Ch 16 patho

The family of a male client documented to be in a vegetative state excitedly reports to the nurse that the client has just opened his eyes for the first time. The best response by the nurse is: "That is a miracle." "I will come and assess the client." "Clients in a vegetative state often open and close their eyes." "That is a just a reflexive action."

"I will come and assess the client."

Which individual has the highest chance of having a primary central nervous system lymphoma? An 88-year-old man who has begun displaying signs and symptoms of increased ICP A 60-year-old woman who is soon to begin radiation therapy for the treatment of breast cancer A 24-year-old man with acquired immunodeficiency syndrome (AIDS) and behavioral and cognitive changes A 68-year-old man who is a smoker and has a family history of cancer

A 24-year-old man with acquired immunodeficiency syndrome (AIDS) and behavioral and cognitive changes

The nurse is caring for a client recovering from ischemic stroke who has expressive aphasia. Which actions will the nurse include in the plan of care? Select all that apply. Ask open-ended questions to allow client to express feelings. Allow additional time to allow for client to respond to questions. Use a validated tool to screen for signs and symptoms of depression. Repeat questions using different wording if client is not responding. Use a picture or keyword board the client can point to for key needs.

Allow additional time to allow for client to respond to questions. Use a validated tool to screen for signs and symptoms of depression. Use a picture or keyword board the client can point to for key needs.

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. Assess for signs/symptoms of cerebrovascular accident (stroke). Contact physician for anti-nausea medication orders. Document the finding as it is an expected symptom.

Assess for other signs/symptoms of increased intracranial pressure.

The nurse caring for a client with a newly diagnosed intracranial tumor anticipates that the neoplasm will be: Meningioma Metastatic carcinoma Astrocytic neoplasms Oligodendroglioma

Astrocytic neoplasms

Manifestations of brain tumors are focal disturbances in brain function and increased ICP. What causes the focal disturbances manifested by brain tumors? Tumor infiltration and increased blood pressure Brain compression and decreased ICP Brain edema and disturbances in blood flow Tumor infiltration and decreased ICP

Brain edema and disturbances in blood flow

When the suspected diagnosis is bacterial meningitis, what assessment techniques can assist in determining if meningeal irritation is present? Kernig sign and Chadwick sign Brudzinski sign and Kernig sign Brudzinski sign and Chadwick sign Chvostek sign and Goodell sign

Brudzinski sign and Kernig sign

Intracranial aneurysms that rupture cause subarachnoid hemorrhage in the client. How is the diagnosis of intracranial aneurysms and subarachnoid hemorrhage made? CT scan MRI Loss of cranial nerve reflexes Venography

CT scan

The nurse developing a plan of care for a client with a cerebral cortex injury should include assessment for which of the following? Stupor Lethargy Difficulty concentrating Ringing in the ears

Difficulty concentrating

According to the Glasgow Coma Scale, opening one's eyes to only painful stimuli would receive which score? 2 1 3 4

2

What medication teaching should be done for a woman of childbearing age with a seizure disorder? Antiseizure drugs increase the risk for congenital abnormalities. Antiseizure drugs do not interact with oral contraceptives. Some antiseizure drugs can interfere with vitamin K metabolism. All women of childbearing age should be advised to take a vitamin C supplement.

Antiseizure drugs increase the risk for congenital abnormalities.

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? Spontaneous eye opening Flaccid motor response Normal flexion Confused conversation

Flaccid motor response

The nurse is caring for an older adult client with hemiplegia following a stroke. While planning the client's care, the nurse knows the client is at risk for developing which condition? Muscle atrophy Muscular dystrophy Involuntary movements Pseudohypertrophy

Muscle atrophy

A client suffering a thrombotic stroke is brought into the emergency department by ambulance and the health care team is preparing to administer a synthetic tissue plasminogen activator for which purpose? Thrombolysis Thrombogenesis Hemolysis Hemostasis

Thrombolysis

The parents of an infant born with hydrocephalus are concerned about the size of the baby's head. The doctors are telling them that the infant needs the surgical placement of a shunt. The nurse caring for the infant in the neonatal intensive care unit explains that placement of a shunt will: decrease the likelihood of further neurological deficits. not affect the size of the infant's head. reverse any neurologic deficits that are present. increase intracranial pressure.

decrease the likelihood of further neurological deficits.

The nurse reading a client's lumbar puncture results notifies the physician of findings consistent with meningitis when which sign/symptom is noted? Large number of polymorphonuclear neutrophils Clear cerebrospinal fluid Decreased protein count Increased glucose

Large number of polymorphonuclear neutrophils

The MRA scan of a client with a suspected stroke reports ruptured berry aneurysm. The nurse plans care for a client with: Encephalitis Subarachnoid hemorrhage Lacunar infarct Thrombotic stroke

Subarachnoid hemorrhage

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 result in an accumulation of small deficits that may eventually equal the effects of a CV. TIAs are relatively benign phenomena that necessitate monitoring, but not treatment. TIAs, by definition, resolve rapidly, but they constitute an increased risk for stroke. The small bleeds that define TIAs can be a warning sign of an impending stroke.

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

The spouse of a client admitted to the hospital after a motor vehicle accident reports to the nurse that the client has become very drowsy. The nurse should: assess the client for additional signs/symptoms of increased intracranial pressure. contact the physician. instruct the spouse not to let the client fall asleep until the physician has assessed the client. prepare the client for EEG testing.

assess the client for additional signs/symptoms of increased intracranial pressure.

The chart of a client admitted because of seizures notes that the seizure activity began simultaneously in both cerebral hemispheres. The nurse should interpret this to mean that the client experienced: generalized seizure. focal seizure without impairment of consciousness. focal seizure with impairment of consciousness. unknown type of seizure.

generalized seizure.

A high school student sustained a concussion during a football game. The school nurse will educate the family about postconcussion syndrome and ask them to watch for and report which manifestations of its presence? headaches and poor concentration recurrent nosebleeds and hypersomnia unilateral weakness and decreased coordination neck pain and decreased neck range of motion

headaches and poor concentration

A client has developed global ischemia of the brain. The nurse determines this is: inadequate to meet the metabolic needs of the entire brain. inadequate perfusion of the nondominant side of the brain. inadequate perfusion of the right side of the brain. inadequate perfusion to the dominant side of the brain.

inadequate to meet the metabolic needs of the entire brain.

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: the client should be in a sitting position. the sign elicited was the Brudzinski sign. resistance should be provided with the knee in a flexed position. the sign elicited was the obturator sign.

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. prone position with arms placed above the head and legs elevated; deep tendon reflexes showing hyperreflexia. flexion of the arms, wrists, and fingers, with abduction of the upper extremities, internal rotation, and plantar flexion of the lower extremities. active range of motion with increased strength in the upper extremities when painful stimulation applied.

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.

The most common cause of ischemic stroke is: thrombosis. arterial vasculitis. vasospasms. cryptogenesis.

thrombosis