Unit 06 Chapters 37

A 20 year-old has been diagnosed with an astrocytic brain tumor located in the brainstem. Which statement by the oncologist treating the client is most accurate?

"Your prognosis will depend on whether we can surgically resect your tumor."

Which client may be experiencing a sensory focal seizure that has sent an abnormal cortical discharge to the autonomic nervous system (ANS)?

56-year-old reporting tingling sensations and has both an elevated pulse and BP

The nurse is caring for a client with a brain tumor when the client begins to vomit. Which intervention should the nurse do first?

Assess for other signs/symptoms of increased intracranial pressure.

Following a collision while mountain biking, the diagnostic work up of a 22-year-old male has indicated the presence of an acute subdural hematoma. Which pathophysiologic process most likely underlies his diagnosis?

Blood has accumulated between the man's dura and subarachnoid space.

Manifestations of brain tumors are focal disturbances in brain function and increased ICP. What causes the focal disturbances manifested by brain tumors?

Brain edema and disturbances in blood flow

A client who has been living with Alzheimer disease and spouse are at the doctor's office and the spouse asks the nurse why the client cannot remember much of anything from the past. The best response by the nurse is that Alzheimer disease affects which part of the brain?

Cells located in the hippocampus

The nurse is working in the emergency room. One client's presenting symptoms include the worst headache ever, nuchal rigidity, and nausea. Another client's presenting symptoms include fever, stiff back, and positive Kernig sign. Which client should the nurse assess first?

Client with the worst headache, nuchal rigidity, and nausea

The nurse assessing a client with a traumatic brain injury assesses for changes in which neurologic component? Select all that apply.

Cognition Level of consciousness Sensory function Motor function

A nurse on a neurology unit is assessing a client with a brain injury. The client is unresponsive to speech, with dilated pupils that do not react to light. The client is breathing regularly with a respiratory rate is 45 breaths per minute. In response to a noxious stimulus, the client's arms and legs extend rigidly. What is the client's level of impairment?

Coma

A client who is diagnosed with seizures describes feeling a strange sensation before losing consciousness. The family members report that the client has been smacking his lips prior to having a seizure. Which type of seizure disorder presents with these symptoms?

Complex partial or focal seizure with impairment of consciousness

The nurse is caring for a 31-year-old trauma victim admitted to the neurologic intensive care unit. While doing the initial assessment, the nurse finds that the client is flexing the arms, wrists, and fingers. There is adduction of the upper extremities with internal rotation and plantar flexion of the lower extremities. How would the nurse describe this in the notes?

Decorticate posturing

Excessive activity of the excitatory neurotransmitters and their receptor-mediated effects is the cause of which type of brain injury?

Excitotoxic

The nurse assessing for the doll's head response (doll's eye response) in an unconscious client documents which eye movement as an abnormal response?

Eyes turn right when head is turned right

A client begins to exhibit manifestations of a stroke while attending a community health fair. What type of emergency care should the staff at the health fair implement first?

Going to the nearest stroke center

A family is sitting in the intensive care unit with a client who sustained significant head injuries in a motorcycle accident. They are questioning the nurse about why the client's eyes open but do not stay open for long. The nurse explains that the client is probably in which state?

In a stuporous state due to a reticular activated system (RAS) injury

Hypoxic injury will result in which effect on the brain?

Neuronal cell injury and death

A nurse at a long term care facility provides care for an 85 year-old man who has had recent transient ischemic attacks (TIAs). Which statement best identifies future complications associated with TIAs?

TIAs resolve rapidly but may place the client at an increased risk for stroke.

A nurse at a long-term care facility provides care for a client who has had recent transient ischemic attacks (TIAs). What significance should the nurse attach to the client's TIAs?

TIAs, by definition, resolve rapidly, but they constitute an increased risk for stroke.

The nurse is caring for a client experiencing a seizure. During the seizure the nurse notes that the client repetitively rubs his/her clothing. When contacting the client's physician, the nurse notes that the client exhibited:

automatisms.

A client has sustained a severe, diffuse brain injury that resulted in seriously compromised brain function. The client is at greatest risk for:

brain death

A soccer player has been diagnosed with a brain contusion after being injured in a game. The best explanation of the injury by the nurse would be that:

bruising on the surface of the brain occurred.

The nurse observes a new nurse performing the test for Kernig sign on a client. The new nurse performs the test by providing resistance to flexion of the knees while the client is lying with the hip flexed at a right angle. The nurse should explain to the new nurse that:

resistance should be provided with the knee in a flexed position.

The nurse is assessing a client and notes the client is now displaying decerebrate posturing. The position would be documented as:

rigidity of the arms with palms of the hands turned away from the body and with stiffly extended legs and plantar flexion of the feet.

A 9 year-old boy has been brought to the emergency department by his father who is concerned by his son's recent fever, stiff neck, pain, and nausea. Examination reveals a petechial rash. Which assessment question by the emergency room physician is most appropriate?

"Has your son had any sinus or ear infections in the last little while?"

When the suspected diagnosis is bacterial meningitis, what assessment techniques can assist in determining if meningeal irritation is present?

Brudzinski sign and Kernig sign

For the past 2 years, a client has had increasing difficulty remembering the events of the day, but has been able to recall events from the distant past. The client's motor skills have slowed, despite the absence of arthritis. Recent echocardiography showed the presence of atherosclerosis and the client experienced a myocardial infarction earlier this year. Which neurologic condition does the client most likely have?

Vascular dementia

A client discharged from the hospital 5 days ago following a stroke has come to the emergency department with facial droop that progressed with hemiplegia and aphasia. The client's spouse is extremely upset because the physician stated that the client cannot receive thrombolytic medications to reestablish cerebral circulation and the spouse asks the nurse why. What is the nurse's most accurate response?

"Thrombolytics may cause cerebral hemorrhage."

According to the Glasgow Coma Scale, opening one's eyes to only painful stimuli would receive which score?

2

The nurse working in an emergency room is caring for a client who is exhibiting signs and symptoms of a stroke. What does the nurse anticipate that the physician's orders will include?

CT scan

A client has developed hydrocephalus and asks the nurse what may have caused this to occur. The best response would be:

Overproduction of cerebrospinal fluid

A client with Alzheimer disease (AD) is forgetful and has started to lose interest in social activities. Which treatment routine would be beneficial for the client?

Donepezil

A teenager, exposed to West Nile virus a few weeks ago while camping with friends, is admitted with headache, fever, and nuchal rigidity. The teenager is also displaying some lethargy and disorientation. The nurse knows which medical diagnosis listed below may be associated with these clinical manifestations?

Encephalitis

An adult client is admitted to the emergency department reporting a headache, stiff neck and lethargy. Based on the intake interview, the nurse suspects that the client had a seizure the day before. The client's vital signs are within reference range with the exception of a heart rate of 102 bpm and oral temperature of 38.6°C (101.5°F). Which diagnosis is most likely?

Encephalitis

An emergency room nurse receives a report that a client's Glasgow Coma Scale (GCS) is 3. The nurse prepares to care for a client with which of the following?

Flaccid motor response

The emergency room doctor suspects a client may have bacterial meningitis. The most important diagnostic test to perform would be:

Lumbar puncture

Following a car accident in which the driver did not have his seatbelt on, the client is diagnosed with a traumatic brain injury requiring emergent craniotomy for severe cerebral edema. Which assessments should the nurse report immediately since they correspond to a supratentorial herniation progressing to midbrain involvement? Select all that apply.

Respiration rate of 40 breaths/min Decerebrate posturing following painful stimulation of the sternum Pupils fixed at ~ 5 mm in diameter

What term is used to describe a level of consciousness that sees a client responding only to vigorous and repeated stimuli and has minimal or no spontaneous movement?

Stupor

The nurse is caring for a client admitted to the emergency room with suspected meningitis. The nurse prepares to perform which nursing intervention upon physician orders, while diagnostic testing is being completed?

administration of antibotics