361 HESI Neurology

A client has a brain attack (stroke) that involves the right cerebral cortex and cranial nerves. Which are of paralysis would the nurse expect to find upon assessment? SATA Rationale: Because the nerve decussates (cross over), paralysis occurs on the side of the body opposite to the area of cerebral involvement. In this situation, the left leg, and left arm would be affected. The face is innervated (to supply nerve to) by the VII (7) cranial nerve which comes in pairs (right and left) that do not decussate; therefore because injury is to the right cerebral cortex, the left VII cranial nerve is damaged. This leads to paralysis of the left side of the face.

*Left leg *Left arm *Left side of face

Which factors can trigger a client's migraine attacks? SATA Rationale: Fatigue tires the body and causes headaches. Sleep problems may increase the risk of disturbance to the brain. Hormonal fluctuations in different stages can trigger a migraine attack.

*fatigue *sleep problem *hormonal fluctuations

In which position would the nurse maintain a client who has experienced a subarachnoid hemorrhage? rationale: With the head of the bed elevated, the force of gravity helps prevent additional intracranial pressure (ICP), which will intensify the ischemic manifestations of hemorrhage.

In bed with the head of the bed elevated.

Which clinical finding is consistent with an increase in intracranial pressure? Rationale: Altered consciousness is the first sign of increased intracranial pressure. An increase in intracranial pressure causes impaired cerebral blood flow affecting the cell of the cerebral cortex, which result in a decreased level of consciousness.

Lower level of consciousness.

Which action would the nurse take first when caring for a client who is admitted to the emergency department after experiencing seizures? Rationale: Data collection is an essential first step for a client with a seizure disorder; it should always include a history of the seizure (type and incidence). Because different seizure medicines are used to control different seizure types. it is important to determine the type before treating.

Obtain a history of a seizure type and incidence.

Which statement by the nursing student about cluster headaches indicates a need for further teaching? Rationale: Sharp stabbing pain is the characteristic type of pain that occurs in cluster headaches. Each episode of a cluster headache may last from a few minutes to 3 hours. Constriction of the pupil, swelling around the eye, and facial flushing occur during the period of cluster headaches. A period of remission after a few weeks or months of headaches is characteristic of cluster headaches.

Pulsating pain is the characteristic type of pain that occurs in cluster headaches.

Which client statement indicates that the instruction to a client with a seizure disorder receiving phenytoin and phenobarbital is understood? Rationale: Combination therapy this client has seizures that are difficult to control. Sudden withdrawal of any antiepileptic medication can cause the onset of frequent seizures or even status epilepticus. Death can occur if seizures are continuous due to a lack of adequate oxygenation and cardiac irregularities. It is important to take medication as prescribed to lessen the frequency of seizures; there is no guarantee that seizures will stop.

"Stopping medication can cause continuous seizures and I may die"

Which intervention would the nurse implement after determining that a client, who sustained a cerebrovascular accident (CVA) needs assistance with eating for optimum nutrition? Rationale: As part of rehabilitation after a cerebrovascular accident (CVA), clients should be encouraged to participate in their own care to the extent they are able and extend their abilities by establishing short-term goals.

Encourage the client to participate in the feeding process.

Which phase of severe unilateral throbbing headache with nausea and intolerance to light and sound involves double vision? Rationale: The AURA phase involves visual changes, flashing lights, or diplopia (double vision). Throbbing and unilateral headaches that are often associated with nausea or sensitivity to light and sound, flashes or light, and double vision may be migraine headaches. There are 3 types of migraines. The headache phase involves severe throbbing headaches. The prodromal phase involves specific symptoms, such as food cravings or mood changes. The intensity of the headache will start to decrease in the termination phase.

Aura phase

Which action would the nurse classify as a priority when caring for a client with tonic-clonic seizures? Rationale: Ensuring a patient's airway is the priority of the nurse because a client may lose consciousness during g seizure. IV fluid should be administered when the condition of the client is stable. The level of consciousness should be monitored during ongoing treatment. Continuous muscle contractions are observed in a client with tonic-clonic seizures, which may cause injury. The client should be protected from injury during seizures.

Ensuring patient airway.

Which nursing action is appropriate for a patient during the tonic-clonic stage of a seizures? Rationale: Protecting the client's head from injury is an appropriate nursing action for a client experiencing a tonic-clonic seizure. The client should not be left unattended. Establishing a patient airway is done after seizures; the mouth should not be pried open to insert an airway during a seizure because injury may occur.

Protect the client's head from injury.

Which medication would be prescribed to the client diagnosed with migraines if she wishes to continue breastfeeding? Rationale: Because sumatriptan is not excreted in breast milk, this medication is safe for a lactating woman with migraines. Morphine is the medication of choice for the lactating woman who reports severe pain. Acetaminophen is also the medication of choice for lactating women with pain.

Sumatriptan

Which explanation would the nurse provide to a client about transient ischemic attacks (TIA's)? rationale: The narrowing of arteries supplying the brain causes temporary neurological deficits that last for a short period. Between attacks neurological functioning is normal.

Temporary episodes of neurological dysfunction.

Which outcome would be a priority for the nurse to incorporate into the plan of care for a client with a migraine? Rationale: The priority nursing intervention for a client with a migraine is to decrease pain because a migraine is accompanied by a severe throbbing headache.

To decrease pain

Which information is important for the nurse to include in a teaching program for a client admitted to the hospital after having a tonic-clonic seizure and being diagnosed with a seizure disorder? Rationale: Injuries occur in many ways during a seizure, and trauma prevention is a priority with these clients. Anticonvulsants can cause gastrointestinal disturbances, especially early in therapy, and the client should take them with food.

Explain strategies a client may use to prevent physical trauma from occurring during a seizure. a

Which assessment is the nurse's priority before beginning an infusion of tissue plasminogen activator (t-PA) to a client in the emergency department? Rationale: Assessment for bleeding is a priority because it is a contraindication for the administration of thrombolytic agents; administration in the presence of bleeding can cause life-threatening hemorrhage.

Signs of bleeding

Which health problem history would increase an older adult's risk of experiencing a cerebrovascular accident (CVA)? Rationale: TIA is a temporary neurological deficit related to cerebral hypoxia; about one-third (1/3) of the people who have TIA will have a cerebrovascular accident (CVA) within 2 to 5 years.

Transient ischemic attacks (TIA's)

A client is admitted to the hospital with a tonic-clonic seizure after his seizures have been well controlled by phenytoin for 6 months. The client states" I am so upset. I didn't think I was going to have any more seizures." Which response would the nurse make to the client? Rationale: This response addresses the client's feelings and encourages communication.

"You are worried about having more seizures?"

Which medication is specifically used to treat a client reporting severe right-sided headache with runny nose, droopy eyelids, tearing of the eye on the right side, and facial sweating? SATA Rationale: Severe unilateral headache with runny nose, drooping eyelids, ipsilateral tearing of the eye, and facial sweating is indicative of CLUSTER headache.

*Lithium *Oral glucosamine

Which other symptom may be manifested by a client reporting a severe, sharp, stabbing headache and intense pain in and around the eye that lasts for up to 1 hour with similar episodes of headaches previously that lasted for 10 weeks? SATA Rationale: Cluster headaches are short headaches occurring in episodes, with characteristic sharp, stabbing pain. Pain occurs in the oculotemporal or oculotemporal regions or deep around the eye. The headache may persist for about 4 to 12 weeks followed by a period of remission of 9 to 12 months. Cluster headaches are associated with other symptoms, including rhinorrhea (runny nose) and ptosis (drooping eyelids.)

*Rhinorrhea *Lacrimation *Pupillary constriction.

A client reports a severe throbbing unilateral headache, nausea, and intolerance to light and sound. Arrange the pathophysiologic events in chronological order. Rationale: Throbbing and unilateral headaches are often associated with nausea or sensitivity to light. sound, or head movement, and may indicate migraine headaches. Vascular changes occur after the stimulation of the hyperexcitable neuronal pathway. Activation of the trigeminal nerve pathways contributes to the activation of nociceptors. Dilation of cerebral arteries will help in the release of prostaglandins. Validation, in turn, allows prostaglandins and other intravascular molecules to extravasate, contributing to widespread tissue swelling and the sensation of throbbing pain.

*Stimulate of the hyperexcitable neuronal pathway. *Activation of trigeminal nerve *activation of nociceptors *release of prostaglandins *Extravasation of intravascular molecules *Throbbing pain.

which statement would a nurse make when a client had a sudden loss of muscle tone that lasted for a few seconds followed by confusion during seizures? SATA Rationale: Atonic (akinetic) seizures are characterized by a sudden loss of muscle tone lasting for a few seconds followed by postictal confusion. These seizures cause the client to fall because of the decreased muscle tone, which may result in injury. This type of seizure tends to be most RESISTANT to medication therapy.

*These seizures increased the risk of injury from a fall. *These seizures are MOST resistant to medication therapy.

Which instruction will the nurse give a client with a migraine headache who is starting triptan medication therapy? Rationale: The client needs to be instructed to report chest discomfort to the healthcare provider immediately. Clients taking triptan medication who experience chest discomfort must be investigated for myocardial ischemia.

Report any chest discomfort to the health care provider.

Which intervention and rationale would the nurse plan for a client admitted to the hospital with a right-sided cerebrovascular accident (CVA)? Rationale: Using hand roll while supporting the left upper extremity on a pillow to prevent contractures will maintain the affected left arm in function; and alignment; the left side of the body will be affected with a right-sided brain attack. a

Use a hand roll and support the left arm on a pillow to prevent contractures.