467: Exam 2 Neuro & Respiratory

A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying: I just don't understand what's wrong with him." Which statement is the **best** response by the nurse?

"Emotional lability is common after a stroke, and it usually improves with time."

A client with newly diagnosed seizures asks about stigma associated with epilepsy. The nurse will respond with which of the following statements?

"Many people with developmental disabilities resulting from neurologic damage also have epilepsy."

A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse?

"My children are at greater risk to develop this disease."

The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the **priority** nursing intervention?

Administer corticosteroids as ordered.

Which term refers to the failure to recognize familiar objects perceived by the senses?

Agnosia

Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?

Apraxia

A client has experienced an ischemic stroke that has damaged the temporal (lateral and superior portions) lobe. Which of the following deficits would the nurse expect during assessment of this client?

Auditory agnosia

What is an early sign of increasing intracranial pressures (ICP)

Decreased level of consciousness or altered mental status

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to

Dehydrate brain and reduce cerebral edema

After the patient has received tPA, the nurse knows to check vital signs every 30 minutes for 6 hours. Which of the following readings would require calling the provider?

Diastolic pressure of 110 mm Hg

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?

Elevated 30 degrees

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client?

Elevating the head of the bed to 30 degrees

Which of the following statements reflects nursing management of the patient with expressive aphasia?

Encourage the patient to repeat sounds of the alphabet

How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)?

Every 15 minutes

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action?

Form words that are understandable or comprehend spoken words

In planning care for a patient with an extrapyramidal disorder, the nurse recognizes that a major difference between Parkinson disease and Huntington disease is the development of what symptom in clients with advanced Huntington disease?

Hallucinations and delusions

The nurse is caring for a client with a traumatic brain injury and experiencing increased intracranial pressure. The nurse has administered mannitol, an osmotic diuretic, as ordered. This medication promotes the shift of fluid from the intracellular to the intravascular compartment. Therefore, it is necessary for the nurse to continually assess for which of the following?

Heart failure

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?

Heparin sodium

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?

Herniation

A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following?

Monro-Kellie

A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator?

More than 200 mL/h

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

Which is the initial diagnostic test for a stroke?

Noncontrast computed tomography

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

After having a stroke, a patient has cognitive deficits. What are the cognitive deficits the nurse recognizes the patient has as a result of the stroke? Select all that apply.

Poor abstract reasoning Decreased attention span Short- and long-term memory loss

A client the nurse is caring for experiences a seizure. What would be a priority nursing action?

Protect the client from injury.

The nurse is caring for a client following an aneurysm coiling procedure. The nurse documents that the client is experiencing Korsakoff syndrome. Which set of symptoms characterizes Korsakoff syndrome?

Psychosis, disorientation, delirium, insomnia, and hallucinations

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.

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

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:

Severe headache and early change in level of consciousness

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value?

The CPP is low

Which method is used to help reduce intracranial pressure?

Using cervical collar

A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms?

Vasopressin

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?

Weakness on one side of the body and difficulty with speech

A client reports light-headedness, speech disturbance, and left-sided weakness lasting for several hours. The neurologist diagnosed a transient ischemic attack, which caused the client great concern. What would the nurse include during client education?

When symptoms cease, the client will return to presymptomatic state.

A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation?

cardio embolic

While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivates nurses to offer the best care possible is preventing:

complications.

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, 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

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms?

impaired cerebral circulation

To meet the sensory needs of a client with viral meningitis, the nurse should:

minimize exposure to bright lights and noise.

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?

Brain tumor

The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following?

Cardiogenic emboli

The nurse recognizes that causes of acquired seizures include what? Select all that apply.

Cerebrovascular disease Metabolic and toxic conditions Hyponatremia Brain tumor Drug and alcohol withdrawal

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

Which is the **priority** nursing diagnosis when caring for a client with increased ICP who has an intraventricular catheter?

Ineffective cerebral tissue perfusion

The nurse is educating a group of people newly diagnosed with migraine headaches. What information should the nurse include in the educational session? Select all that apply.

Keep a food diary. Maintain a headache diary.

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?

Lethargy and stupor

A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment?

Limited attention span and forgetfulness

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)

Which of the following is accurate regarding a hemorrhagic stroke?

Main presenting symptom is an "exploding headache."

A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome?

Maintains a patent airway

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?

6.3 mg

A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be?

70 mm Hg

Which of the following, if left untreated, can lead to an ischemic stroke?

A fib

The nurse is caring for a client who was involved in a motorcycle accident 7 days ago. Since admission the client has been unresponsive to painful stimuli. The client had a ventriculostomy placed upon admission to the ICU. The current assessment findings include ICP of 14 with good waveforms, pulse 92, respirations per ventilator, temperature 102.7°F (rectal), urine output 320 mL in 4 hours, pupils pinpoint and briskly reactive, and hot, dry skin. Which is the **priority** nursing action?

Administer acetaminophen per orders.

The nurse is caring for a client with bacterial meningitis. Which assessment finding(s) is most important in determining nursing care for a client with bacterial meningitis? Select all that apply.

Cloudy cerebral spinal fluid Purpura of hands and feet

Which is a late sign of increased intracranial pressure (ICP)?

Altered respiratory patterns

The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes which measure to assist the client in reducing the pain associated with the headache?

Apply warm or cool cloths to the forehead or back of the neck.

A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply.

Bradycardia Bradypnea Hypertension

A 76-year-old client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain?

Carotid endarterectomy

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?

LR

Which of the following antiseizure medication has been found to be effective for post-stroke pain?

Lamotrigine (Lamictal)

A family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when a client experiences a stroke on the right side of the brain, common deficits include what? Select all that apply.

Left-sided hemiplegia Tendency to distractibility Neglect of objects and people on the left side

The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? Select all that apply.

Loosening constrictive clothing Positioning the patient on his or her side with head flexed forward Providing for privacy

A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following?

There is a strong familial tendency

When the nurse observes that the client has extension and external rotation of the arms and wrists and plantar flexion of the feet, the nurse records the client's posture as

decerebrate