Neurological

Which intervention should the nurse implement to decrease increased ICP for a client on a ventilator? Select all that apply. 1. Position the client with the head of the bead up 30 degrees. 2. Cluster activities of care. 3. Suction the client every three (3) hours. 4. Administer soapsuds enemas until clear. 5. Place the client in Trendelenburg position.

1,2

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

1,2,4

Which client would the nurse identify as being most at risk for experiencing a CVA? 1. A 55-year-old African American male. 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female.

1. A 55-year-old African American male. African Americans have twice the rate of CVAs as Caucasians and men have a higher incidence than women; African Americans suffer more extensive damage from a CVA than do people of other cultural groups.

A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? 1. Administer a stool softener b.i.d. 2. Encourage the client to cough hourly. 3. Monitor neurological status every shift. 4. Maintain the dopamine drip to keep BP at 160/90.

1. Administer a stool softener b.i.d. The client is at risk for increased intracranial pressure whenever performing the Valsalva maneuver, which will occur when straining during defecation. Therefore, stool softeners would be appropriate.

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? 1. An oral anticoagulant medication. 2. A beta blocker medication. 3. An anti-hyperuricemic medication. 4. A thrombolytic medication.

1. An oral anticoagulant medication. The nurse would anticipate an oral anticoagulant, warfarin (Coumadin), to be prescribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. The thrombi can become embolic and may cause a TIA or CVA (stroke).

The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. 1. Position the client to prevent shoulder adduction. 2. Turn and reposition the client every shift. 3. Encourage the client to move the affected side. 4. Perform quadriceps exercises three (3) times a day. 5. Instruct the client to hold the fingers in a fist.

1. Position the client to prevent shoulder adduction. Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture. 3. Encourage the client to move the affected side. The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible; a written schedule may assist the client in exercising.

The client diagnosed with atrial fibrillation complains of numbness and tingling of her left arm and leg. The nurse assesses facial drooping on the left side and slight slurring of speech. Which nursing interventions should the nurse implement first? 1. Schedule a STAT MRI of the brain. 2. Call a Code STROKE. 3. Notify the HCP. 4. Have the client swallow a glass of water.

2

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

2

The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse document? 1. Hemiparesis of the client's left arm and apraxia. 2. Paralysis of the right side of the body and ataxia. 3. Homonymous hemianopsia and diplopia. 4. Impulsive behavior and hostility toward family.

2. Paralysis of the right side of the body and ataxia. The most common motor dysfunction of a CVA is paralysis of one side of the body, hemiplegia; in this case with a left-sided CVA, the paralysis would affect the right side. Ataxia is an impaired ability to coordinate movement.

The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? 1. Potential for injury. 2. Powerlessness. 3. Disturbed thought processes. 4. Sexual dysfunction.

2. Powerlessness. Expressive aphasia means that the client cannot communicate thoughts but understands what is being communicated; this leads to frustration, anger, depression, and the inability to verbalize needs, which, in turn, causes the client to have a lack of control and feel powerless.

A 78-year-old client is admitted to the ED with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factor that caused the symptoms. 3. Schedule for a STAT CT scan of the head. 4. Notify the speech pathologist for an emergency consult.

3

The nurse is caring for a client with increased intracranial pressure who has secretions pooled in the throat. Which intervention should the nurse implement first? 1. Set the ventilator to hyperventilate the client in preparation for suctioning. 2. Assess the client's lung sounds and check for peripheral cyanosis. 3. Turn the client to the side to allow the secretions to drain from the mouth. 4. Suction the client using the in-line suction, wait 30 seconds, and repeat.

3

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? 1. A blood glucose level of 480 mg/dL. 2. A right-sided carotid bruit. 3. A blood pressure of 220/120 mm Hg. 4. The presence of bronchogenic carcinoma.

3. A blood pressure of 220/120 mm Hg. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel inside the cranium.

The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The assistant places a gait belt around the client's waist prior to ambulating. 2. The assistant places the client on the back with the client's head to the side. 3. The assistant places a hand under the client's right axilla to move up in bed. 4. The assistant praises the client for attempting to perform ADLs independently.

3. The assistant places a hand under the client's right axilla to move up in bed. This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the back or using a lift sheet.

The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? 1. "We need to discourage him from wearing eyeglasses." 2. "We need to place objects in his impaired field of vision." 3. "We need to approach him from the impaired field of vision." 4. "We need to remind him to turn his head to scan the lost visual field."

4

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

4

The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? 1. Administer a nonnarcotic analgesic. 2. Prepare for STAT magnetic resonance imaging (MRI). 3. Start an intravenous infusion with D5W at 100 mL/hr. 4. Complete a neurological assessment.

4. Complete a neurological assessment. The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action.

The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? 1. Obtain a rubber mat to place under the dinner plate. 2. Purchase a long-handled bath sponge for showering. 3. Purchase clothes with Velcro closure devices. 4. Obtain a raised toilet seat for the client's bathroom.

4. Obtain a raised toilet seat for the client's bathroom. Raising the toilet seat is modifying the home and addresses the client's weakness in being able to sit down and get up without straining muscles or requiring lifting assistance from the wife.

The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care? 1. Observe the client swallowing for possible aspiration. 2. Position the client in a semi-Fowler's position when sleeping. 3. Place a suction setup at the client's bedside during meals. 4. Refer the client to an occupational therapist for evaluation.

4. Refer the client to an occupational therapist for evaluation. A collaborative intervention is an intervention in which another health-care discipline—in this case, occupational therapy—is used in the care of the client.