Quiz 6: Neurologic Critical Condition

A client is admitted post traumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. What score on the Glasgow Coma scale should the nurse document?

3

What are key features of a brainstem tumor? SATA A. Vomiting unrelated to food intake B. Facial pain or weakness C. Nystagmus D. Headache E. Hearing loss F. Hoarseness

B. Facial pain or weakness C. Nystagmus E. Hearing loss F. Hoarseness

The nurse has just admitted a client with bacterial meningitis who reports a severe headache with photophobia and has a temperature of 102.6 orally. Which prescribed intervention should be implemented first? A. Administer codeine 15 mg orally for the client's headache B. Infuse ceftriaxone 2000 mg IV to treat the infection C. Give acetaminophen 650 mg orally to reduce the fever D. Give furosemide 40 mg IV to decrease intracranial pressure

B. Infuse ceftriaxone 2000 mg IV to treat the infection

Which patients are at increased risk for stroke? SATA A. 66-year-old man with diabetes mellitus B. 43-year-old healthy woman who uses oral contraceptives C. 47-year-old woman who exercises regularly D. 35-year-old man with history of multiple transient ischemic attacks E. 25-year-old woman with Bell's palsy F. 53-year-old man with chronic alcoholism

A. 66-year-old man with diabetes mellitus B. 43-year-old healthy woman who uses oral contraceptives D. 35-year-old man with history of multiple transient ischemic attacks F. 53-year-old man with chronic alcoholism

When caring for a client with a head injury that may have involved the medulla, the nurse bases assessments on the knowledge that the medulla controls a variety of functions. Which ones apply? SATA A. Breathing B. Pulse rate C. Fat metabolism D. Blood vessel diameter E. Temperature regulation

A. Breathing B. Pulse rate D. Blood vessel diameter

A client with a cervical spinal cord injury has been placed in fixed skeletal traction with a halo fixation device. When caring for this client, the nurse may assign which actions to the LPN/LVN? SATA A. Checking the client's skin for pressure from the device B. Assessing the client's neurologic status for changes C. Observing the halo insertion sites for signs of infection D. Cleaning the halo insertion sites with hydrogen peroxide E. Developing the nursing plan of care for the client F. Administering oral medications as ordered

A. Checking the client's skin for pressure from the device C. Observing the halo insertion sites for signs of infection D. Cleaning the halo insertion sites with hydrogen peroxide F. Administering oral medications as ordered

After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone. For which manifestation of excessive levels of antidiuretic hormone (ADH) should the nurse assess? A. Decreased urine output B. Decreased urine specific gravity C. Increased serum sodium D. Increased blood urea nitrogen

A. Decreased urine output

The nurse is mentoring a student nurse in the intensive care unit while caring for a client with meningococcal meningitis. Which action by the student nurse requires that the nurse intervene most rapidly? A. Entering the room without putting on a protective mask and gown B. Instructing the family that visits are restricted to 10 minutes C. Giving the client a warm blanket when he says he feels cold D. Checking the client's pupil response to light every 30 minutes

A. Entering the room without putting on a protective mask and gown

A nurse is assessing a client with a brain tumor. Which clinical findings indicate an increase in intracranial pressure? SATA A. Fever B. Stupor C. Orthopnea D. Rapid pulse E. Hypotension

A. Fever B. Stupor

What action should the nurse take when caring for a client who has a possible skull fracture as a result of trauma? A. Monitor the client for signs of brain injury B. Check for hemorrhaging from the oral and nasal cavities C. Elevate the foot of the bed if the client develops symptoms of shock D. Observe for clinical indicators of decreased intracranial pressure and temperature

A. Monitor the client for signs of brain injury

A patient with a right cerebral hemisphere stroke may have safety issues related to which factor? A. Poor impulse control B. Alexia and agraphia C. Loss of language and analytical skills D. Slow and cautious behavior

A. Poor impulse control

The nurse is performing discharge teaching for the family and patient who had prolonged hospitalization and rehabilitation therapy for severe craniocerebral trauma after a motorcycle accident. What important points does the nurse include? SATA A. Review seizure precautions B. Stimulate the patient with frequent changes in the environment C. Develop a routine of activities with consistency and structure D. Attend follow-up appointments with therapists E. Encourage the family to seek respite care if needed F. Encourage the patient to wear a helmet when riding

A. Review seizure precautions C. Develop a routine of activities with consistency and structure D. Attend follow-up appointments with therapists E. Encourage the family to seek respite care if needed

When caring for a client who has sustained a head injury, it is important that the nurse assess for which clinical indicator? A. Slowing of the heart rate B. Decreased carotid pulses C. Bleeding from the oral cavity D. Absence of deep tendon reflexes

A. Slowing of the heart rate

The nurse caring for a patient who has decreased level of consciousness with the medical diagnosis of epidural hematoma. During the shift, the patient becomes lucid and is alert and talking. The family reports that this is her baseline mental status. What is the nurse's next action? A. Stay with the patient and have the charge nurse alert the health care provider because this is an ominous sign for the patient B. Document the patient's exact behaviors, compare to previous nursing entries, and continue the neurologic assessments every 2 hours C. Point out to the family that the dangerous period has passed, but encourage them to leave so the patient does not become overly fatigued D. Monitor the patient for the next 48 hours to 2 weeks because a subacute condition may be slowly developing

A. Stay with the patient and have the charge nurse alert the health care provider because this is an ominous sign for the patient

The nurse is caring for a client with a glioblastoma who is receiving dexamethasone 4 mg IV push every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns the nurse the most? A. The client no longer recognizes family members B. The blood glucose level is 234 mg/dL C. The client reports a continuing headache D. The daily weight has increased 2.2 lb

A. The client no longer recognizes family members

A patient sustained a stroke that affected the right hemisphere of the brain. The patient has visual spatial deficits of proprioception. After assessing the safety of the patient's home, the home health nurse identifies which enviornmental feature that represents a potential safety problem for this patient? A. The handrail that borders the bathtub is on the right-hand side B. The patient's favorite chair faces the front door of the house C. The patient's bedside table is on the left-hand side of the bed D. Family has relocated the patient to a ground-floor bedroom

A. The handrail that borders the bathtub is on the right-hand side

When performing a neurologic assessment of a client, a nurse identifies that the client has a dilated right pupil. The nurse concludes that this suggests a problem with which cranial nerve? A. Third B. Fourth C. Second D. Seventh

A. Third

The nurse is caring for a patient who had a craniotomy. What interventions should the nurse use to prevent respiratory complications of atelectasis and pneumonia? A. Turn frequently and encourage frequent deep breaths B. Perform deep suction frequently to keep airway patent C. Place in a high Fowler's position and apply oxygen D. Coach to perform deep coughing to expectorate secretions

A. Turn frequently and encourage frequent deep breaths

In which position should the nurse initially place a client who has experienced a brain attack? A. Prone B. Lateral C. Supine D. Trendelenburg

B. Lateral

The home health nurse reads in the patient's chart that he has a mild hemiparesis and ataxia that are residual from a stroke that occurred several years ago. Based on this information, the nurse would assess for functionality and availability of what type of adaptive equipment for this patient? A. Walker and wheelchair for mobility and handrails in the bathroom B. Picture boards, flash cards, or other methods of communication C. Cell phone, computer with internet access, or medical alert device D. Hearing aid, corrective eyeglasses, dentures, and orthotic devices

A. Walker and wheelchair for mobility and handrails in the bathroom

The nurse on the neurologic acute care unit is assessing the orientation of a client with severe headaches. Which questions would the nurse use to determine orientation? SATA A. When did you first experience the headache symptoms? B. Who is the mayor of Cleveland? C. What is your health care provider's name? D. What year and month is this? E. What is your parent's address? F. What is the name of this healthcare facility?

A. When did you first experience the headache symptoms? C. What is your health care provider's name? D. What year and month is this? F. What is the name of this healthcare facility?

Several clients are admitted to the emergency department with brain injuries as a result of an automobile collision. The nurse concludes that the client with an injury to which part of the brain will most likely not survive? A. Pons B. Medulla C. Midbrain D. Thalamus

B. Medulla

In planning care for a patient with increased intracranial pressure (ICP), what does the nurse do to minimize ICP? A. Gives the bath, changes the linens, does passive range of motion (ROM) to hands/fingers, and then allows the patient to rest B. Gives the bath, allows rest, changes linens, allows rest, and then performs passive ROM exercises to hands/fingers C. Gives the bath; defers the linen change and passive ROM exercises until the danger of increased ICP has passed D. Contacts healthcare provider for specific orders about activities related to patient care that might cause increased ICP

B. Gives the bath, allows rest, changes linens, allows rest, and then performs passive ROM exercises to hands/fingers

The nurse observes that a patient who had surgery for a benign hemangioblastoma has bilateral periorbital edema and ecchymosis. Because this patient's care is based on the general principles of caring for the patient with a craniotomy, what is the nurse's first action? A. Immediately inform the surgeon B. Apply cold compresses C. Check the pupillary response D. Perform a full neurologic assessment

B. Apply cold compresses

A patient with an ischemic stroke is placed on a cardiac monitor. Which cardiac dysrhythmia places the patient at risk for emboli? A. Sinus bradycardia B. Atrial fibrillation C. Sinus tachycardia D. First-degree heart block

B. Atrial fibrillation

What therapeutic effect does the nurse expect to identify when mannitol (Osmitrol) is administered parenterally to a client with cerebral edema? A. Improved renal blood flow B. Decreased intracranial pressure C. Maintenance of circulatory volume D. Prevention of the development of thrombi

B. Decreased intracranial pressure

The neurologic assessment of a client who had a craniotomy includes the Glasgow Coma Scale. What does the nurse evaluate to assess the client's score on the Glasgow Coma Scale? SATA A. Ability of the client's pupils to react to light B. Degree of purposeful movements by the client C. Appropriateness of the client's verbal responses D. Stimulus necessary to cause the client's eyes to open E. Symmetry of muscle strength of the client's extremities

B. Degree of purposeful movements by the client C. Appropriateness of the client's verbal responses D. Stimulus necessary to cause the client's eyes to open

The nurse is providing discharge teaching to a patient following carotid stent placement. The nurse would tell the patient to immediately report which symptoms to the health care provider? SATA A. Weight gain B. Drowsiness or new-onset confusion C. Muscle weakness or motor dysfunction D. Severe neck pain E. Neck swelling F. Hoarseness or difficulty swallowing

B. Drowsiness or new-onset confusion C. Muscle weakness or motor dysfunction D. Severe neck pain E. Neck swelling F. Hoarseness or difficulty swallowing

A patient who had a stroke several years ago continues to have the potential for aspiration. Which intervention is best to delegate to the unlicensed assistive personnel? A. Monitor the patient for and notify the charge nurse of any occurrence of coughing, choking, or difficulty breathing B. Elevate the head of the bed and slowly feed small spoonfuls of pudding, pausing between each spoonful C. Check for swallow reflex by placing index finger and thumb on the Adam's apple and palpating during swallowing D. Give the patient a glass of water before feeding solid foods, and have oral suction ready at bedside

B. Elevate the head of the bed and slowly feed small spoonfuls of pudding, pausing between each spoonful

The emergency department nurse is caring for a trauma patient. The spinal board has been removed, but the healthcare provider indicates that spinal precautions should be maintained. What is included? SATA A. Bedrest with bathroom privileges B. No neck flexion with a pillow or roll C. No thoracic or lumbar flexion with head of bed elevated/bed controls D. No reverse trendelenburg positioning E. Manual control of the cervical spine anytime the rigid collar is removed F. "Log-roll" procedure to reposition the patient

B. No neck flexion with a pillow or roll C. No thoracic or lumbar flexion with head of bed elevated/bed controls E. Manual control of the cervical spine anytime the rigid collar is removed F. "Log-roll" procedure to reposition the patient

The home health nurse is assessing a patient who had a stroke that affected the right hemisphere. What would the nurse expect to observe? A. Patient is overly anxious and cautious when asked to do a new task B. Patient is euphoric and smiling but disoriented to person, place, and time C. Patient is depressed and expresses ongoing worries about the future D. Patient has a flat affect but is able to answer most questions appropriately

B. Patient is euphoric and smiling but disoriented to person, place, and time

The nurse is caring for a patient with an ischemic stroke. Which concept underlies the rationale for placing the patient in a supine position with a low head-of-bed elevation? A. Comfort B. Perfusion C. Gas exchange D. Mobility

B. Perfusion

Which interventions does the nurse use for a patient with a left cerebral hemisphere stroke? SATA A. Teach the patient to wash both sides of the face B. Place pictures and familiar objects around the patient C. Reorient the patient frequently D. Repeat names of commonly used objects E. Approach the patient from the affected side F. Establish a structured routine for the patient

B. Place pictures and familiar objects around the patient C. Reorient the patient frequently D. Repeat names of commonly used objects F. Establish a structured routine for the patient

A patient has sustained a traumatic brain injury. Which nursing intervention is best for this patient? A. Assess vital signs every 8 hours B. Position to avoid extreme flexion of neck C. Increase fluid intake for the first 48 hours D. Restrict visitors until cognition improves

B. Position to avoid extreme flexion of neck

A patient has been diagnosed with a large lesion of the parietal lobe and demonstrates loss of sensory function. Which nursing intervention is applicable for this patient? A. Play music for the patient for at least 30 minutes each day B. Teach the patient to test the water temperature used for bathing C. Position the patient reclining in bed or in a chair for meals D. Show a picture of the spouse and ask patient to identify the person

B. Teach the patient to test the water temperature used for bathing

The critical care nurse is assessing a client whose baseline Glasgow Coma Scale (GCS) score in the emergency department was a 5. The current GCS score is 3. What is the nurse's best interpretation of this finding? A. The client's condition is improving B. The client's condition is deteriorating C. The client will need intubation and mechanical ventilation D. The client's medication regime will need adjustments

B. The client's condition is deteriorating

The nurse notices that a patient seems to be having trouble swallowing. Which intervention does the nurse employ for this patient? A. Limit the diet to clear liquids given through a straw B. Withhold food and fluids until swallowing is assessed C. Monitor the patient's weight and compare trends to baseline D. Observe the patient while eating and note problematic foods

B. Withhold food and fluids until swallowing is assessed

The nurse is providing care for a client with an acute hemorrhagic stroke. The client's spouse tells the nurse that he has been reading a lot about strokes and asks why his wife has not received alteplase. What is the nurse's best response? A. "Your wife was not admitted within the time frame that alteplase is usually given" B. "This drug is used primarily for clients who experience an acute heart attack" C. "Alteplase dissolves clots and may cause more bleeding into your wife's brain" D. "Your wife had gallbladder surgery just 6 months ago, so we can't use alteplase"

C. "Alteplase dissolves clots and may cause more bleeding into your wife's brain"

The emergency department (ED) nurse is giving discharge instructions to the mother of a child who bumped his head on a table. Which statement by the mother indicates an understanding of the instructions? A. "I should not let him fall asleep today or during the early evening" B. "There's really nothing to worry about. It was just a bump on the head" C. "I should take him back to the ED for weakness or slurred speech" D. "He can run and play as he usually does, as long as he doesn't climb"

C. "I should take him back to the ED for weakness or slurred speech"

The nurse is teaching a patient who will receive a disc-shaped wafer (carmustine) as part of the treatment for a brain tumor. Which statement by the patient indicates understanding of how the wafer works? A. "I'll place the wafer under my tongue and allow it to dissolve" B. "The wafer will be taped to my chest, and the drug will be absorbed" C. "The wafer will be placed directly into the cavity during the surgery" D. "The wafer is to be dissolved in water and taken with meals"

C. "The wafer will be placed directly into the cavity during the surgery"

The nurse is taking a history on a teenager who was involved in a motor vehicle accident with friends. The patient has an obvious contusion of the forehead, seems confused, and is laughing loudly and yelling, "Ruby! Ruby!" What is the best question for the nurse to ask the patient's friends? A. "Where and why did the accident occur?" B. "How can we notify the family for consent for treatment?" C. "Was the patient using drugs or alcohol prior to the accident?" D. "Who is Ruby, and why is the patient calling for her?"

C. "Was the patient using drugs or alcohol prior to the accident?"

Which client in the neurologic intensive care unit should the charge nurse assign to an RN who has been floated from the medical unit? A. A 26-year-old client with a basilar skull fracture who has clear drainage coming out of the nose B. A 42-year-old admitted several hours ago with a headache and a diagnosis of a ruptured berry aneurysm C. A 46-year-old client who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due D. A 65-year-old client with an astrocytoma who has just returned to the unit after undergoing craniotomy

C. A 46-year-old client who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due

The nurse is assessing a client with a neurologic health problem and discovers a change in level of consciousness from alert to lethargic. What is the nurse's best action? A. Perform a complete neurologic assessment B. Assess the cranial nerve functions C. Contact the Rapid Response Team D. Reassess the client in 30 minutes

C. Contact the Rapid Response Team

A patient is admitted for a closed head injury sustained during a fall down the stairs. The patient has no history of respiratory disease and no apparent respiratory distress. However, the healthcare provider orders oxygen 2 L via nasal cannula. What is the nurse's best action? A. Use pulse oximeter and apply the oxygen if the saturation levels drop below 90% B. Question the order because oxygen is unnecessary and therefore an extra cost to the patient C. Deliver oxygen as ordered because hypoxemia may increase intracranial pressure D. Apply nasal cannula as ordered and wean from oxygen when patient is discharged

C. Deliver oxygen as ordered because hypoxemia may increase intracranial pressure

Which patient is demonstrating an early indicator of change in level of consciousness? A. Middle-aged patient with a brain tumor wanders naked in the halls B. Older patient who had a stroke several days ago is snoring loudly C. Elderly patient is restless and irritable after a fall and bump to the head D. Adolescent patient is difficult to arouse, after drinking and fighting

C. Elderly patient is restless and irritable after a fall and bump to the head

What is the priority concept for the interdisciplinary care and treatment of a patient who is suspected of having a stroke? A. Pain B. Cognition C. Perfusion D. Sensory perception

C. Perfusion

The nurse is assessing a patient who was struck in the head several times with a baseball bat. There is clear fluid that appears to be leaking from the nose. What action does the nurse take first? A. Ask the patient to gently blow the nose; observe the nasal drainage for blood clots B. Immediately report the finding to the health care provider and document the observation C. Place a drop of the fluid on a white absorbent background and look for a yellow halo D. Assist patient to wipe his nose, but no other action is needed; he has probably been crying

C. Place a drop of the fluid on a white absorbent background and look for a yellow halo

Which clinical indicator is the nurse most likely to identify when assessing a client with a ruptured cerebral aneurysm? A. Tonic-clonic seizures B. Decerebrate posturing C. Sudden severe headache D. Narrowed pulse pressure

C. Sudden severe headache

Which clinical finding could help the health care team differentiate a transient ischemic attack from a stroke? A. Patient has a unilateral facial droop B. Patient has slurred speech C. Symptoms resolve in 30-60 minutes D. Electrocardiogram is normal

C. Symptoms resolve in 30-60 minutes

A client with a brain attack is comatose on admission. Which clinical indicator is the nurse most likely to identify? A. Twitching motions B. Purposeful motions C. Urinary incontinence D. Unresponsiveness to pain

C. Urinary incontinence

The neurologist tells the nurse that the stroke patient has some deficits associated with cranial nerves V, VII, IX, X, and XII. Which intervention is the nurse most likely to initiate? A. Prevention of valsalva maneuver B. Fall precautions C. Prevention of corneal abrasions D. Aspiration precautions

D. Aspiration precautions

A patient with increased intracranial pressure is to receive IV mannitol. Which assessment would the nurse perform to prevent complications in a body system other than the nervous system? A. Assess for cardiac dysrhythmias B. Assess for gastric bleeding C. Assess for respiratory distress D. Assess for acute renal failure

D. Assess for acute renal failure

A client experiences a traumatic brain injury. Which finding identified by the nurse indicates damage to the upper motor neurons? A. Absent reflexes B. Flaccid muscles C. Trousseau sign D. Babinski response

D. Babinski response

What should the nurse assess for in the immediate postoperative period after a client has brain surgery? A. Tachycardia B. Constricted pupils C. Elevated diastolic pressure D. Decreased level of consciousness

D. Decreased level of consciousness

A patient had an infratentorial craniotomy. Which position does the nurse use for this patient? A. High Fowler's position, turned to the operative side B. Head of bed at 30 degrees, turned to the non-operative side C. Flat in bed, except elevate head of bed for meals and medication D. Flat and positioned side-lying, alternating sides every 2 hours

D. Flat and positioned side-lying, alternating sides every 2 hours

A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure? A. Thready, weak pulse B. Narrowing pulse pressure C. Regular, shallow breathing D. Lowered level of consciousness

D. Lowered level of consciousness

A client with a spinal cord injury at level C3 to C4 is being cared for by the nurse in the emergency department (ED). What is the priority nursing assessment? A. Determine the level at which the client has intact sensation B. Assess the level at which the client has retained mobility C. Check blood pressure and pulse for signs of spinal shock D. Monitor respiratory effort and oxygen saturation level

D. Monitor respiratory effort and oxygen saturation level

The stroke patient is prescribed a stool softener every morning. What is the purpose of this drug specific to this patient? A. Stimulates peristaltic action to aid defecation B. Increases frequency of bowel movements C. Decreases fluid and fiber content of stool D. Prevents Valsalva maneuver during defecation

D. Prevents Valsalva maneuver during defecation

A patient had a brain tumor removed. Which position does the nurse place the patient in? A. Place on operative side to protect the unaffected side of the brain B. Place flat and repositioned on either side to decrease tension on the incision C. Do not reposition unless specific positions are ordered by the surgeon D. Reposition every 2 hours but do not turn the patient onto the operative side

D. Reposition every 2 hours but do not turn the patient onto the operative side

The nurse is providing postoperative care for a patient who had a craniotomy. The nurse would immediately notify the surgeon of which assessment finding? A. Drainage via Jackson-Pratt of 45 mL/8 hours B. Intracranial pressure of 15 mm Hg C. PCO2 level of 35 mm Hg D. Serum sodium of 119 mEq/L

D. Serum sodium of 119 mEq/L

An LPN/LVN under the RNs supervision, is assigned to provide nursing care for a client with Guillain-Barre syndrome (GBS). What observation should the LPN/LVN be instructed to report immediately? A. Reports numbness and tingling B. Facial weakness and difficulty speaking C. Rapid heart rate of 102 beats/min D. Shallow respirations and decreased breath sounds

D. Shallow respirations and decreased breath sounds

A patient presents to the advanced stroke center with signs and symptoms of an ischemic stroke. What is the priority factor when considering fibrinolytic therapy? A. Age less than 80 years B. History of stroke C. Recent surgery D. Time of onset of symptoms

D. Time of onset of symptoms

Following a left cerebral hemisphere stroke, the patient has expressive (Broca's) aphasia. Which intervention is best to use when communicating with this patient? A. Repeat the names of objects on a routine basis B. Face the patient and speak slowly and clearly C. Obtain a whiteboard with an erasable marker D. Use a picture board that displays objects and activities

D. Use a picture board that displays objects and activities