PREP U-Intracranial regulation and palliation

A patient is suspected of having had a stroke. Which of the following is the initial diagnostic test for a stroke? A. Noncontrast CT scan B. Carotid Doppler C. ECG D. Transcranial Doppler studies

A. Noncontrast CT scan

After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question? A. Performing a lumbar puncture B. Placing him on mechanical ventilation C. Giving him a barbiturate D. Elevating the head of his bed

A. Performing a lumbar puncture

The nurse is caring for a patient diagnosed with a hemorrhagic stroke. The nurse recognizes that which of the following interventions is most important? A. Elevating the head of the bed at 30 degrees B. Maintaining a patent airway C. Monitoring for seizure activity D. Administering a stool softener

B. Maintaining a patent airway

A nurse is providing hospice care in Portland, Oregon,to client with terminal liver cancer. The client confides to the nurse, "I'm in agony all the time. I want this to be over now—please help me." Which of the following interventions is the best for the nurse to implement? Select all that apply. A. Advise the client's physician of the client's condition. B. Comfort the client by saying it will all be over soon. C. Recommend that the client consider physician-assisted suicide. D. Control the client's pain with prescribed medication. E. Encourage the client to explain his wishes.

A. Advise the client's physician of the client's condition. D. Control the client's pain with prescribed medication. E. Encourage the client to explain his wishes.

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

A. Major abdominal surgery within 10 days E. Intracranial hemorrhage

Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply. A. Motor response B. Verbal response C. Muscle strength D. Eye opening E. Intelligence

A. Motor response B. Verbal response D. Eye opening

A nurse is caring for a client with a terminal illness. The client asks the nurse to help him end his own life to alleviate his suffering and that of his family. When responding to the client, the nurse integrates knowledge of which of the following? A. Participating in assisted suicide violates the Code of Ethics for Nurses. B. Most states have enacted laws that allow for physician-assisted suicide. C. A client has the right to make independent decisions about the timing of his or her death. D. Nurses may administer medications prescribed by physicians to hasten end of life.

A. Participating in assisted suicide violates the Code of Ethics for Nurses.

During unplanned, spontaneous moments, dying patients usually discuss fears or concerns that nurses should not ignore or rush. What is the nurse's best response in such situations? A. The nurse can communicate interest and a willingness to listen by sitting down, leaning forward in the patient's direction, and making direct eye contact. B. The nurse can call out to the patient's family members and ask them to sit next to the patient. C. The nurse should ask the patient questions about his or her feelings of death and talk about other things to distract the dying patient's attention. D. The nurse should administer a pain killer and sedative to the patient and put him or her to sleep.

A. The nurse can communicate interest and a willingness to listen by sitting down, leaning forward in the patient's direction, and making direct eye contact.

For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? A. using a "picture board" for the client to point to pictures B. speaking loudly C. speaking in short sentences D. writing directions so client can read them

A. using a "picture board" for the client to point to pictures

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 28-year-old pregnant African-American woman B. A 60-year-old African-American man C. A 40-year-old Caucasian woman D. A 62-year-old Caucasian woman

B. A 60-year-old African-American man

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? A. Assess vital signs. B. Assess for a patent airway. C. Assess Glasgow Coma Scale. D. Assess pupils.

B. Assess for a patent airway.

A nurse is reviewing the trend of a patient's scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the patient's status? A. Sensory involvement B. Level of consciousness C. Cognitive ability D. Reflex activity

B. Level of consciousness

Thrombolytic therapy for the treatment of an ischemic stroke should be initiated within how many hours of the onset of symptoms to obtain the best functional outcome? A. 9 hours B. 12 hours C. 3 hours D. 6 hours

C. 3 hours

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes? A. Trendelenburg's B. Side-lying C. 30-degree head elevation D. Flat

C. 30-degree head elevation

A terminally ill patient has feelings of rage toward the nurse. According to Elisabeth Kübler-Ross, the patient is in which stage of dying? A. Denial B. Bargaining C. Anger D. Depression

C. Anger

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

C. Bleeding

A client with Alzheimer's disease says, "I'm so afraid. Where am I? Where is my family?" How should the nurse respond? A. "The name of the hospital is on the sign over the door. Let's go read it again." B. "You know where you are. You were admitted here 2 weeks ago. Don't worry, your family will be back soon." C. "I just told you that you're in the hospital and your family will be here soon." D. "You are in the hospital and you're safe here. Your family will return at 10 o'clock, which is 1 hour from now."

D. "You are in the hospital and you're safe here. Your family will return at 10 o'clock, which is 1 hour from now."

While providing care to a terminally ill client, the client's niece asks the nurse about the client's condition and prognosis. Which of the following would be most appropriate? A. Refer the niece to the client's physician for information. B. Provide the niece with the information that she is requesting. C. Check with the client's immediate family members about sharing information. D. Ask the client's consent before sharing any information with the niece.

D. Ask the client's consent before sharing any information with the niece.

A client has learned of a terminal illness and impending death. The client asks the nurse to explain the concepts and care that are provided under the definition of palliative care. Which of the following would the nurse include in the explanation for this client? Select all that apply. A. Enhances quality of life B. Offers a team approach to care C. Provides pain relief D. Includes chemotherapy E. Integrates spirituality F. Hastens death

A. Enhances quality of life B. Offers a team approach to care C. Provides pain relief E. Integrates spirituality

The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of "ineffective cerebral tissue perfusion." What would be an expected outcome that the nurse would document for this diagnosis? A. Copes with sensory deprivation. B. Obeys commands with appropriate motor responses. C. Pays attention to grooming. D. Registers normal body temperature.

B. Obeys commands with appropriate motor responses.

A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take? A. Face the client and establish eye contact. B. Use one long sentence to say everything that needs to be said. C. Keep the television on while she speaks. D. Talk in a louder than normal voice.

A. Face the client and establish eye contact.

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. Lumbar puncture D. Brain CT scan or MRI

D. Brain CT scan or MRI

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? A. "TIA is a warning sign. Let's talk about lowering your risks." B. "I sense that you are happy it was not a stroke". C. "TIA symptoms are shortlived and resolve within 24 hours". D. "People who experience a TIA will develop a stroke".

A. "TIA is a warning sign. Let's talk about lowering your risks."

A client with Alzheimer's disease has a nursing diagnosis of Risk for injury related to memory loss, wandering, and disorientation. To prevent injury, which nursing intervention should appear in this client's care plan? A. Use restraints at all times. B. Remove potential hazards from the client's environment. C. Keep the client sedated whenever possible. D. Provide the client with detailed instructions.

B. Remove potential hazards from the client's environment.

What safety actions does the nurse need to take for a patient on oxygen therapy who is undergoing magnetic resonance imaging (MRI)? A. Note that no special safety actions need to be taken B. Check the patient's oxygen saturation level using a pulse oximeter after the patient has been placed on the MRI table C. Ensure that no patient care equipment containing metal enters the room where the MRI is located. D. Securely fasten the patient's portable oxygen tank to the bottom of the MRI table after the patient has been positioned on the top of the MRI table

C. Ensure that no patient care equipment containing metal enters the room where the MRI is located.

Which of the following is a modifiable risk factor for transient ischemic attacks and ischemic strokes? A. Advanced age B. Thyroid disease C. History of smoking. D. Social drinking

C. History of smoking.

Which of the following nursing actions by the nurse demonstrates an effective method to assess the patient and the patient's family's ability to cope with end-of-life interventions? A. Providing evidenced-based advice for end-of-life care based on the nurse's experiences with previous patients in hospice B. Filling voids in conversation with information related to death and dying to avoid awkward moments during the admission interview C. Remaining silent, allowing the patient and family to respond after asking a question related to end-of-life care D. Offering reassurance that the nurse has had 5 years of assisting patients in hospice and their families care for loved ones at the end of life

C. Remaining silent, allowing the patient and family to respond after asking a question related to end-of-life care

Your client has been informed that he has terminal COPD. He and his family have not yet agreed on his final arrangements and are discussing his options. How can you best intervene as his nurse in his final decisions? A. Ask the family members about coordinating spiritual care for the client. B. Remind the family that the client needs to focus his energy on recovery. C. Respect the client's autonomy and right to determine how to spend the rest of his life. D. Persuade the client to follow his family's preferences for end-of-life care.

C. Respect the client's autonomy and right to determine how to spend the rest of his life.

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. Footdrop and external hip rotation B. Vomiting and seizures C. Weakness on one side of the body and difficulty with speech D. Severe headache and early change in level of consciousness

C. Weakness on one side of the body and difficulty with speech

Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)? A. turning B. deep breathing C. coughing D. passive range-of-motion (ROM) exercises

C. coughing

Which of the following 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 of age or older C. Ischemic stroke D. Intracranial hemorrhage

D. Intracranial hemorrhage

The patient tells the doctor that he and his family have accepted the terminal diagnosis of pancreatic cancer. The patient further explains that he is interested in being comfortable and that he no longer wishes to fight the cancer. This approach to end-of-life care is known as which of the following? A. Interdisciplinary care B. Euthanasia care C. Terminal care D. Palliative care

D. Palliative care

The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate? A. the head elevated on two pillows B. Trendelenburg's position C. left Sims position D. the head of the bed elevated 15 to 20 degrees

D. the head of the bed elevated 15 to 20 degrees

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? A. She had surgery 6 weeks ago. B. She is taking coumadin. C. She is taking digoxin. D. She is not within the treatment time window.

B. She is taking coumadin.

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? A. Instruct the patient to lie on the bed when eating B. Offer liquids frequently in large quantities C. Help the patient sit upright when eating and feed slowly D. Allow optimum physical activity before meals to expedite digestion

C. Help the patient sit upright when eating and feed slowly

You are the nurse caring for an elderly patient who is confused and agitated. When the patients' family comes to visit the patient you ask them how long the patient has been confused. The family states that the patient has been confused for a long time and the confusion is getting worse. The patient is subsequently diagnosed with dementia. What is the most common cause of dementia in an elderly patient? A. Excessive drug use. B. Depression. C. Delirium. D. Alzheimer's disease.

D. Alzheimer's disease.

While talking with a client who has been diagnosed with a terminal illness, the client asks, " Am I dying?" Which response from the nurse would be appropriate? Select all that apply. A. "This must be very difficult for you." B. "Tell me more about what's on your mind." C. "You still have time for a good life." D. "Let's focus on what your doctor has planned." E. "I know just how you must feel."

A. "This must be very difficult for you." B. "Tell me more about what's on your mind."

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? A. pupil size and pupillary response B. bowel sounds C. cholesterol level D. echocardiogram

A. pupil size and pupillary response

The nurse has created a plan of care for a patient who is at risk for increased ICP. The patient's care plan should specify monitoring for what early sign of increased ICP? A. Decreased pulse and respirations B. Loss of corneal reflex C. Projectile vomiting D. Disorientation and restlessness

D. Disorientation and restlessness

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 actions would be the first priority? A. Determination of the cause B. Positioning to prevent complications C. Assessment of pupillary light reflexes D. Maintenance of a patent airway

D. Maintenance of a patent airway