Exam 2- Collective- Post Exam

Blood-brain Barrier Exam 2

- Helps maintain the metabolic balance in the CNS. - Wall of high density cells that restricts passage of substances from the bloodstream into the brain Most drugs or compounds that are lipid soluble and stable at body pH rapidly cross the blood-brain barrier. The barrier is also highly permeable to water, oxygen, carbon dioxide, and glucose - Metabolites or toxic compounds, cannot cross the blood-brain barrier - Antibiotics, cross slowly, resulting in lower concentrations of them in the brain than in other areas of the body. - Regulates the transport of nutrients, ions, water and waste products - Stabilizes physical and chemical environment surrounding neurons •Disruption or alteration of blood-brain barrier permeability occurs with injury to brain tissue from trauma, toxic insults, and ischemic injury.

Which statements are correct regarding the assessment of motor function in the neurologically impaired patient? (Select all that apply.) a. The presence of a Babinski reflex is an abnormal finding in an adult. b. Lower extremity muscle tone is assessed by asking the patient to push or pull his or her foot against resistance. c. When using noxious stimuli to elicit a motor response, each limb is tested separately. d. The presence of abnormal extension indicates a less positive outcome for the patient than abnormal flexion. e. The evaluation of deep tendon reflexes is an essential part of the nursing neurologic assessment. Pg. 553

ANS: A, C, D The presence of a Babinski response in an adult is indicative of neurologic dysfunction, pushing or pulling against resistance tests muscle strength not tone, and deep tendon reflexes are not routinely checked by the critical care nurse during an assessment.

The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.) a. Alcohol intake b. Diabetes c. High-fat diet d. Obesity e. Smoking Exam 2

ANS: A, C, D, E Alcohol intake, a high-fat diet, obesity, and smoking are all modifiable risk factors for stroke. *Diabetes is not modifiable but is a risk factor that can be controlled with medical intervention.

41. A patient has been admitted with an ischemic stroke. The patient received recombinant tissue plasminogen activator (rtPA) in the emergency department. The nurse checks the medication administration record to make sure the patient does not have which medications for the next 24 hours? (Select all that apply.) a. Aspirin b.Sodium nitroprusside c. Warfarin d. Labetalol e. Any antiplatelet drugs PG 577 E2

ANS: A, C, E The major risk and complication of rtPA therapy is bleeding, especially intracranial hemorrhage. Unlike fibrinolytic protocols for acute myocardial infarction, subsequent therapy with anticoagulant or antiplatelet agents is not recommended after rtPA administration in ischemic stroke. Patients receiving fibrinolytic therapy for stroke should not receive aspirin, heparin, warfarin, ticlopidine, or any other antithrombotic or antiplatelet drugs for at least 24 hours after treatment. Sodium nitroprusside and labetalol are used to manage blood pressure after a stroke.

A client had an embolic stroke and is having an echocardiogram. When the client asks why the provider ordered "a test on my heart," how should the nurse respond? a. "Most of these types of blood clots come from the heart." b. "Some of the blood clots may have gone to your heart too." c. "We need to see if your heart is strong enough for therapy." d. "Your heart may have been damaged in the stroke too." EXAM 2

ANS: A- "Most of these types of blood clots come from the heart." An embolic stroke is caused when blood clots travel from one area of the body to the brain. The most common source of the clots is the heart. The other statements are inaccurate.

19. A lack of which two substances can cause disruption in neuronal function and irreversible damage? a. Oxygen and glucose b. Protein and insulin c. Oxygen and protein d. Protein and glucose EXAM 2

ANS: A- Oxygen and glucose No reserve of either oxygen or glucose is found in the cerebral tissues. A lack or inadequate amount of either one rapidly disrupts cerebral function and produces irreversible damage. REF: p. 521

A client with a stroke has damage to Broca's area. What intervention to promote communication is best for this client? a. Assess whether or not the client can write. b. Communicate using "yes-or-no" questions. c. Reinforce speech therapy exercises. d. Remind the client not to use neologisms. EXAM 2

ANS: A-Assess whether or not the client can write. Damage to Broca's area often leads to expressive aphasia, wherein the client can understand what is said but cannot express thoughts verbally. In some instances the client can write. The nurse should assess to see if that ability is intact. "Yes-or-no" questions are not good for this type of client because he or she will often answer automatically but incorrectly. Reinforcing speech therapy exercises is good for all clients with communication difficulties. Neologisms are made-up "words" often used by clients with sensory aphasia.

34. Which patient may need sedation before having a magnetic resonance imaging (MRI) scan? a. Claustrophobic patient b. Comatose patient c. Elderly patient d. Patient with a spinal cord injury Pg. 561 E2

ANS: A-Claustrophobic patient The magnetic resonance imaging procedure is lengthy and requires the patient to lie motionless in a tight, enclosed space. Mild sedation, a blindfold, or both may be necessary for claustrophobic patients.

CH 21 2. Which neurologic structure carries nerve impulses from the central nervous system (CNS) to the periphery to produce a response such as contraction of the skeletal muscles? a.Efferent fibers (The Elephant) b.Afferent fibers c.Sensory fibers d.Neurotransmitters E2

ANS: A-Efferent fibers Efferent fibers (motor fibers) transmit the central nervous system (CNS) response to the periphery to produce a motor response such as contraction of skeletal muscles, contraction of the smooth muscles of organs, or secretion by endocrine glands. This sensory information is transmitted to the CNS by afferent fibers (sensory fibers). Fibers enclosed in the sheath are called myelinated fibers. Neurotransmitters help with nerve transmission from one neuron to the next. REF: p. 520

IGGY E2 A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The client's spouse is very frustrated, stating that the client's personality has changed and the situation is intolerable. What action by the nurse is best? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse this is expected and he or she will have to learn to cope. EXAM 2 REF:953

ANS: A-Explain that personality changes are common following brain injuries. Personality and behavior often change permanently after head injury. The nurse should explain this to the spouse. Asking the client about his or her behavior isn't useful because the client probably cannot help it A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to learn to cope belittles the spouse's concerns and feelings

11. The incidence of rebleeding after a ruptured cerebral aneurysm is highest during which of the following time periods? a. First 24 hours b. 4 to 12 days c. 3 to 4 weeks d. 3 to 6 months PG 582 E2

ANS: A-First 24 hours Rebleeding is the occurrence of a second subarachnoid hemorrhage in an unsecured aneurysm or, less commonly, an arteriovenous malformation. The incidence of rebleeding during the first 24 hours after the first bleed is 4%, with a 1% to 2% chance per day for the following month. Mortality with aneurysmal rebleeding is approximately 70%.

27. Stimulation of what nerve will elicit the gag reflex? a.Glossopharyngeal b.Facial c.Spinal accessory d.Hypoglossal EXAM 2

ANS: A-Glossopharyngeal The glossopharyngeal nerve is a sensory nerve whose functions are taste in the posterior third of the tongue and sensation in the back of the throat; stimulation elicits the gag reflex.

33. Which diuretic is the most effective in the reduction of increased intracranial pressure (ICP)? a. Mannitol b. Furosemide c. Urea d. Glycerol PG 602 Q4

ANS: A-Mannitol The most widely used diuretic is mannitol, a large-molecule agent that is retained almost entirely in the extracellular compartment and has little of the rebound effect observed with other osmotic diuretics. Administration of mannitol increases cerebral blood flow and thus induces cerebral vasoconstriction as part of the brain's autoregulatory response to keep blood flow constant.

9. Which statement is true regarding the occurrence of subarachnoid hemorrhages (SAHs)? a. Occurrence is greater in men than women younger than the age of 40 years old. b. Occurrence is greater in men than women older than the age of 40 years old. c. 90% of SAHs are caused by traumatic injury. d. Patients with SAHs have a better survival rate than patients with arteriovenous malformations. REF: pp. 578-579 E2

ANS: A-Occurrence is greater in men than women younger than the age of 40 years old Among people younger than 40 years, more men than women are likely to have subarachnoid hemorrhages (SAHs); among those older than 40 years, more women have SAHs. Hemorrhage from arteriovenous malformation rupture has a better chance of survival and is associated with an overall mortality rate of 10% to 15%. Ninety percent of aneurysms are congenital, the cause of which is unknown. The other 10% can be the result of traumatic injury (that stretches and tears the muscular middle layer of the arterial vessel) or infectious material.

20. A right-handed patient has been admitted with an intracerebral hemorrhage. A computed tomography (CT) scan of the patient's head reveals a large left parietal area bleed. Based on the type of stroke, which signs and symptoms might the patient exhibit? a. Right-sided hemiplegia and receptive aphasia b. Left-sided hemiplegia and tactile agnosia c. Decorticate posturing and unequal pupils d. Unilateral neglect and dressing apraxia REF: pp. 586-587 Q4

ANS: A-Right-sided hemiplegia and receptive aphasia Damage to the dominant hemisphere produces problems with speech and language and abstract and analytic skills.

29. A patient is undergoing a preoperative evaluation for carotid arteries. What two test should the nurse expect to see ordered for the patient? a. Ultrasound and magnetic resonance angiography b. Conventional angiography and evoked potential c. Computed tomography (CT) and magnetic resonance angiography d. Transcranial Doppler and extracranial Doppler Pg. 564

ANS: A-Ultrasound and magnetic resonance angiography Magnetic resonance angiography of the carotid arteries has become an established complement to preoperative ultrasound evaluation. It helps determine the area of salvageable tissue (or penumbra) after acute stroke and head injury. REF: p. 564

Which cranial nerves are responsible for motor functions of the eye? (Select all that apply.) a. Optic nerve b. Oculomotor c. Trochlear d. Trigeminal e. Abducens f. Acoustic EXAM 2 REF: pp. 533-536|Table 21-3

ANS: B, C, E The oculomotor nerve is the motor nerve whose function is raising the eyelids and extraocular movement of the eyes. The trochlear nerve is the motor nerve whose function is the extraocular movement of the eyes. The abducens nerve is the motor nerve that functions with extraocular eye movement and rotates the eyeball outward. The trigeminal nerve is the sensory nerve that gives sensation to the cornea, ciliary body, iris, and lacrimal gland. The optic nerve is the sensory nerve whose function is the vision The acoustic nerve is the sensory nerve whose function is hearing.

A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess neurologic status with the Glasgow Coma Scale. b. Check and document oxygen saturation every 1 to 2 hours. c. Cluster client care to allow periods of uninterrupted rest. d. Elevate the head of the bed to 45 degrees to prevent aspiration. e. Position the client supine with the head in a neutral midline position. EXAM 2

ANS: B, E The UAP can take and document vital signs, including oxygen saturation, and keep the client's head in a neutral, midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees.

4. A patient with a serious head injury has been admitted. The nurse knows that certain neurologic findings can indicate the prognosis for the patient. Which finding denotes the most serious prognosis? a. Decorticate posturing b. Decerebrate posturing c. Absence of Babinski reflex d. Glasgow Coma Scale (GCS) score of 14 Pg. 553 Fig. 22.1 E2- Part of Select All

ANS: B- Decerebrate posturing Outcome studies indicate that abnormal flexion or decorticate posturing has a less serious prognosis than does extension, or decerebrate posturing. Onset of posturing or a change from abnormal flexion to abnormal extension requires immediate physician notification. The Babinski reflex is a pathologic finding; absence of this reflex is a normal neurologic finding in adults. The range of scores for the Glasgow Coma Scale is 3 to 15. A score of 14 denotes a minimal deficit. REF: p. 553

7. Ideally fibrinolytic therapy should be administered within how many hours of the onset of stroke symptoms? a. 1 hour (rtPA-infusion after bolus over one hour) b. 3 hours (Fibrinolytic- (3 to 4.5 hours of onset) c. 6 hours d. 10 PG 577 Q4

ANS: B- Three Hours This study demonstrated that administration of recombinant tissue plasminogen activator within 3 hours of the onset of the stroke was an effective and safe therapy for ischemic stroke. This time frame has now been expanded from 3 to 4.5 hours with additional excursion criteria. National guidelines for the management of stroke are based on the results of the National Institute of Neurologic Disorders and Stroke rtPA Stroke Study.

IGGY-Chapter 45 A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the client's neurologic examination is normal. About what drug should the nurse plan to teach the client? a. Alteplase (Activase) b. Clopidogrel (Plavix) c. Heparin sodium d. Mannitol (Osmitrol) EXAM 2

ANS: B-Clopidogrel (Plavix) This client's manifestations are consistent with a transient ischemic attack, and the client would be prescribed aspirin or clopidogrel on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition.

25. Which procedure is the diagnostic study of choice for acute head injury? a. Magnetic resonance imaging b. Computed tomography c. Transcranial Doppler d. Electroencephalography Pg. 560 E2

ANS: B-Computed tomography Computed tomography offers rapid, convenient, noninvasive visualization of structures and is the diagnostic study of choice for an acute head injury. REF: p. 560

32. Which independent nursing measures can assist in reducing increased intracranial pressure (ICP)? a. Decreasing the ventilator rate b. Decreasing noxious stimuli c. Frequent orientation checks d. Administration of loop diuretics PG-602 E2- Not asked the same way

ANS: B-Decreasing noxious stimuli A treatment modality that increases the incidence of noxious stimulation to the patient carries with it the potential for increasing intracranial pressure.

9. A person with a cerebellar lesion will have difficulty with which physiologic mechanism? a. Breathing b. Equilibrium c. Memory d. Speech EXAM 2

ANS: B-Equilibrium Cerebellar impulses are communicated to descending motor pathways to integrate spatial orientation. Equilibrium with posture and muscle tone, ensuring synchronized adjustments in a movement that maintain overall balance and motor coordination. Cerebellar monitoring and adjustment of motor activity occur simultaneously with movement, enabling significant control of fine motor function. REF: p. 532

A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best? a. Have the student ask the client if it is desired or not. b. Inform the student that the docusate should be given. c. Tell the student to document the rationale. d. Tell the student to give it unless the client refuses. EXAM 2

ANS: B-Inform the student that the docusate should be given. Stool softeners should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Valsalva maneuver when constipated. The supervising nurse should instruct the student to administer the docusate. The other options are not appropriate. The medication could be held for diarrhea.

6. The nurse is caring for a patient immediately after a craniotomy. When assessing the size and shape of the patient's pupils the nurse notes the patient's left pupil is oval. What does this finding indicate? a. Cortical dysfunction b. Intracranial hypertension c. Hydrocephalus d. Metabolic coma Pg. 554 E2

ANS: B-Intracranial hypertension Pupil shape is also noted in the assessment of pupils. Although the pupil is normally round, an irregularly shaped or oval pupil may be noted in patients with eye surgery. Initial stages of cranial nerve III compression from elevated intracranial pressure can also cause the pupil to have an oval shape. REF: p. 554

10. Which of the following statements best describes assessment of arousal? a. It measures content of consciousness and is a higher-level function. b. It is an evaluation of the reticular activating system and its connection with the thalamus and the cerebral cortex. c. It becomes a valid parameter when the patient is able to respond to verbal stimuli, such as squeezing the hands on command. d. Noxious stimuli are not to be used as an assessment parameter. Pg. 550 E2

ANS: B-It is an evaluation of the reticular activating system and its connection with the thalamus and the cerebral cortex. Assessment of the arousal component of consciousness is an evaluation of the reticular activating system and its connection with the thalamus and the cerebral cortex. Arousal is the lowest level of consciousness, and observation centers on the patient's ability to respond to verbal or noxious stimuli in an appropriate manner.

13. The nurse is precepting a nursing student. The student asks about the testing of extraocular eye movements. What should the nurse tell the student? a. It tests the pupillary response to light. b. It tests function of the three cranial nerves. c. It tests the ability of the eyes to accommodate to a closer moving object. d. It tests the oculocephalic reflex. Pg. 554 Fig. 22.5 E2

ANS: B-It tests the function of the three cranial nerves. Control of eye movements occurs with the interaction of three cranial nerves: oculomotor (III), trochlear (IV), and abducens (VI). REF: p. 554

14. Substances most likely to pass across the blood-brain barrier have what characteristics? a. Low pH compared with body fluids b. Lipid solubility c. Large particle size d. A close relation to toxic metabolites EXAM 2

ANS: B-Lipid solubility Passage of substances across the blood-brain barrier is a function of particle size, lipid solubility, and protein-binding potential. Most drugs or compounds that are lipid soluble and stable at body pH rapidly cross the blood-brain barrier. The blood-brain barrier is also very permeable to water, oxygen, carbon dioxide, and glucose. REF: p. 526

6. Appropriate therapy for ischemic stroke depends on rapid completion of which diagnostic study? a. Magnetic resonance imaging b. Noncontrast computed tomography c. Contrast computed tomography d. Lumbar puncture PG 577 Q4 E2

ANS: B-Noncontrast computed tomography Confirmation of the diagnosis of ischemic stroke is the first step in the emergent evaluation of these patients. Differentiation from intracranial hemorrhage is vital. Noncontrast computed tomography (CT) scanning is the method of choice for this purpose, and it is considered the most important initial diagnostic study. In addition to excluding intracranial hemorrhage, CT can assist in identifying early neurologic complications and the cause of the insult. Magnetic resonance imaging (MRI) can demonstrate infarction of cerebral tissue earlier than can CT but is less useful in the emergent differential diagnosis. Lumbar puncture is performed only if subarachnoid hemorrhage is suspected and the CT scan findings are normal.

25. The primary functions of which lobe are hearing, speech, behavior, and memory? a. Frontal lobe b. Temporal lobe c. Occipital lobe d. Parietal lobe EXAM 2

ANS: B-Temporal lobe The temporal lobe lies beneath the temporal bone in the lateral portion of the cranium. Separated from the frontal and parietal lobes by the lateral fissure, this lobe has the primary functions of hearing, speech, behavior, and memory. p. 530

15. The nurse is caring for a patient who has sustained a traumatic head injury. The practitioner has asked the nurse to test the patient's oculocephalic reflex. Which findings indicate that the patient has an intact oculocephalic reflex? a. The patient's eyes move in the same direction the head is turned. b. The patient's eyes move in the opposite direction to the movement of the patient's head. c. The patient's eyes rove and move in opposite directions from each other. d. The patient's eyes move up and down and then back and forth. Pg. 556 Fig. 22.6 E2

ANS: B-The patient's eyes move in the opposite direction to the movement of the patient's head. To assess the oculocephalic reflex, the nurse holds the patient's eyelids open and briskly turns the head to one side while observing the eye movements and then briskly turns the head to the other side and observes. If the eyes deviate to the opposite direction in which the head is turned, doll's eyes are present, and the oculocephalic reflex arc is intact. If the oculocephalic reflex arc is not intact, the reflex is absent. REF: p. 556|Figure 22-6

11. Which statement best describes the role of neuroglial cells? a. They are fewer in number than neurons. b. They provide support to the neuron in nutrients and structural formation. c. They protect the central nervous system (CNS) from nonmetabolic primary neoplasms. d. They produce a steady supply of neurotransmitters. E2

ANS: B-They provide support to the neuron in nutrients and structural formation.These cells provide the neuron with structural support, nourishment, and protection (Table 26-1). They also retain their ability to replicate but can replicate abnormally and hence are the primary source of central nervous system neoplasms. REF: p. 520

18. The nurse is caring for a severely head injured comatose patient who is dying. The nurse knows the patient has entered the late stages of intracranial hypertension when the nurse observes which signs? a. Pupils are equal and reactive b. Widening pulse pressure c. Eupnea d. Decreased intracranial pressure Pg. 558 E2

ANS: B-Widening pulse pressure Attention must also be paid to the pulse pressure because widening of this value may occur in the late stages of intracranial hypertension. With the loss of autoregulation as blood pressure increases, cerebral blood flow (CBF) and cerebral blood volume increase and intracranial pressure (ICP) therefore increases. The mean arterial pressure must be maintained at a level sufficient to produce adequate CBF in the presence of elevated ICP.

7. What is the region of the brain that acts as a relay station for both motor and sensory activity called? a. Cerebrum b. Cerebellum c. Thalamus d. Hypothalamus EXAM 2

ANS: C- Thalamus The thalamus consists of two connected ovoid masses of gray matter and forms the lateral walls of the third ventricle. The two thalami serve as a relay station and gatekeeper for motor and sensory stimuli, preventing or enhancing transmission of impulses based on the behavioral needs of the person.

6. What percentage of the body's total resting cardiac output is used by the brain? a. 5% b. 10% c. 20% d. 40% E2

ANS: C-20%The brain constitutes 2% of the body's weight but uses 20% of the body's total resting cardiac output.It requires approximately 750 mL of blood flow per minute and can extract as much as 45% of arterial oxygen to meet normal metabolic needs.REF: p. 539

45. According to the 2007 Brain Trauma Foundation guidelines, the recommended CPP range is: a. 10 to 30 mm Hg. b. 30 to 50 mm Hg. c. 50 to 70 mm Hg. d. 70 to 85 mm Hg. Pg. 570 E2

ANS: C-50 to 70 mm Hg. The 2007 Brain Trauma Foundation guidelines now recommend a cerebral perfusion pressure (CPP) in the range of 50 to 70 mm Hg and consideration of cerebral autoregulation status when selecting a CPP target in a specific patient.

24. Which intervention should be considered LAST in treating uncontrolled intracranial hypertension? a. Sedatives b. Analgesics c. Barbiturates d. Hyperventilation PG 602 E2

ANS: C-Barbiturates Barbiturate therapy is a treatment protocol developed for the management of uncontrolled intracranial hypertension that has not responded to the conventional treatments previously described. The two most commonly used drugs in high-dose barbiturate therapy are pentobarbital and thiopental. The goal with either of these drugs is a reduction of intracranial pressure to 15 to 20 mm Hg while a mean arterial pressure of 70 to 80 mm Hg is maintained.

13. Obstructive hydrocephalus can occur in the presence of what abnormality? a. Blockage in the arachnoid villi b. Malformation of the falx cerebelli c. Blockage of cerebrospinal fluid (CSF) flow in the ventricular system d. Increased production of CSF EXAM 2

ANS: C-Blockage of cerebrospinal fluid (CSF) flow in the ventricular system Blockage of cerebrospinal fluid (CSF) flow occurring within the ventricular system obstructs the normal circulation of CSF, causing dilation of the ventricles, a condition called obstructive hydrocephalus. REF: p. 524

31. What is one of the earliest signs of increased intracranial pressure (ICP)? a. Cushing triad b. Decerebrate posturing (abnormal extension) c. Change in level of consciousness d. Increase in pupillary size PG 577 E2

ANS: C-Change in level of consciousness One of the earliest and most important signs of increased intracranial pressure is a decrease in the level of consciousness.

A nurse is caring for four clients in the neurologic/neurosurgical intensive care unit. Which client should the nurse assess first? a. Client who has been diagnosed with meningitis with a fever of 101° F (38.3° C) b. Client who had a transient ischemic attack and is waiting for teaching on clopidogrel (Plavix) c. Client receiving tissue plasminogen activator (t-PA) who has a change in respiratory pattern and rate d. Client who is waiting for subarachnoid bolt insertion with the consent form already signed EXAM 2

ANS: C-Client receiving tissue plasminogen activator (t-PA) who has a change in respiratory pattern and rate The client receiving t-PA has a change in neurologic status while receiving this fibrinolytic therapy. The nurse assesses this client first as he or she may have an intracerebral bleed. The client with meningitis has expected manifestations. The client waiting for discharge teaching is a lower priority. The client waiting for surgery can be assessed quickly after the nurse sees the client who is receiving t-PA, or the nurse could delegate checking on this client to another nurse.

CH 23 1. What is one cause of metabolic coma? a. Trauma b. Ischemic stroke c. Drug overdose d. Intracerebral hemorrhage REF: p. 589|Box 23-9 E2

ANS: C-Drug overdose Causes of metabolic coma include drug overdose, infectious diseases, endocrine disorders, and poisonings. Structural causes of coma include ischemic stroke, intracerebral hemorrhage, trauma, and brain tumors.

39. The nurse is precepting a new graduate nurse. The new graduate asks about the difference between electroencephalography and evoked potentials. What should the nurse tell the new graduate? a. Evoked potentials measure and record electric and muscle activity in response to noxious stimuli. b. Electroencephalography measures cerebral blood flow and oxygen extraction. c. Evoked potentials measure cerebral electrical impulses generated in response to sensory stimuli. d. Electroencephalography measures the biochemical changes in the brain to assess metabolic activity. Pg. 566-567

ANS: C-Evoked potentials measure cerebral electrical impulses generated in response to sensory stimuli. Evoked potentials involve the recording of electrical impulses generated by a sensory stimulus as it travels through the brainstem and into the cerebral cortex. Electroencephalography (EEG) records electric impulses, commonly called brain waves, generated by the brain.

9. Why is assessment of level of conscious (LOC) the most important aspect of the neurologic examination? a. The LOC is the most prognostic indicator of the patient's outcome. b. The LOC is generally limited to the Glasgow Coma Scale making it the quickest part of the assessment. c. In most situations the LOC deteriorates before any other neurologic changes are noted. d. The LOC is the easiest part of the neurologic exam and thus is generally performed first. Pg. 550 E2

ANS: C-In most situations the LOC deteriorates before any other neurologic changes are noted. Assessment of the level of consciousness is the most important aspect of the neurologic examination.

CH 22 1. The nurse is caring for a patient with a closed head injury with a Glasgow Coma Scale (GCS) score of 6. What does this score indicate about the patient's neurologic status? a. Patient is in a vegetative state. b. Patient is a paraplegic. c. Patient is in a coma. d. Patient is able to obey commands. Pg. 55 E2

ANS: C-Patient is in a coma. The best possible score on the Glasgow Coma Scale (GCS) is 15, and the lowest score is 3. Generally, a score of 7 or less on the GCS indicates coma. Originally, the scoring system was developed to assist in general communication concerning the severity of neurologic injury.

12. What is the tissue that adheres directly to the brain called? a. Dura mater b. Arachnoid mater c. Pia mater d. Blood-brain barrier EXAM 2 REF: p. 524

ANS: C-Pia mater The pia mater adheres directly to brain tissue. Rich in small blood vessels that supply a large volume of arterial blood to the central nervous system, this membrane closely follows all folds and convolutions of the brain's surface. The outermost layer of meninges directly beneath the skull is the dura mater. The arachnoid membrane is a delicate, fragile membrane that loosely surrounds the brain. Cerebrospinal fluid (CSF) circulates freely in the subarachnoid space fragile membrane that loosely surrounds the brain.

28. After neurosurgery, the patient is at risk of developing what problem? a. Aspiration b. Diabetes mellitus c. Seizures d. Corneal abrasions PG 597 E2

ANS: C-Seizures After neurosurgery, the patient is at risk for infection, corneal abrasions, and injury from falls or seizures. After neurosurgery, patients are at risk for a variety of infections, including meningitis, cerebral abscesses, bone flap infections, and subdural empyema.

11. The nurse is caring for a critically injured patient who can only be aroused by vigorous external stimuli. Which category should the nurse use to document the patient's level of consciousness? a. Lethargic b. Obtunded c. Stuporous d. Comatose Pg. 552 Box 22.2 E2

ANS: C-Stuporous Stuporous means the patient can be aroused only by vigorous and continuous external stimuli. Motor response is often withdrawal or localizing to stimulus. Obtunded means the patient displays dull indifference to external stimuli, and response is minimally maintained. Questions are answered with a minimal response. Lethargic means the patient displays a state of drowsiness or inaction in which the patient needs an increased stimulus to be awakened. Comatose means vigorous stimulation fails to produce any voluntary neural response in the patient. REF: p. 552|Box 22-2

23. A patient has coherent speech but the words are illogical. Which part of the brain has been affected? a. The cerebellum b. The Broca area c. The Wernicke area d. The hypothalamus EXAM 2 REF: p. 530|Figure 21-9

ANS: C-The Wernicke area The Wernicke area (Brodmann area 22) is partially located within the parietal lobe and partially in the temporal lobe, most commonly on the left side of the cerebral cortex. This area is concerned with reception of written and verbal language and includes many intricate connections to other parts of the brain associated with auditory and visual functions, cognitive appraisal, and expressive language. Injury to this area of the brain may result in disability ranging from minor receptive language dysfunction to receptive or fluent aphasia, in which expressive language function remains but is illogical in content or a "word salad."

28. Cerebral infarction is a serious complication of which procedure? a. Extracranial Doppler b. Evoked potential testing c. Myelography d. Cerebral angiography Pg. 564 E2

ANS: D- Cerebral angiography Complications associated with cerebral angiography include cerebral embolus caused by the catheter dislodging a segment of atherosclerotic plaque in the vessel, hemorrhage or hematoma Formation at the insertion site, vasospasm caused by the irritation of catheter placement, thrombosis of the extremity distal to the injection site, and allergic or adverse reaction to the contrast medium.

16. The sensory, motor, and cognitive functions are the primary functions of which area of the brain? a. Diencephalon b. Basal ganglia c. Cerebellum d. Cerebrum EXAM 2

ANS: D-Cerebrum The outermost aspect of the cerebrum is called the cerebral cortex. The primary functions of the cerebral cortex include sensory, motor, and intellectual (cognitive) functions, making this area of the brain vital to normal human functioning and providing capabilities that make humans unique as a species. REF: p. 527

17. The nurse is caring for a patient with a head injury and observes a rhythmic increase and decrease in the rate and depth of respiration followed by brief periods of apnea. What should the nurse document under breathing pattern? a. Central neurogenic hyperventilation b. Apneustic breathing c. Ataxic respirations d. Cheyne-Stokes respirations Pg. 557-558 Fig. 22.8 Table 22.3 E2

ANS: D-Cheyne-Stokes respirations Cheyne-Stokes respirations have a rhythmic crescendo and decrescendo of rate and depth of respiration, including brief periods of apnea. These respirations are usually seen with bilateral deep cerebral lesions or some cerebellar lesions. Central neurogenic hyperventilations are very deep, very rapid respirations with no apneic periods. They are usually seen with lesions of the midbrain and upper pons. Apneustic breathing includes clusters of irregular, gasping respirations separated by long periods of apnea. They are usually seen in lesions of the lower pons or upper medulla.

The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first? a. Client with cerebral perfusion pressure of 72 mm Hg b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg who is on a ventilator d. Client who has a temperature of 102° F (38.9° C) Exam 2 REF:953

ANS: D-Client who has a temperature of 102° F (38.9° C) A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and cerebral perfusion pressure of 72 mm Hg are all desired outcomes.

42. A patient has been told he has a nonencapsulated tumor that has infiltrated the brain tissue. Why type of tumor does the nurse suspect the patient has? a. Angioma b. Pituitary adenoma c. Meningioma d. Glioma REF: p. 594|Table 23-3 E2

ANS: D-Glioma Gliomas are nonencapsulated; tend to infiltrate brain tissue; arise in any part of brain connective tissue; infiltrate primarily cerebral hemisphere tissue; are not well outlined, so they are difficult to excise completely; and grow rapidly. Angiomas arise from vascular structures and are usually difficult to resect. Pituitary adenomas arise from various tissues. Meningiomas arise from meningeal coverings of brain and are usually encapsulated.

18. A patient with neurologic damage continues with extremely high core body temperature despite interventions to lower temperature. The nurse suspects the patient has sustained damage to which area of the brain? a. Cerebrum b. Cerebellum c. Thalamus d. Hypothalamus EXAM 2

ANS: D-Hypothalamus Areas of the internal environment regulated and maintained by the hypothalamus include temperature regulation, autonomic nervous system responses, food and water intake, hormonal secretions, and behavioral responses. REF: p. 531

8. Damage to the upper portion of the reticular activating system results in which condition? a. Seizures b. Diabetes insipidus c. Apnea d. Impaired consciousness EXAM 2

ANS: D-Impaired consciousness The reticular activating system (RAS) works through activation of the hypothalamus, which results in diffuse cortical stimulation and autonomic stimulation. Damage to the thalamic or hypothalamic RAS pathways results in impaired consciousness. REF: p. 539

18. Which nursing diagnosis has the highest priority in the nursing management plan for a patient with Guillain-Barré syndrome? a. Imbalanced nutrition: less than body requirements related to lack of exogenous nutrients or increased metabolic demand b. Acute pain related to transmission and perception of cutaneous, visceral, muscular, or ischemic impulses c. Risk for aspiration d. Ineffective breathing pattern related to musculoskeletal fatigue or neuromuscular impairment REF: pp. 591-592|Box 23-12 E2

ANS: D-Ineffective breathing pattern related to musculoskeletal fatigue or neuromuscular impairment The most common cause of death of patients with Guillain-Barré syndrome (GBS) is respiratory arrest; thus, the highest nursing priority for a patient with GBS is directed toward providing ventilatory support and maintaining surveillance for complications. Facilitating nutritional support, providing comfort and emotional support, and educating the patient and family are important but rank lower than issues with the respiratory system.

19. A right-handed patient has been admitted with an intracerebral hemorrhage. A computed tomography (CT) of the patient's head reveals a large left parietal area bleed. Patient assessment includes temperature (T), 98.7° F; pulse (P), 98 beats/min and thready; respirations (R), 8 breaths/min; and blood pressure (BP), 168/100 mm Hg. Initial management of the patient includes which intervention? a. Placing the patient in the Trendelenburg position b. Administering an antihypertensive agent c. Initiating induced hypertensive therapy d. Intubating and ventilating the patient REF: p. 585 E2

ANS: D-Intubating and ventilating the patient Intracerebral hemorrhage is a medical emergency. Initial management requires attention to airway, breathing, and circulation. Intubation is usually necessary. Blood pressure management must be based on individual factors. Reduction in blood pressure is usually necessary to decrease ongoing bleeding, but lowering blood pressure too much or too rapidly may compromise cerebral perfusion pressure, especially in a patient with elevated intracranial pressure. National guidelines recommend keeping the mean arterial blood pressure below 130 mm Hg in patients with a history of hypertension by moderate blood pressure reduction to a mean arterial pressure below 110 mm Hg. Vasopressor therapy after fluid replenishment is recommended if systolic blood pressure falls below 90 mm Hg.

8. A patient presents with aphasia, decreased level of consciousness, and right-sided weakness. The patient has a history of heart disease, hyperlipidemia, and transient ischemic attacks. Based on the history, the nurse suspects that the patient has sustained which type of stroke? a. Hemorrhagic stroke b. Intracerebral hemorrhages c. Subarachnoid hemorrhages d. Ischemic stroke PG 575 E2

ANS: D-Ischemic stroke Ischemic stroke results from interruption of blood flow to the brain and accounts for 80% to 85% of all strokes. The interruption can be the result of a thrombotic or embolic event. Thrombosis can form in large vessels (large-vessel thrombotic strokes) or small vessels (small-vessel thrombotic strokes). Embolic sources include the heart (cardioembolic strokes) and atherosclerotic plaques in larger vessels (atheroembolic strokes). In 30% of the cases, the underlying cause of the stroke is unknown (cryptogenic strokes). Strokes are classified as ischemic and hemorrhagic. Hemorrhagic strokes can be further categorized as subarachnoid hemorrhages and intracerebral hemorrhages.

10. What is a pathologic consequence of an unruptured cerebral aneurysm? a. It shunts blood away from the surrounding tissues. b. It leaks blood into the subarachnoid space. c. It causes damage the middle layer of the arterial wall. d. It places pressure on the surrounding tissues. REF: pp. 578-579 Q4

ANS: D-It places pressure on the surrounding tissues. An unruptured aneurysm may be problematic because it places pressure on the surrounding tissues. The aneurysm becomes clinically significant when the vessel wall becomes so thin that it ruptures, sending arterial blood at a high pressure into the subarachnoid space.

42. A patient is being prepared for a neurologic work-up. The practitioner is getting ready to perform a lumbar puncture. What is the best position for the nurse to place the patient in for the procedure? a. Prone b. Reverse Trendelenburg c. High Fowler d. Lateral recumbent position with knees and head slightly tucked. Pg. 565 Fig. 22.13 E2

ANS: D-Lateral recumbent position with knees and head slightly tucked. Patients undergoing a lumbar puncture are placed either in the lateral recumbent position, with the knees and head tightly tucked, or in the sitting position, leaning over a bedside table or some other support.

34. What are the most common medications used in high-dose barbiturate therapy? a. Phenytoin and fosphenytoin b. Mannitol and nimodipine c. Lidocaine and phenobarbital d. Pentobarbital and thiopental REF: pp. 602-603|Table 23-5 E2

ANS: D-Pentobarbital and thiopental (Barb is going to the Penthouse with T-Pen) The goal with either drug is a reduction of intracranial pressure to 15 to 20 mm Hg while a mean arterial pressure of 70 to 80 mm Hg is maintained. Phenytoin and fosphenytoin are anticonvulsants. Mannitol is an osmotic diuretic, lidocaine is a local anesthetic, and nimodipine is a calcium channel blocker.

17. Which of the following statements regarding Guillain-Barré syndrome (GBS) supports the admission to a critical care unit? a. The demyelination process of the peripheral nerves is irreversible. b. The demyelination process is limited to the peripheral nervous system only. c. The paralysis associated with the syndrome occurs in a descending pattern. d.The most common cause of death is respiratory arrest. PG-591 Q4 E2 Q answer closest was-inadequate airway monitoring

ANS: D-The most common cause of death is respiratory arrest. Most patients with Guillain-Barré syndrome (GBS) do not require admission to the critical care unit. However, the prototype of GBS, known as acute inflammatory demyelinating polyradiculoneuropathy (AIDP), involves a rapidly progressive, ascending peripheral nerve dysfunction, which leads to paralysis that may produce respiratory failure. Because of the need for ventilatory support, AIDP is one of the few peripheral neurologic diseases that necessitates care in a critical care environment.

2. Emergency treatment of coma of unknown cause includes rapid intravenous administration of which three agents? a. Epinephrine, hydrocortisone, and Benadryl b. Dopamine, 10% dextrose in distilled water, and calcium chloride c. Mannitol, dexamethasone, and sodium bicarbonate d. Thiamine, glucose, and opioid antagonist REF: PG 590 Q4

ANS: D-Thiamine, glucose, and opioid antagonist "COMA COCKTAIL" The goal of medical management of the patient in coma is identification and treatment of the underlying cause of the condition. Initial medical management includes emergency measures to support vital functions and prevent further neurologic deterioration. Protection of the airway and ventilatory assistance are often needed. Administration of thiamine (at least 100 milligrams [mg]), glucose, and an opioid antagonist is suggested when the cause of coma is not immediately known.

Expressive aphasia (Broca's) Exam 2

The inability to produce language ( despite being able to understand language)-A disturbance in which the individual knows what he/she wants to say but cannot say it

What are the three signs of Cushing's Triad that indicate that the pressure in the brain is increasing? a. Hypotension, hypoventilation, bradycardia b. Hypertension, disordered breathing, bradycardia c. Hypertension, hypoventilation, tachycardia d. Hypotension, disordered breathing, tachycardia

b. Hypertension, disordered breathing, bradycardia Rationale: Cushing's triad refers to a classic presentation of increased ICP/intracranial hypertension. The triad is identified as the presence of hypertension, bradycardia, and respiratory depression/disordered breathing.

Apraxia Exam 2

impaired ability to carry out motor activities despite intact motor function