** Complex Concept I Final Exam: Intracranial Regulation Module

Assessing a client with a suspected stroke. The nurse should place the priority on which of the following findings? Dysphagia Aphasia Ataxia Hemianopsia

Dysphagia

This screening assessment tool is used when the client has a decreased level of consciousness or orientation.

Glascow Coma Scale

A nurse is assisting a client who is ambulating to the bathroom. The client begins to have a seizure. Which actions should the nurse take? Select all that apply. A. The nurse should provide privacy. B. Ease the client to the floor if standing. C. Move furniture away from the client. D. Loosen the client's clothing. E. Protect the client's head. F. Restrain the client.

A, B, C, D, E

A nurse in a clinic is caring for a client who has frequent migraine headaches. The client asks about foods that can cause headaches. The nurse should recommend that the client avoid which of the following foods? A. Baked salmon B. Chocolate C. Frozen strawberries D. Fresh asparagus

B The nurse understands that chocolate contains tyramine, which can trigger migraine headaches. avoid fish that is smoked because it contains tyramine.

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for A STAT computer tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult.

3

A patient has experienced right side brain damage. You note the patient is experiencing neglect syndrome. What nursing intervention will you include in the patient's plan of care? A. Remind the patient to use and touch both sides of the body daily. B. Offer the patient a soft mechanical diet with honey thick liquids. C. Ask direct questions that require one word responses. D. Offer the bedpan and bedside commode every 2 hours.

A

The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following? A. Giving the client thin liquids B. Thickening liquids to the consistency of oatmeal C. Placing food on the unaffected side of the mouth D. Allowing plenty of time for chewing and swallowing

A

The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke? A) Facial droop B) Dysrhythmias C) Periorbital edema D) Projectile vomiting

A

You are creating a teaching plan for a patient with newly diagnosed migraine headaches. Which key items should be included in the teaching plan? Select all that apply. A. Avoid foods that contain tyramine, such as alcohol and aged cheese. B. Avoid drugs such as Tagamet, nitroglycerin and Nifedipine. C. Abortive therapy is aimed at eliminating the pain during the aura. D. A potential side effect of medications is rebound headache. E. Complementary therapies such as relaxation may be helpful. F. Continue taking estrogen as prescribed by your physician.

A, B, C, D, E

A nurse is planning care for a client who had a stroke and is experiencing dysphagia. Which of the following actions should the nurse include in the plan? ​​​​​​​ Select all that apply. A. Have suction equipment available for use. B. Eliminate distractions during mealtime. C. Place food on the unaffected side of the client's mouth. D. Assign assistive personnel to provide initial feeding. E. Inform client to swallow with the neck flexed forward.

A, B, C, E

A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following interventions should the nurse implement? ​​​​​​​Select all that apply. A. Speak slowly to the client. B. Assist the client to use cards with pictures. C. Speak to the client in a loud voice. D. Complete sentences that the client cannot finish. E. Give instructions to the client one step at a time.

A, B, E

A nurse is providing teaching with a newly licensed nurse about the manifestations of stroke. Match the findings of stroke to the corresponding term. Agnosia Aphasia Agraphia Ataxia Apraxia Difficulty writing Inability to recognize familiar objects by sight, hearing or touch Inability to perform simple commands Loss of balance or coordination Inability to speak or understand language

Agnosia- recognize objects Aphasia- inability to speak Agraphia- difficulty writing Ataxia- Loss of balance/coordination Apraxia- Inability to perform simple commands

A patient recently started on phenytoin (Dilantin) to control simple complex seizures is seen in the outpatient clinic. Which information obtained during his chart review and assessment will be of greatest concern? A. The gums appear enlarged and inflamed. B. The white blood cell count is 2300/mm3. C. Patient occasionally forgets to take the phenytoin until after lunch. D. Patient wants to renew his driver's license next month.

B

The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client's history should be reported to the doctor? A. Diabetes B. Prinzmetal's angina C. Cancer D. Cluster headaches

B

The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client? A. Roast beef sandwich, potato chips, pickle spear, iced tea B. Split pea soup, mashed potatoes, pudding, milk C. Tomato soup, cheese toast, Jello, coffee D. Hamburger, baked beans, fruit cup, iced tea

B

The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition: A. The client has complete bilateral paralysis of the arms and legs. B. The client has weakness on the right side of the body, including the face and tongue. C. The client has lost the ability to move the right arm but can walk independently. D. The client has lost the ability to move the right arm but can walk independently

B Hemiparesis is a weakness of one side of the body that may occur after a stroke. Complete hemiparesis is a weakness of the face and tongue, arm, and leg on one side. Complete bilateral paralysis does not occur in this condition

A nurse is caring for a client who has left homonymous hemianopsia. Which of the following actions should the nurse take? ​​​​​​​ A. Teach the client to scan to the right to see objects on the right side of the body. B. Place the client's bedside table on the right side of the bed. C. Orient the client to the food on the plate using the clock method. D. Place the wheelchair on the client's left side.

B the nurse should identify that a client who has left homonymous hemianopsia has lost the left visual field of both eyes which causes vision impairment on their left side. Therefore, the nurse should place the bedside table and wheelchair on the client's right side of the bed for visualization of the items on the table and instruct the client to turn their head to the left to visualize the entire field of vision.

A nurse in a provider's office is obtaining a health history from a client who has cluster headaches. Which of the following are expected findings? Select all that apply. A. Pain is bilateral across the posterior occipital area. B. Client experiences altered sleep-wake cycle. C. Headache occurs approximately 1 to 8 times daily. D. Client describes headache pain as dull and throbbing. E. Nasal congestion and drainage occur.

B, C, E Cluster headaches can be due to a lack of continuity in the sleep-wake cycle.

A nurse in a clinic is teaching a client who has a history of migraine headaches about a new prescription for zolmitriptan. Which of the following statements by the client indicates understanding of the teaching? A. "This medication will relieve my symptoms by causing my blood vessels to dilate." B. "I should take this medication daily to prevent the headache from occurring." C. "I should expect facial flushing when I take this medication." D. "This medication will lower my sensitivity to food triggers."

C

A nurse is providing discharge instructions to a client who has a prescription for phenytoin. Which of the following information should the nurse include? A. Discontinue the medication if there is no seizure activity for 6 months. B. Watch for receding gums when taking the medication. C. Take the medication at the same time every day. D. Provide a urine sample to determine therapeutic levels of the medication.

C

A patient who has hemianopia is at risk for injury. What can you educate the patient to perform regularly to prevent injury?* A. Wearing anti-embolism stockings daily B. Consume soft foods and tuck in chin while swallowing C. Scanning the room from side to side frequently D. Muscle training

C

John suddenly experiences a seizure, and Nurse Gina notices that John exhibits uncontrollable jerking movements. Nurse Gina documents that John experienced which type of seizure? A. Tonic seizure B. Absence seizure C. Myoclonic seizure D. Clonic seizure

C

While working in the ICU, you are assigned to care for a patient with a seizure disorder. Which of these nursing actions will you implement first if the patient has a seizure? A. Place the patient on a non-rebreather mask will the oxygen at 15 L/minute. B. Administer lorazepam (Ativan) 1 mg IV. C. Turn the patient to the side and protect the airway. D. Assess level of consciousness during and immediately after the seizure.

C

A fragile 87-year-old female has recently been admitted to the hospital with increased confusion and falls over the last two (2) weeks. She is also noted to have a mild left hemiparesis. Which of the following tests is most likely to be performed? A. CBC (Complete blood count) B. ECG (electrocardiogram) C. Thyroid function tests D. CT scan

D

A nurse is providing discharge instructions to a client who has a new diagnosis of migraine headaches. Which of the following instructions should the nurse include? A. Use music therapy for relaxation with the onset of the headache. B. Increase physical activity when a headache is present. C. Drink beverages that contain artificial sweeteners to prevent headaches. D. Apply a cool cloth to the face during a headache.

D

Mike with epilepsy is having a seizure. During the active seizure phase, the nurse should: A. Place the client on his back, remove dangerous objects, and insert a bite block. B. Place the client on his side, remove dangerous objects, and insert a bite block. C. Place the client on his back, remove dangerous objects, and hold down his arms. D. Place the client on his side, remove dangerous objects, and protect his head.

D

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? a) Footdrop and external hip rotation b) Vomiting and seizures c) Severe headache and early change in level of consciousness d) Weakness on one side of the body and difficulty with speech

D

A nurse is obtaining a health history from a client who is being evaluated for the cause of frequent headaches. Which of the following questions should the nurse ask to identify the aura type of migraine headaches? A. "Do the headaches occur multiple times each day?" B. "Is your headache accompanied by profuse facial sweating?" C. "Does your headache occur on one side of your head?" D. "Do you have the same manifestations each time the headache occurs?"

D Clients who have aura type migraines typically have the same manifestations each time the headache occurs.

Teaching a client with a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which instruction should be included in the teaching? Place a warm compress on your head Darken the lights Light a scented candle Drink a caffeinated beverage

Darken lights

A nurse in a neurology clinic is caring for clients who have seizure disorders. Match each manifestation the nurse observes with the type of seizure each client is experiencing. Myoclonic Tonic-clonic Absence Simple partial Atonic Experienced incontinence Seizure lasted for several seconds Experienced loss of muscle tone Flushing and an offensive smell was experienced Repeatedly experienced loss of consciousness with no motor activity

Myoclonic- lasts several seconds Tonic-clonic- incontinence Absence- LOC with no motor activity Simple partial- flushing with offensive smell Atonic- loss of muscle tone

The wife of a patient who is recovering from a cerebral vascular accident (CVA) tells the healthcare provider, "My husband acts as though I'm talking to him in a foreign language." The healthcare provider will correctly document this communication disorder as which of the following? Receptive aphasia Expressive aphasia Dysphasia Dysarthria

Receptive aphasia

Left hemisphere stroke is noted on a client. Which finding would you expect? Reduced left side motor function Difficulty with speech Impulsive behavior Neglect of the left side of the body

Speech

A nurse responds to a call for assistance with a client that just had a seizure and is unconscious. Which assessment is the nurse's priority? Vital signs Neuro exam Check for patent airway Assess client for injuries

airway

Planning care for a client following a stroke. Which intervention should the nurse identify as the priority in the client's plan of care? Prevent depression Refer to occupational therapy Support the client's family Monitor client for increased intracranial pressure.

increased ICP

Caring for a patient who is experiencing a tonic-clonic seizure. What action should the nurse take? Insert a padded tongue blade. Apply oxygen. Restrain the client. Loosen restrictive clothing.

loosen clothing

The nurse is assessing the client experiencing a left sided CVA. Which clinical manifestations would the nurse expect the client to exhibit? Hemiparesis of the left arm & apraxia. Paralysis of the right side of the body & aphasia. Inability to recognize & use familiar objects. Impulsive behavior & hostility toward family.

paralysis of right side & aphasia

Teaching a client with new diagnosis of simple partial seizures about auras. Which statement by the client indicates an understanding ? An aura is a sensory warning that a seizure is imminent It is a continuous seizure in which the seizure occurs in rapid succession A aura is a period of sleepiness following a seizure It is a brief loss of consciousness accompanied by staring.

sensory warning