year-old Black man B) A 40-year-old White woman C) A 62-year-old White woman D) A 28-year-old pregnant Black woman

A The 60-year-old Black man has three risk factors: gender, age, and race. Black people have almost twice the incidence of first stroke compared with White people.

Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord? A) MS B) Huntington's disease C) Parkinson's disease D) Creutazfeldt-Jakob disease

A The cause of MS is not known, and the disease affects twice as many women as men. Parkinson disease is associated with decreased levels of dopamine caused by destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary dancelike movements and dementia. Creutzfeldt-Jakob disease is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain.

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? A) Weakness on one side of the body and difficulty with speech B) Severe headache and early change in level of consciousness C) Foot drop and external hip rotation D) Vomiting and seizures

A 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. Foot drop 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. What intervention should the nurse do after the seizure? A) Keep the client on one side. B) Place a cooling blanket beneath the client. C) Sit the client up D) Pry open the client's mouth to create a patent airway

A 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 hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety? A) Place in side-lying position B) Pad the rails C) Reassure the patient and family D) Administer antianxiety meds as prescribed

A 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.

Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis? A) Apraxia B) Agnosia C) Perseveration D) Agraphia

A Verbal apraxia refers to difficulty forming and organizing intelligible words although the musculature is intact. Agnosia is a failure to recognize familiar objects perceived by the senses. Agraphia refers to disturbances in writing intelligible words. Perseveration is the continued and automatic repetition of an activity or word or phrase that is no longer appropriate.

The nurse is initiating a bladder-training schedule for a patient. What intervention can be provided for optimal success? (Select all that apply.) A) Encourage the patient to wait 30 minutes after drinking a measured amount of fluid before attempting to void. B) Give up to 3,000 mL of fluid daily. C) Teach bladder massage to increase intra-abdominal pressure. D) Instruct patient to restrict fluid intake during the day E) Administer a diuretic every morning

A, B, C At no time should the fluid intake be restricted to decrease the frequency of urination. Sufficient fluid intake (2,000 to 3,000 mL per day, according to patient needs) must be ensured. To optimize the likelihood of voiding as scheduled, measured amounts of fluids may be administered about 30 minutes before voiding attempts. In addition, most of the fluids should be consumed before evening to minimize the need to void frequently during the night. Massage of the abdomen can be effective in increasing intra-abdominal pressure and thus promoting the urge to void. The goal of bladder training is to restore the bladder to normal function, so diuretics should not be used.

Which nursing interventions might need to be considered in a care plan for a client with advanced multiple sclerosis? Select all that apply. A) Ensure access to a language board when communicating with the client. B) Obtain daily weights to monitor weight gain. C) Establish a voiding time schedule. D) Encourage the client to walk with feet wide apart.

A, B, D Language assistive devices may be needed if communication is severely affected. Occasional bladder incontinence may lead to total incontinence. A voiding time schedule will allow the client greater independence. If motor dysfunction causes problems of incoordination and clumsiness, the patient is at risk for falling. As the disease progresses, nutritional deficiencies may develop. Weight should be assessed to ensure that there is no significant weight loss. Weight gain should not be an issue.

A family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when a client experiences a stroke on the right side of the brain, common deficits include what? Select all that apply. A) Left-sided hemiplegia B) Tendency to distractibility C) Impairment of long-term memory D) Hyperaware of deficits E) Neglect of objects and people on the left side

A, B, E Left-sided hemiplegia (stroke on right side of brain) may have the following neurologic deficits: spatial-perceptual defects; disregard for the deficits of the affected side require special safety considerations; tendency to distractibility; impulsive behavior, unaware of deficits; poor judgment; defects in left visual fields; misjudge distances; difficulty distinguishing upside-down and right-side up; impairment of short-term memory; and neglect left side of body, objects and people on left side.

A health care provider has prescribed a standard electroencephalogram (EEG) test for the client. What general instructions should the nurse provide to the client? Select all that apply. A) The procedure generally takes 45 to 60 minutes. B) Please remove all jewelry and any metal objects prior to the procedure. C) This procedure uses a water-soluble lubricant for electrode contact which can be easily wiped off and removed using shampoo. D) If you feel nervous about the test I can provide you a light sedative medication to ease your anxiety. E) Please refrain from drinking coffee and any caffeinated beverages the morning prior to the procedure. F) It is required that you withhold taking your anticonvulsant medication 72 hours before the procedure.

A, C, E A standard EEG usually takes 45 to 60 minutes. Typically, a water-soluble lubricant is used to aid electrode contact. This lubricant is easily removed with shampoo. Coffee, tea, chocolate, and cola drinks are omitted from the meal before the test because of their stimulating effect. Sedation is not considered because it may lower the seizure threshold in clients and it may alter brain activity. Stimulants, tranquilizers, anticonvulsants, and depressants are advised to be held 24 to 48 hours, not 72 hours, prior to the procedure because these medications can alter the EEG wave patterns or mask the abnormal wave patterns of seizure disorders. The client is instructed to eat before the test because keeping the client NPO (nothing by mouth) can alter blood glucose levels and cause changes in brain wave patterns. The client can wear jewelry during the test, although some facilities will request that earrings be removed.

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? A) Large artery thrombosis B) Cerebral aneurysm C) Cardiogenic emboli D) Small artery thrombosis

B A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache.

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? A) Restrict protein to 10% of daily intake B) High in protein, low in carb C) Low-fat D) At least 50% carbohydrate

B A dietary intervention, referred to as the ketogenic diet, may be helpful for control of seizures in some patients. This high-protein, low-carbohydrate, high-fat diet is most effective in children whose seizures have not been controlled with two antiseizure medications, but it is sometimes used for adults who have had poor seizure control

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? A) Dexamethasone B) Heparin sodium C) Methyldopa D) Phenytoin

B 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.

A client is demonstrating an altered level of consciousness from a traumatic brain injury. Which assessment will the nurse use as a sensitive indicator of neurologic function? A) Cerebellar function B) Glasgow Coma Scale C) Cranial nerve function D) Mental status evaluation

B An altered level of consciousness (LOC) is present when the client is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness. LOC is gauged on a continuum, with a normal state of alertness and full cognition (consciousness) on one end and coma on the other end. LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response. Cerebellar function, cranial nerve function, and mental status evaluation are all elements of the neurologic assessment.

Which of the following, if left untreated, can lead to an ischemic stroke? A) Arteriovenous malformations B) Atrial fibrillation C) Ruptured cerebral arteries D) Cerebral aneurysm

B Atrial fibrillation is the most frequently diagnosed arrhythmia in the United States. If left untreated, it can lead to an ischemic stroke. Cerebral hemorrhage, arteriovenous malformation, and cerebral hemorrhage can lead to a hemorrhagic stroke. Cerebral aneurysm, arteriovenous malformations, and ruptured cerebral arteries can lead to hemorrhagic stroke.

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? A) Seizure began at 1300 hours. B) Seizure was 1 minute in duration including tonic-clonic activity. C) The client cried out before the seizure began. D) Sleeping quietly after the seizure

B 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 is providing care for a client who has limited mobility after a stroke. In order to assess the client for contractures, the nurse should assess the client's: A) level of joint pain B) ROM C) deep tendon reflexes D) tendon sizes

B Each joint of the body has a normal range of motion. To assess a client for contractures, the nurse should assess whether the client can complete the full range of motion. Assessing DTRs, muscle size, or joint pain does not reveal the presence or absence of contractures.

The nurse is caring for a client with multiple sclerosis (MS). The client tells the nurse the hardest thing to deal with is the fatigue. When teaching the client how to reduce fatigue, what action should the nurse suggest? A) Avoid naps during the day B) Resting in an air-conditioned room whenever possible C) Ensure to take a hot bath at least once daily D) Increasing the dose of muscle relaxants

B Fatigue is a common symptom of clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.

If warfarin is contraindicated as a treatment for stroke, which medication is the best option? A) Dipyridamole B) Aspirin C) Clopidogrel D) Ticlodipine

B If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.

A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? A) 6 B) 3 C) 15 D) 9

B LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response (Barlow, 2012). The patient's responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive (see Chapter 68).

A 33-year-old client presents at the clinic with reports of weakness, incoordination, dizziness, and loss of balance. The client is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS? A) Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexe B) Blurred vision, intention tremor, and urinary hesitancy C) Flexor spasm, clonus, and negative Babinski reflex D) Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs

B Optic neuritis, leading to blurred vision, is a common early sign of MS, as is intention tremor (tremor when performing an activity). Nerve damage can cause urinary hesitancy. In MS, deep tendon reflexes are increased or hyperactive. A positive Babinski reflex is found in MS. Abdominal reflexes are absent with MS.

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? A) One hour B) Three hours C) Six hours D) Nine hours

B 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 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? A) "Have your heart checked regularly." B) "Stop smoking as soon as possible." C) "Take your prescribed medication to bring down your sodium levels." D) "Eat a nutritious diet."

B 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 patient suffering a stroke is having a difficult time swallowing. What would the nurse document this finding as? A) Dysphasia B) Dysphagia C) Ataxia D) Dyspnea

B 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.

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? A) Moderate in fruits and vegetables B) Moderate in low-fat dairy products C) High in animal proteins D) High in salt

B The DASH diet is high in fruits and vegetables, moderate in low-fat dairy products, and low in animal protein.

A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last? A) Up to 2 weeks B) 1 to 3 days C) Up to 1 week D) Up to 24 hrs

B 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 nurse is taking care of a client with swallowing difficulties after a stroke. What are some interventions the nurse can accomplish to prevent the client from aspirating while eating? Select all that apply. A) Encourage the client to increase his/her intake of water and juice. B) Assist the client out of bed and into the chair for meals. C) Instruct the client to tuck his/her chin towards their chest when swallowing. D) Request a swallowing assessment by a speech therapist before the client's discharge. E) Recommend the insertion of a percutaneous endoscopic gastrostomy (PEG) tube.

B, C If swallowing function is partially impaired, it may return over time, or the client may be educated in alternative swallowing techniques, advised to take smaller boluses of food, and educated about types of foods that are easier to swallow. The client may be started on a thick liquid or pureed diet, because these foods are easier to swallow than thin liquids. Having the client sit upright, preferably out of bed in a chair, and instructing them to tuck the chin toward the chest as they swallow will help prevent aspiration. Recommending the insertion of a percutaneous endoscopic gastrostomy (PEG) tube would not prevent the client from aspirating while eating. A PEG tube could be placed if the client was unable to tolerate or resume an oral intake. A swallowing assessment should be done before allowing any oral intake and preferably within 4 to 24 hours after a stroke. A nurse can also accomplish a swallowing study using a validated and reliable

The nurse is preparing to assess a client with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply. A) The ability to select basic medications for the neurologic dysfunction B) Understanding of the tests used to diagnose neurologic disorders C) Knowledge of nursing interventions related to assessment and diagnostic testing D) Knowledge of the anatomy of the nervous system E) The ability to interpret the results of diagnostic tests

B, C, D Assessment requires knowledge of the anatomy and physiology of the nervous system and an understanding of the array of tests and procedures used to diagnose neurologic disorders. Knowledge about the nursing implications and interventions related to assessment and diagnostic testing is also essential. Selecting medications and interpreting diagnostic tests are beyond the normal scope of the nurse.

The nurse is caring for a client with aphasia. Which action will the nurse take when communicating with the client? Select all that apply. A) Talk over the TV B) Use gestures when talking C) Speak in a normal tone D) Face the client E) Pause between phrases

B, C, D, E Communicating with a client with aphasia can be challenging. Actions to improve communication include pausing between phrases, using gestures when talking, facing the client when talking, and speaking in a normal tone of voice. Extraneous background noise should be kept to a minimum. Turning off the sound on the television would be beneficial to improve communication.

The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? Select all that apply. A) Place mouth gag in mouth B) Loosen constrictive clothing C) Restrain the patient from moving D) Place the patient on side with head flexed forward E) Provide privacy

B, D, E During a patient's seizure, the nurse should do the following. Loosen constrictive clothing. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions. Provide privacy, and protect the patient from curious onlookers. (The patient who has an aura [warning of an impending seizure] may have time to seek a safe, private place.) The nurse should not attempt to pry open jaws that are clenched in a spasm or attempt to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. No attempt should be made to restrain the patient during the seizure, because muscular contractions are strong and restraint can produce injury.

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke? A) Altered intellectual ability B) Aphasia C) Left visual field deficit D) Slow, cautious behavior

C 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.

Which of the following is the most common side effect of tissue plasminogen activator (tPA)? A) Hypertension B) Headache C) Bleeding D) Increased ICP

C Bleeding is the most common side effect of tPA. The patient is closely monitored for bleeding (at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness). Headache, increased ICP, and hypertension are not side effects of tPA.

A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment? A) Prothrombin level B) Chest x-ray C) Brain CT scan or MRI D) Lumbar puncture

C CT scan or MRI differentiates CVA from other disorders and can differentiate between ischemic or hemorrhagic strokes. PT level would be done if the client is receiving anticoagulant therapy. Chest x-ray may be performed if respiratory concerns are indicated. Lumbar puncture would be done if subarachnoid bleeding is suspected.

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer? A) "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client." B) "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing." C) "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation." D) "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved."

C Clinical manifestations following a stroke are highly variable and depend on the area of the cerebral cortex and the affected hemisphere, the degree of blockage (total, partial), and the presence or absence of adequate collateral circulation. (Collateral circulation is circulation formed by smaller blood vessels branching off from or near larger occluded vessels.) Clinical manifestations of a stroke do not depend on the cardiovascular health of the client or how quickly the clot can be dissolved. Clinical manifestations of a stroke are not "general" but individual.

Which is often the most disabling clinical manifestation of multiple sclerosis? A) Ataxia B) Muscle spasms C) Fatigue D) Pain

C Fatigue affects 87% of people with MS, and 40% of that group indicate that fatigue is the most disabling symptom. Pain, spasticity, and ataxia are other clinical manifestations of MS, but are not the most disabling.

A patient having an acute stroke with no other significant medical disorders has a blood glucose level of 420 mg/dL. What significance does hyperglycemia have for this patient? A) The patient has new onset diabetes. B) The patient has liver failure. C) This is significant for poor neurologic outcomes. D) The patient has developed diabetes insipidus due to the location of the stroke.

C Hyperglycemia has been associated with poor neurologic outcomes in acute stroke and should be treated if the blood glucose is above 140 mg/dL

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is: A) Obesity B) Smoking C) Hypertension D) Diabetes

C Hypertension is the most modifiable risk factor for either ischemic or hemorrhagic stroke. Unfortunately, it remains under-recognized and undertreated in most communities.

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? A) The client's hip joint should be maintained in a flexed position. B) The client should be in a supine position unless ambulating. C) The client should be placed in a prone position for 15 to 30 minutes several times a day. D) The client should be placed in a Trendelenburg position two to three times daily to promote cerebral perfusion.

C If possible, the clients 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 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? A) large-artery thrombotic B) small, penetrating artery thrombotic C) cardio embolic D) cryptogenic

C Ischemic strokes are further divided into five subtypes, according to a mechanism-based classification system: large-artery thrombotic strokes (representing 20% of ischemic strokes); small, penetrating artery thrombotic strokes (25%); cardio embolic strokes (20%); cryptogenic strokes (strokes that cannot be attributed to any specific cause) (30%); and "other" (5%). Large-artery thrombotic strokes are caused by atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion can occur at the site of the atherosclerosis and result in ischemia and infarction (tissue death). Small, penetrating artery thrombotic strokes that affect one or more vessels and cause reduced blood flow are the most common type of ischemic stroke, typically caused by longstanding hypertension, hyperlipidemia, or diabetes. Cardio embolic strokes are associated with cardiac dysrhythmias, such as atrial fibrillation, but can also be associated with valvular heart disease or left ventricular thrombus. The last two classifications of ischemic strokes are cryptogenic strokes, which have no identified cause, and strokes from other causes, such as illicit drug use (cocaine), coagulopathies, migraine, or spontaneous dissection of the carotid or vertebral arteries.

What nursing intervention is appropriate for a client with receptive aphasia? A) Encourage the client to repeat sounds of the alphabet. B) Explore the client's ability to write. C) Speak slowly and clearly. D) Frequently reorient the client to time, place, and situation.

C Nursing management of the client with receptive aphasia includes speaking slowing and clearly to assist the client in forming the sounds. Nursing management of the client with expressive aphasia includes encouraging the client to repeat sounds of the alphabet or to explore the client's ability to write. Nursing management of the client with cognitive deficits, such as memory loss, includes frequently reorienting the client to time, place, and situation.

A nurse in a rehabilitation facility is coordinating the discharge of a client who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team? A) chaplain B) home care nurse C) spouse D) physical therapist

C The client's spouse and family would need to be involved in the everyday care of the client; without their support, it is unlikely that the client would be able to manage at home.

A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What should the nurse do? A) Anticipate the client will exhibit some degree of expressive or receptive aphasia. B) Place the wheelchair on the client's left side when transferring him into a wheelchair. C) Provide close supervision because of the client's impulsiveness and poor judgment. D) Support the right arm with a sling or pillow to prevent subluxation.

C 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.

A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take? A) Speak over the television volume B) Speak in a louder tone than normal C) Face the client and establish eye contact D) Say everything in one long sentence

C 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.

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? A) Transient ischemic attack (TIA) B) Right-sided cerebrovascular accident (CVA) C) Left-sided cerebrovascular accident (CVA) D) Completed Stroke

C 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.

The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following? A) Arteriovenous malformation B) Intracerebral hemorrhage C) Cerebral aneurysm D) Cardiogenic emboli

D Aneurysms, hemorrhages, and malformations are all examples of a hemorrhagic stroke. An embolism can block blood flow, leading to ischemia.

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? A) Limited attention span and forgetfulness B) Hemiplegia or hemiparesis C) Lack of deep tendon reflexes D) Auditory agnosia

D 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, hemiplegia, and a change in

The nurse recognizes health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle, including A) a high-protein diet and increased weight-bearing exercise. B) eating fish no more than once a month. C) a low-cholesterol, low-protein diet, and decreased aerobic exercise. D) a low-fat, low-cholesterol diet and increased exercise.

D Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle, including a low-fat, low-cholesterol diet and increased exercise. Recent evidence suggests that eating fish two or more times per week reduces the risk of thrombotic stroke for women.

Which of the following drugs may be used after a seizure to maintain a seizure-free state? A) IV diazepam (Valium) B) Lorazepam (Ativan) C) Fosphenytoin (Cerebyx) D) Phenobarbital

D 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 stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe? A) Parietal B) Occipital C) Temporal D) Frontal

D 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.

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? A) Systolic blood pressure less than or equal to 185 mm Hg B) Age 18 years or older C) Ischemic stroke D) Intracranial hemorrhage

D Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA. Clinical diagnosis of ischemic stroke, age 18 years or older, and a systolic blood pressure less than or equal to 185 mm Hg are eligibility criteria.

Which is a modifiable risk factor for transient ischemic attacks and ischemic strokes? A) Thyroid disease B) Social drinking C) Advanced age D) Smoking

D Modifiable risk factors for TIAs and ischemic stroke include hypertension, diabetes, cardiac disease, smoking, and excessive alcohol consumption. Advanced age, gender, and race are nonmodifiable risk factors for stroke.

A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? A) Tachycardia, tachypnea, and hypotension B) Difficulty breathing or swallowing C) Nausea, vomiting, and profuse sweating D) Hemiplegia, seizures, and decreased level of consciousness

D Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased level of consciousness, aphasia, hemiparesis, and increased focal symptoms. Nausea, vomiting, and profuse sweating suggest a delayed reaction to the contrast medium used in cerebral angiography. Difficulty breathing or swallowing may signal a hematoma in the neck. Tachycardia, tachypnea, and hypotension suggest internal hemorrhage

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? A) Focal seizure B) Unclassified seizure C) Generalized seizure D) Absence seizure

D Staring episodes characterize an absence seizure, whereas focal seizures, generalized seizures, and unclassified seizures involve uncontrolled motor activity.

A middle-aged client has sought care from the primary provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the client to seek care? A) Personality changes B) Cognitive declines C) Contractures D) Difficulty in coordination

D The symptoms of MS most commonly reported are fatigue, depression, weakness, numbness, difficulty in coordination, loss of balance, spasticity, and pain. Cognitive changes and contractures usually occur later in the disease.

A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse? A) "This behavior is common in clients with stroke. Which does your spouse do more often? Laugh or cry?" B) "You seem upset, and it may be hard for you to focus on the teaching, I'll come back later." C) "You sound stressed; maybe using some stress management techniques will help." D) "Emotional lability is common after a stroke, and it usually improves with time."

D This is the most therapeutic and informative response. Often, most relatives of clients with stroke handle the physical changes better than the emotional aspects of care. The family should be prepared to expect occasional episodes of emotional lability. The client may laugh or cry easily and may be irritable and demanding or depressed and confused. The nurse can explain to the family that the client's laughter does not necessarily connote happiness, nor does crying reflect sadness, and that emotional lability usually improves with time. The remaining responses are nontherapeutic and do not address the spouse's concerns.