Prep U 260- Neuro
An unresponsive patient is brought to the ED by a family member. The family states, "We don't know what happened." Which of the following is the priority nursing intervention?
Assess for a patent airway.
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
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.
The causes of acquired seizures include what? (Mark all that apply.)
• Cerebrovascular disease • Metabolic and toxic conditions • Brain tumor • Drug and alcohol withdrawal
A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?
3
Which of the following terms refer to the failure to recognize familiar objects perceived by the senses?
Agnosia
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
Which of the following is the earliest sign of increasing ICP?
Change in level of consciousness
Which disturbance results in loss of half of the visual field?
Homonymous hemianopsia
Following a motorcycle accident, a client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure?
Lethargy
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
When providing teaching to a client who reports tension headaches, which of the following instructions would be most beneficial to prevent onset of symptoms?
Perform stretching exercises and frequent position change.
A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke?
Severe headache Explanation: The patient with a hemorrhagic stroke can present with a wide variety of neurologic deficits, similar to the patient with ischemic stroke. The conscious patient most commonly reports a severe headache.
The nurse is caring for a patient immediately following supratentorial intracranial surgery. What action by the nurse is appropriate?
Place patient in supine position with head slightly elevated.
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?
6.3mg RATIONALE: A person who weighs 154 lbs weighs 70 kg. To calculate dosage, multiply 70 × 0.9 mg/ kg = 63 mg. The nurse gives 10% (6.3 mg) over 1 minute.
A client with Parkinson's disease asks the nurse what their treatment is supposed to do since the disease is progressive. What would be the nurse's best response?
"Treatment aims at keeping you independent as long as possible." Explanation: Treatment aims at prolonging independence. Treatment does matter, it is not palliative, and it is not aimed at keeping you emotionally healthy.
Which of the following is indicative of a right hemisphere stroke?
Spatial-perceptual deficits Explanation: Patients with right hemisphere stroke exhibit partial perceptual deficits, left visual field deficit, and paralysis is weakness on the left side of the body. Left hemisphere damage causes aphasia, slow, cautious behavior, and altered intellectual ability.
A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time?
4:00 p.m. Explanation: Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset.
The nurse recognizes health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle, including which of the following?
A low-fat, low-cholesterol diet, and increasing exercise
A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?
Administer stool softeners. Explanation: Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return.
A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)?
Administering a stool softener as ordered. Explanation: To prevent the client from straining at stool, which may cause a Valsalva maneuver that increases ICP, the nurse should institute a regular bowel program that includes use of a stool softener. For a client at risk for increased ICP, the nurse should prevent, not encourage, oral fluid intake and should elevate the head of the bed only 30 degrees.
A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the medical treatment to include which of the following?
Anticoagulant therapy Explanation: Anticoagulant or antiplatelet therapy can prevent clot formation associated with cardiac dysrhythmias such as atrial fibrillation.
A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first?
Ask the client if he has trouble breathing. The nurse should first assess the client's breathing. A complication of a carotid endarterectomy is an incisional hematoma, which could compress the trachea causing breathing difficulty for the client. Although the other measures are important actions, they aren't the nurse's top priority.
An unresponsive patient is brought to the ED by a family member. The family states, "We don't know what happened." Which of the following is the priority nursing intervention?
Assess for a patent airway. Explanation: A patient with altered LOC may be unable to protect his or her airway and therefore the priority nursing intervention should be to assess for a patent airway. The nurse should assess pupils, vital signs, and Glasgow Coma Scale, but only after ensuring the patient has a patent airway.
Which of the following positions are employed to help reduce intracranial pressure (ICP)?
Avoiding flexion of the neck with use of a cervical collar Explanation: Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.
Which of the following is one of the earliest signs of increased ICP?
Decreased level of consciousness (LOC). Explanation: Decreasing LOC is one of the earliest signs of increased ICP. Headache is a symptom of increased ICP, but decreasing LOC is one of the earliest signs of increased ICP. Cushing's triad occurs late in increased ICP. Decreasing LOC is one of the earliest signs of increased ICP. If untreated, increasing ICP will lead to coma. Decreasing LOC is one of the earliest signs of increased ICP.
The nurse is caring for a patient with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which of the following postoperative findings would cause the nurse the most concern?
Difficulty swallowing. Explanation: The patient's inability to swallow without difficulty would cause the nurse the most concern.
The nurse is caring for a client hospitalized after a motor vehicle accident. The client has a comorbidity of Parkinson's disease. Why should the nurse closely monitor the condition and the drug regimen of a client with Parkinson's disease?
Drugs administered may cause a wide variety of adverse effects.
A patient has been diagnosed as having global aphasia. The nurse recognizes that the patient will be unable to do which of the following actions?
Form words that are understandable or comprehend the spoken word
From which direction should a nurse approach a client who is blind in the right eye?
From the left side of the client
A patient with neurological disorder has difficulty swallowing. The nurse should take special care of the patient's diet because of a potential risk of imbalanced nutrition in the patient. Which of the following measures may be taken by the nurse to ensure that the patient's diet allows for easy swallowing?
Help the patient sit upright when eating and feed slowly
A client undergoes cerebral angiography for evaluation after an intracranial computed tomography scan revealed a subarachnoid hemorrhage. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?
Hemiplegia, seizures, and decreased level of consciousness (LOC)
Which of the following terms will the nurse use when referring to blindness in the right or left halves of the visual fields of both eyes?
Homonymous hemianopsia Homonymous hemianopsia occurs with occipital lobe tumors. Scotoma refers to a defect in vision in a specific area in one or both eyes. Diplopia refers to double vision or the awareness of two images of the same object occurring in one or both eyes. Nystagmus refers to rhythmic, involuntary movements or oscillations of the eyes
The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring?
Increased ICP An increase in blood pressure and decrease in pulse with respiratory failure may indicate increased ICP.
The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?
Increased pulse rate, adventitious breath sounds. Explanation: An increased pulse rate above baseline with adventitious breath sounds indicate compromised respirations and signal a need for airway clearance.
A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?
Increased urine output. The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output.
A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following nursing diagnoses would be the first priority for the plan of care?
Ineffective airway clearance related to altered LOC
Which of the following is a contraindication for the administration of tissue plasminogen activator (t-PA)?
Intracranial hemorrhage. Explanation: Intracranial hemorrhage, neoplasm, or aneurysm is a contraindication to t-PA.
You are the nurse caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should you keep always ready at the bedside?
Intubation tray and suction apparatus Explanation: Progressive GBS can move to the upper areas of the body and affect the muscles of respiration. If the respiratory muscles are involved, endotracheal intubation and mechanical ventilation become necessary. A spirometer is used to evaluate the client's ventilation capacity. A blood pressure apparatus, nebulizer, and thermometer are not required because generally a client with GBS does not show signs of increased blood pressure or temperature.
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 patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem?
Lioresal (Baclofen)
The nurse is caring for a patient diagnosed with a hemorrhagic stroke. The nurse recognizes that which of the following interventions is most important?
Maintaining a patent airway
A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?
Mannitol(Osmitrol) Explanation: With increasing ICP, hypertonic solutions, like mannitol, are used to decrease swelling in the brain cells. D5W, 0.45% NSS, and 0.33% NSS are all hypotonic solutions that will move more fluid into the cells, worsening the ICP.
A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for?
Noncontrast computed tomogram. Explanation: The initial diagnostic test for a stroke is usually a noncontrast computed tomography (CT) scan. This should be performed within 25 minutes or less from the time the patient presents to the emergency department (ED) to determine if the event is ischemic or hemorrhagic (the category of stroke determines treatment).
A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate?
Notify the physician of a possible cerebrospinal fluid leak.
A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, Cogentin, and Eldepryl. The nurse knows that most likely, the client has a diagnosis of ________.
Parkinson's disease
Which of the following would not be a recommended intervention for a patient with dysphagia?
Place food on the affected side of mouth
The geriatric advanced practice nurse (APN) is doing client teaching with a client who has had a cerebrovascular accident (CVA) and the client's family. One concern the APN addresses is a potential for falls related to the CVA and resulting muscle weakness. What would be most important for the APN to include in teaching of the client and family related to this concern?
Remove throw rugs and electrical cords from home environment. Explanation: Client and family teaching is essential and focuses on the following points: Remove throw rugs, clutter, and electrical cords from the client's home environment to reduce the potential for falls.
A patient with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following is an important nursing action for this patient?
Restricting fluid intake and hydration
A patient with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following is an important nursing action for this patient?
Restricting fluid intake and hydration
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
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.
An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following reasons?
She is taking coumadin. To be eligible for thrombolytic therapy, the client cannot be taking coumadin. Initiation of thrombolytic therapy must be within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetelol do not prohibit thrombolytic therapy.
A female patient is receiving hypothermic treatment for uncontrolled fevers related to increased intracranial pressure (ICP). Which of the following assessment finding requires immediate intervention?
Shivering Explanation: Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption.
The nurse has just received report on a patient in the ED being transferred to the acute stroke unit with a diagnosis of a right hemispheric stroke. Which of the following findings does the nurse understand is indicative of a right hemispheric stroke?
Spatial-perceptual deficits. Explanation: Patients with right hemispheric stroke exhibit partial perceptual deficits, left visual field deficit, and paralysis with weakness on the left side of the body. Left hemispheric damage causes aphasia, slow, cautious behavior, and altered intellectual ability.
A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for?
Suicidal ideations
You are caring for a client with chronic migraines who is prescribed medication. What drug-related instructions should the nurse give the client?
Take medication as soon as symptoms of the migraine begin.
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 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.
In your assessment of a 39-year-old victim of a motor vehicle collision, he directly and accurately answers your questions. Beginning at his head, you note a contusion to his forehead; the client reports a headache. As you assess his pupils, what reaction would confirm your suspicion of increasing intracranial pressure?
Unequal response In increased ICP, the pupil response is unequal. One pupil responds more sluggishly than the other or becomes fixed and dilated. This is not a sign of increasing ICP. In increased ICP, the pupil response is unequal.
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:
diminished responsiveness. Explanation: Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later. Increased ICP causes systolic blood pressure to rise.
The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regime, 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:
Hypertension Explanation: Hypertension is the most modifiable risk factor for either ischemic or hemorrhagic stroke.
A client is receiving intravenous (IV) dobutamine (Dobutrex) to help provide adequate perfusion to the brain. The order is for dobutamine 50 mg in 500 mL D5W at 2 mcg/kg/min. The client weighs 58 kg. At how many mL per hour will the nurse administer this medication? Enter the correct number ONLY.
70 Explanation: 58 kg X 2 = 116 mcg/min. 116 mcg X 60 minutes = 6,960 mcg per hour. 6,960 mcg/1000 = 6.96 mg, rounded to 7 mg/hour. (7 mg/50 mg) X 500 mL = 70 mL/hour.
The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes measures to assist the client in reducing the pain associated with his headache. Which of the following appropriate nursing interventions may be provided by the nurse to assist this client in reducing or eliminating his pain?
Apply warm or cool cloths to the forehead or back of the neck. Explanation: Warmth promotes vasodilation; cool stimuli reduce blood flow.
