Neuro- Nursing 201

A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last? A. Up to 2 weeks B. 1 to 3 days C. Up to 1 week D. Up to 24 hours

B. 1 to 3 days Rationale: The acute phase of an ischemic stroke may last 1 to 3 days, but ongoing monitoring of all body systems is essential as long as the patient requires care.

An emergency department nurse understands that a 110-lb (50-kg) recent stroke victim will receive at least the minimum dose of recombinant tissue plasminogen activator (t-PA). What minimum dose will the client receive? A. 90 mg B. 45mg C. 50mg D. 85 mg

B. 45mg Rationale: The client is weighed to determine the dose of t-PA. Typically, two or more IV sites are established prior to administration of t-PA (one for the t-PA and the other for administration of IV fluids). The dosage for t-PA is 0.9 mg/kg, with a maximum dose of 90 mg. 50 kg X 0.9 mg= 45 mg dose

A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mm Hg and the ICP is 18 mm Hg; therefore his cerebral perfusion pressure (CPP) is: A. 88 mm Hg. B. 52 mm Hg. C. 68 mm Hg. D. 48 mm Hg.

B. 52 mm Hg Rationale: To determine CPP, subtract the ICP from the mean arterial pressure (MAP). The MAP is derived using the following formula using the diastolic pressure (DP) and systolic pressure (SP): MAP = DP + 1/3(SP - DP) In this case MAP = 60 mm Hg + 1/3(90 mm Hg - 60 mm Hg) = 70 mm Hg CPP = MAP - ICP CPP = 70 mm Hg - 18 mm Hg = 52 mm Hg

Which of the following is the most common side effect of tissue plasminogen activator (tPA)? A. Headache B. Bleeding C. Increased intracranial pressure (ICP) D. Hypertension

B. Bleeding Rationale: Bleeding is the most common side effect of tPA. The patient is closely monitored for bleeding (at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness). Headache, increased ICP, and hypertension are not side effects of tPA.

At which of the following spinal cord injury levels does the patient have full head and neck control? A. C2 B. C5 C. C4 D. C3

B. C5 Rationale: At the level of C5, the patient should have full head and neck control, shoulder strength, and elbow flexion. At C4 injury, the patient will have good head and neck sensation and motor control, some shoulder elevation, and diaphragm movement. At C2 to C3, the patient will have head and neck sensation, some neck control, and can be independent of mechanical ventilation for short periods of time.

Which are characteristics of autonomic dysreflexia? A. severe hypotension, slow heart rate, anxiety, dry skin B. severe hypertension, slow heart rate, pounding headache, sweating C. severe hypotension, tachycardia, nausea, flushed skin D. severe hypertension, tachycardia, blurred vision, dry skin

B. severe hypertension, slow heart rate, pounding headache, sweating Rationale: Autonomic dysreflexia is an exaggerated sympathetic nervous system response. Hypertension, tachycardia, bradycardia, and flushed skin would occur

A nurse is preparing to conduct a complete community assessment survey. Which data should the nurse collect as part of this assessment? (SATA) A. Ethnicity of Community Members B. Individuals who hold the power in the community C. Natural community boundaries D. Prevalence of disease E. Presence of public protection

A,B,C,D, & E

While stopped at a stop sign, a patient's car was struck from behind by another vehicle. The patient sustained a cerebral contusion and was admitted to the hospital. During what time period after the injury will the effects of injury peak? A. 18-36 hours B. 48- 72 hours C. 12-24 hours D. 6-8 hours

A. 18-36 hours Rationale: Contusions are characterized by loss of consciousness associated with stupor and confusion. Other characteristics can include tissue alteration and neurologic deficit without hematoma formation, alteration in consciousness without localizing signs, and hemorrhage into the tissue that varies in size and is surrounded by edema. The effects of injury (hemorrhage and edema) peak after about 18 to 36 hours.

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? A. Vasopressin B. Phenobarbital C. Furosemide (Lasix) D. Mannitol

A. Vasopressin Rationale: Manipulation of the posterior pituitary gland during surgery may produce transient diabetes insipidus of several days' duration (Hickey, 2009). It is treated with vasopressin but occasionally persists.

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? A. Administering a stool softener as ordered B. Suctioning the client once each shift C. Encouraging oral fluid intake D. Elevating the head of bed 90 degrees

A. Administering a stool softener as ordered. Rationale: To prevent the client from straining at stool, which may cause a Valsalva maneuver that increases ICP, the nurse should institute a regular bowel program that includes use of a stool softener. For a client at risk for increased ICP, the nurse should prevent, not encourage, oral fluid intake and should elevate the head of the bed only 30 degrees. Suctioning, indicated for a client with lung congestion, isn't necessary for this client.

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as? A. An intracerebral hematoma B. A subdural hematoma C. An epidural hematoma D. An extradural hematoma

A. An intracerebral hematoma Rationale: Intracerebral hemorrhage (hematoma) is bleeding within the brain, into the parenchyma of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries). A subdural hematoma (SDH) is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid. After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura.

An older adult with mild dementia is diagnosed with a terminal illness. Which action will the nurse take to support this client's right to self-determination? A. Ask the client if there is someone who can help make decisions for treatment. B. Tell the client what treatment is needed C. Petition the court to appoint a guardian to make decisions for the client. D. Provide care based upon the specific condition.

A. Ask the client if there is someone who can help make decisions for treatment. Rationale: People with mild dementia tend to be viewed as incapable of self-determination. However, people with mild dementia may have sufficient cognitive capability to make some, but perhaps not all, decisions. A client may be able to identify a proxy decision maker and yet be unable to select specific treatment options. People with mild dementia may be competent to understand the nature and significance of different options for care and should not be told what treatment is needed as this does not support the client's self-determination. Providing care based upon the specific condition does not support the client's right to self-determination. There is no reason to petition the court to appoint a guardian at this time.

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? A. Auditory agnosia B. Visual agnosia C. Limited attention span. C. Hemiparesis

A. Auditory agnosia Rationale: Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation. Damage to motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes.

Which positions is used to help reduce intracranial pressure (ICP)? A. Avoiding flexion of the neck with use of a cervical collar B. Extreme hip flexion, with the hip supported by pillows C. Keeping the head flat, avoiding the use of a pillow D. Rotating the neck to the far right with neck support

A. Avoiding flexion of the neck with use of the cervical collar. Rationale: Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.

A nurse is preparing a presentation for a local senior citizen group about nutrition in the older adult. Which of the following recommendations would the nurse include? Select all that apply. A. Carbohydrate intake accounting for 55% of total calories consumed B.Vitamin D intake of 600 IU per day C.Fat consumption accounting for 40% or more of daily caloric intake D. Decreased protein to reduce the risk of nitrogen imbalance E. Daily calcium intake of 1200 mg

A. Carbohydrate intake accounting for 55% of total calories consumed B.Vitamin D intake of 600 IU per day E. Daily calcium intake of 1200 mg Rationale: Older adults should consume carbohydrates to supply 55% to 60% of the daily caloric intake. Those older than 50 years should have a daily calcium intake of 1200 mg and vitamin D intake of 600 IU to maintain bone health. Fats should account for no more than 30% of the daily calories, and protein may need to be increased to maintain adequate nitrogen balance.

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? A. Increased ICP B. Increase in cerebral perfusion pressure C. Infection D. Exacerbation of uncontrolled hypertension

A. Increased ICP Rationale: Increased ICP and bleeding are life threatening to the patient who has undergone intracranial surgery. An increase in blood pressure and decrease in pulse with respiratory failure may indicate increased ICP.

A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To confirm that this drug is producing its therapeutic effect, the nurse should consider which finding most significant? A. Increased urine output B. Decreased heart rate C. Decreased level of consciousness (LOC) D. Elevated blood pressure

A. Increased urine output Rationale: The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.

A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication? A. Lamictal B. Lomotil C. Lamisil D. Labetalol

A. Lamictal Rationale: Lamictal is an antiseizure medication. Its packaging was recently changed in an attempt to reduce medication errors, because this medication has been confused with Lamisil (an antifungal), labetalol (an antihypertensive), and Lomotil (an antidiarrheal).

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? A. Left-sided cerebrovascular accident (CVA) B. Completed Stroke C. Right-sided cerebrovascular accident (CVA) D. Transient ischemic attack (TIA)

A. Left-sided cerebrovascular accident (CVA) Rationale: When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.

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? A. Lioresal (Baclofen) B. Pregabalin (Lyrica) C. Diphenhydramine (Benadryl) D. Heparin

A. Lioresal (Baclofen) Rationale: Spasticity, particularly in the hand, can be a disabling complication after stroke. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity (although the effect is temporary, typically lasting 2 to 4 months) (Teasell, Foley, Pereira, et al., 2012). Other treatments for spasticity may include stretching, splinting, and oral medications such as baclofen (Lioresal).

The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)? A. Maintain cerebral perfusion pressure from 50 to 70 mm Hg B. Restrain the client, as indicated C. Administer enemas, as needed D. Position the client in the supine position

A. Maintain cerebral perfusion pressure from 50 to 70 mm Hg Rationale: The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to help control increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the client's head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation.

A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority? A. Maintenance of a patent airway B. Assessment of pupillary light reflexes C. Positioning to prevent complications D. Determination of cause

A. Maintenance of patent airway Rationale: The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.

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? A. Monro-Kellie B. Dawn phenomenon C. Hashimoto's disease D. Cushing's

A. Monro-Kellie Rationale: The Monro-Kellie hypothesis states that, because of the limited space for expansion in the skull, an increase in any one of its components causes a change in the volume of the others. Cushing's response is seen when cerebral blood flow decreases significantly. Systolic blood pressure increases, pulse pressure widens, and heart rate slows. The Dawn phenomenon is related to high blood glucose levels in the morning in clients with diabetes. Hashimoto's disease is related to the thyroid gland.

Why are IV solutions usually given at a slower rate to older adults? A. Older adults may have cardiac or renal disorders. B. Older adults may have poor skin turgor C. Older adults often find infusions painful. D. Veins of older adults tend to be rigid.

A. Older adults may have cardiac or renal disorders. Rationale: IV solutions usually are given at a slower rate to older adults because these clients usually have cardiac or renal disorders. Veins of older adults tend to be rigid and they have poor skin turgor, making venipuncture difficult; however, this factor does not affect infusion. Older adults do not find infusion more painful than other clients.

A client comes to the clinic for a follow-up visit. During the interview, the client states, "Sometimes when I have to urinate, I can't control it and do not reach the bathroom in time." The nurse suspects that the client is experiencing which type of incontinence? A. Urge B. Functional C. Stress D. Overflow

A. Urge Rationale: Urge incontinence occurs when the client experiences the sensation to void but cannot control voiding in time to reach a toilet. Stress incontinence occurs when the client has an involuntary loss of urine that results from a sudden increase in intra-abdominal pressure. Overflow incontinence occurs when the client experiences an involuntary loss of urine related to an over distended bladder; the client voids small amounts frequently and dribbles. Functional incontinence occurs when the client has function of the lower urinary tract but cannot identify the need to void or ambulate to the toilet.

A nurse is caring for a client with a history of severe migraines. The client has a medical history that includes asthma, gastroesophageal reflux disease, and three pregnancies. Which medication does the nurse anticipate the physician will order for the client's migraines? A. Verapamil (Calan) B. Carvedilol (Coreg) C. Metoprolol (Lopressor) D. Amiodarone (Cordarone)

A. Verapamil (Calan) Rationale: Calcium channel blockers, such as verapamil, and beta-adrenergic blockers, such as metoprolol, are commonly used to treat migraines because they help control cerebral blood vessel dilation. Calcium channel blockers, however, are ordered for clients who may not be able to tolerate beta-adrenergic blockers, such as those with asthma. Amiodarone and carvedilol aren't used to treat migraines.

A client is experiencing severe pain related to increased ICP. Which analgesic would be ordered for this client to help alleviate pain? A. codeine B. morphine C. hydrocodone D. fentanyl

A. codeine Rationale: Avoid administering opioid analgesics, except codeine. Opioids interfere with accurate assessment of neurologic function because they constrict the pupils and depress LOC.

A client with Alzheimer's disease is prescribed donepezil hydrochloride. When teaching the client and family about this drug, which of the following would the nurse include? A."The drug helps to control the symptoms of the disease." B. This drug will help to stop the disease from getting worse." C. "The client need to take this drug for the rest of his or her life." D. "Once it becomes effective, you can stop the drug."

A."The drug helps to control the symptoms of the disease." Rationale: Donepezil hydrochloride is a cholinesterase inhibitor used to control symptoms of Alzheimer's disease. It does not cure or slow progression. Typically cognitive ability improves within 6 to 12 months of therapy, but if stopped, cognitive progression occurs. It is recommended that treatment continue at least through the moderate stage of the illness. However, it usually is not prescribed as life-long therapy.

A family member brings a 76-year-old client to the clinic, stating that the client has had two transient ischemic attacks (TIAs) in the past week. The health care provider orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option(s) does the nurse expect the health care provider to offer this client to increase blood flow to the brain? Select all that apply. A. Administration of tissue plasminogen activator B. Carotid endarterectomy C. Percutaneous transluminal coronary artery angioplasty D. Balloon angioplasty of the carotid artery followed by stent placement E. Removal of the carotid artery

B. Carotid endarterectomy D. Balloon angioplasty of the carotid artery followed by stent placement Rationale: If narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a carotid endarterectomy (surgical removal of atherosclerotic plaque) could be performed. A balloon angioplasty of the carotid artery, a procedure similar to a percutaneous transluminal coronary artery angioplasty, may be performed alternatively to dilate the carotid artery and increase blood flow to the brain, followed by stent placement. The other options are not options to increase blood flow through the carotid artery to the brain.

The community nurse should be aware that community members exposed to Anthrax will need access to which medication? A. Metronidazole B. Ciprofloxacin C. Zanamivir C. Fluconazole

B. Ciprofloaxcin Rational: Prophylactic treatment for Anthrax. Also used for UTIs. Metronidazole - used to treat trichomoniasis, skin infections, and septicemia Ciprofloxacin - Prophylactic treatment for Anthrax Zanamivir - used to treat influenza Fluconazole - used to treat fungal infections, such as candidiasis

Which stage of shock is characterized by normal blood pressure? A. Initial B. Compensatory C. Progressive D. Irreversible

B. Compensatory Rationale: In compensatory stage, BP remains within normal limits. In the second stage of shock, the mechanisms that regulate BP can no longer compensate and the MAP falls below normal limits. Patients are clinically hypotensive; this is defined as systolic BP of less than 90 mm Hg or a decrease in systolic BP of 40 mm Hg from baseline. The irreversible stage of shock represents the point along the shock continuum at which organ damage is so severe the patient does not respond to treatment and cannot survive. Despite treatment BP remains low

A 24-year-old female rock climber is brought to the emergency department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond? A. Contusions occur when the brain is jarred and bounces off the skull on the opposite side from the blow. B. Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue. C. Contusions are deep brain injuries. D. Contusions are microscopic brain injuries.

B. Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue. Rationale: Contusions result in bruising, and sometimes, hemorrhage of superficial cerebral tissue. When the head is struck directly, the injury to the brain is called a coup injury. Dual bruising can result if the force is strong enough to send the brain ricocheting to the opposite side of the skull, which is called a contrecoup injury. Edema develops at the site of or in areas opposite to the injury. A skull fracture can accompany a contusion. Therefore the other options are incorrect.

The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop? A. Damage to the vagal nerve B. Damage to the optic nerve C. Damage to the facial nerve D. Damage to the olfactory nerve

B. Damage to the optic nerve Rationale: Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing. Sequelae to meningitis do not include damage to the vagal nerve, the olfactory nerve or the facial nerve.

An older adult has lost 10% of body weight because of diet changes and exercise. The nurse would provide anticipatory guidance regarding dosage changes in which of the client's daily medications based on this weight loss? A. Acetaminophen B. Diazepam C. Vitamin B and C supplements D. Aspirin

B. Diazepam Rationale: Some medications are affected by the percentage of body fat. Even though the client has lost 10% of total body weight, the proportion of body fat increases with age, resulting in an increased ability to store fat-soluble medications, increased accumulation of the drug in the body, and delayed excretion. Medications affected include diazepam. Aspirin and acetaminophen are not among the fat-soluble medications affected by percentage of body fat. Vitamin B and C supplements are water-soluble vitamins and would not be affected by the percentage of body fat.

How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)? A. Every 45 minutes B. Every 15 minutes C. Every hour D. Every 30 minutes

B. Every 15 minutes Rationale: Neurological assessment and vital signs (except temperature) should be taken every 15 minutes initially while the patient is receiving tPA infusion.

During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect? A. Ataxia B. Gingival hyperplasia C. Diplopia D. Alopecia

B. Gingival Hyperplasia Rationale: Side-effects of dilantin include visual problems, hirsutism, gingival hyperplasia, arrhythmias, dysarthria, and nystagmus.

An older adult who is scheduled for the annual influenza vaccination has yet to receive the pneumococcal vaccination. Which action will the nurse take when the client is prescribed to receive both vaccinations? A. Give the pneumococcal vaccine first and schedule the client to return the next day for the influenza vaccine. B. Give the client the influenza vaccine first and then administer the pneumococcal vaccine in another site. C.Mix the vaccines in a syringe before administering as one injection in order to minimize client discomfort. D. Give the influenza vaccine and schedule the client to return in a week for the pneumococcal vaccine.

B. Give the client the influenza vaccine first and then administer the pneumococcal vaccine in another site. Rationale: Influenza and pneumococcal vaccinations lower the risks of hospitalization and death in older adults. The influenza vaccine, which is prepared yearly to adjust for the specific immunologic characteristics of the influenza viruses at that time, should be given annually in autumn. The pneumococcal vaccine should be administered as recommended. Both of these injections can be received at the same time in separate injection sites. The vaccines are not mixed to be given as one injection. There is no reason for the client to return later to receive either the pneumococcal or influenza vaccinations.

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? A. Restricts protein to 10% of daily caloric intake B. High protein and low in carbohydrate C. Low fat D. At least 50% carbohydrate

B. High protein and low in carbohydrate Rationale: A dietary intervention, referred to as the ketogenic diet, may be helpful for control of seizures in some patients. This high-protein, low-carbohydrate, high-fat diet is most effective in children whose seizures have not been controlled with two antiseizure medications, but it is sometimes used for adults who have had poor seizure control

An older adult voids a small amount of urine in the toilet but experiences a large volume of incontinence while walking back to the bed. Which nursing intervention would be appropriate for this client? A. Remind the client to verbalize toileting needs. B. Implement a prompted, timed voiding schedule. C. Provide education about medications to treat this problem. D. Show disapproval to help prevent reoccurence.

B. Implement a prompted, timed voiding schedule. Rationale: Detrusor hyperactivity with impaired contractility is a type of urge incontinence that is seen predominantly in the older adult population. In this variation of urge incontinence, clients have no warning that they are about to urinate. They often void only a small volume of urine or none at all and then experience a large volume of incontinence after leaving the bathroom. Nurses should be familiar with this form of incontinence and plan for routine toileting times with these clients, including the implementation of a prompted, timed voiding schedule. Intermittent catheterization may also be necessary because of postvoid residual urine volumes. Showing disapproval or reminding the client to verbalize toileting needs would be inappropriate actions for this type of incontinence, as the client has no warning they are about to urinate. Medications do exist to treat some forms of incontinence; however, the adverse affects associated with these medications usually make them inappropriate choices for older adults.

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? A. A bounding pulse B. Lethargy and stupor C. Bradycardia D. Hypertension

B. Lethargy and stupor Rationale: As ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli. At this stage, serious impairment of brain circulation is probably taking place, and immediate intervention is required.

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? A. Hemiplegia or hemiparesis B. Limited attention span and forgetfulness C. Lack of deep tendon reflexes D. Visual and auditory agnosia

B. Limited attention span and forgetfulness Rationale: Damage to the frontal lobe may impair learning capacity, memory, or other higher cortical intellectual functions. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation. Damage to the motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes. Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia.

Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply. A. Elevating the head of the bed to 90 degrees B. Maintaining aseptic technique with an intraventricular catheter C. Encouraging deep breathing and coughing every 2 hours D. Administering prescribed antipyretics E. Frequent oral care

B. Maintaining aseptic technique with an intraventricular catheter D. Administering prescribed antipyretics E. Frequent oral care Rationale: Controlling fever is an important intervention for a client with increased ICP because fevers can cause an increase in cerebral metabolism and can lead to cerebral edema. Antipyretics are appropriate to control a fever. It is imperative that the nurse use aseptic technique when caring for the intraventricular catheter because of its risk for infection. Oral care should be provided frequently because the client is likely to be placed on a fluid restriction and will have dry mucous membranes. A nondrying oral rinse may be used. Coughing should be discouraged in a client with increased ICP because it increases intrathoracic pressure, and thus ICP. Unless contraindicated, the head of the bed should be elevated to 30 to 45 degrees and in a neutral position to allow for venous drainage.

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? A. Carotid ultrasound study B. Noncontrast computed tomogram C. Transcranial Doppler flow study D. 12-lead electrocardiogram

B. Noncontrast computed tomogram Rationale: The initial diagnostic test for a stroke is usually a noncontrast computed tomography (CT) scan. This should be performed within 25 minutes or less from the time the patient presents to the emergency department (ED) to determine if the event is ischemic or hemorrhagic (the category of stroke determines treatment).

Which lobe is responsible for interpreting tactile sensations such as pain and temperature? A. Frontal B. Parietal C. Occipital D. Temporal

B. Parietal Rationale: The parietal lobe interprets tactile sensations. The frontal lobe directs voluntary, skeletal actions, communication, emotions, intellect, judgment, and so on. The occipital lobe is the primary visual receptor center. The temporal lobe receives and interprets impulses from the ear.

A client with meningitis has a history of seizures. Which should the nurse do to safely manage the client during a seizure? Select all that apply. A. Inspect the oral cavity and teeth. B. Provide verbal reassurance C. Physically restrain the client's movements. D. Turn the client to the side

B. Provide verbal reassurance D. Turn the client to the side Rationale: Turning client to the side will allow accumulated saliva to drain from the mouth. The person may not be able to hear you while unconscious, but verbal assurances will help as the person is regaining consciousness. Physically restraining a client during a seizure increases the potential for injuries. Inspection of oral cavity occurs after a generalized seizure and not during a seizure.

Which term refers to inflammation of the renal pelvis? A. Interstitial nephritis B. Pyelonephritis C. Urethritis D. Cystitis

B. Pyelonephritis Rationale: Pyelonephritis is an upper urinary tract inflammation, which may be acute or chronic. Cystitis is inflammation of the urinary bladder. Urethritis is inflammation of the urethra. Interstitial nephritis is inflammation of the kidney.

When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP? A. Hypertension and narrowing pulse pressure B. Rising blood pressure and bradycardia C. Hypotension and tachycardia D. Hypotension and bradycardia

B. Rising blood pressure and bradycardia Rationale: Late cardiovascular indicators of increased ICP include rising blood pressure, bradycardia, and widening pulse pressure — known collectively as Cushing's triad. Increased ICP usually causes a bounding pulse; as death approaches, the pulse becomes irregular and thready.

The nurse has just received report on a client in the ED being transferred to the acute stroke unit with a diagnosis of a right hemispheric stroke. Which findings does the nurse understand is indicative of a right hemispheric stroke? A. Altered intellectual ability B.Spatial-perceptual deficits

B. Spatial-perceptual deficits Rationale: Clients with right hemispheric stroke exhibit partial perceptual deficits, left visual field deficit, and paralysis with weakness on the left side of the body. Left hemispheric damage causes aphasia, slow, cautious behavior, and altered intellectual ability.

The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern? A. Pulse oximetry decrease from 99% to 97% room air B. Temperature increase from 98.0°F to 99.6°F C. Urinary output increase from 40 to 55 mL/hr D. Heart rate decrease from 100 to 90 bpm

B. Temperature increase from 98.0°F to 99.6°F Rationale: Fever in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the client's temperature every 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia. The other clinical findings are within normal limits.

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value? A. The CPP is high B. The CPP is low C. The CPP is within normal limits D. The CPP is inaccurate

B. The CPP is low Rationale: The normal CPP is 70 to 100 mm Hg. Therefore, a CPP of 40 mm Hg is low. Changes in intracranial pressure (ICP) are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage.

The nurse advises a patient with renal stones to avoid eating shellfish, asparagus, and organ meats. She emphasizes these foods because she knows that his renal stones are composed of which of the following substances? A. Calcium B. Uric Acid C. Struvite D. Cystine

B. Uric Acid Rationale: Uric acid stones are found in patients with gout and myeloproliferative disorders. Therefore, a diet low in purines is recommended.

The nurse recognizes health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle, including A. eating fish no more than once a month. B. a low-fat, low-cholesterol diet and increased exercise. C. a high-protein diet and increased weight-bearing exercise D. a low-cholesterol, low-protein diet and decreased aerobic exercise

B. a low-fat, low-cholesterol diet and increased exercise Rationale: Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle, including a low-fat, low-cholesterol diet and increased exercise. Recent evidence suggests that eating fish two or more times per week reduces the risk of thrombotic stroke for women

The nurse is caring for a client who has a type of urinary diversion that requires an external ostomy bag to collect the urine. This client has: A. a cystectomy B. an incontinent urinary diversion. C. a urethroplasty. D. a continent urinary diversion.

B. an incontinent urinary diversion Rationale: An incontinent urinary diversion requires an external ostomy bag to collect the urine. A continent urinary diversion is the creation of a reservoir within the body for urine collection. The reservoir is catheterized to drain urine. Urethroplasty is a surgical repair of the urethra. Cystectomy is a surgical removal of the bladder and is performed for large tumors that have penetrated the muscle wall.

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? A. cryptogenic B. cardio embolic C. large-artery thrombotic D. small, penetrating artery thrombotic

B. cardio embolic Rationale: Ischemic strokes are further divided into five subtypes, according to a mechanism-based classification system: large-artery thrombotic strokes (representing 20% of ischemic strokes); small, penetrating artery thrombotic strokes (25%); cardio embolic strokes (20%); cryptogenic strokes (strokes that cannot be attributed to any specific cause) (30%); and "other" (5%). Large-artery thrombotic strokes are caused by atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion can occur at the site of the atherosclerosis and result in ischemia and infarction (tissue death). Small, penetrating artery thrombotic strokes that affect one or more vessels and cause reduced blood flow are the most common type of ischemic stroke, typically caused by longstanding hypertension, hyperlipidemia, or diabetes. Cardio embolic strokes are associated with cardiac dysrhythmias, such as atrial fibrillation, but can also be associated with valvular heart disease or left ventricular thrombus. The last two classifications of ischemic strokes are cryptogenic strokes, which have no identified cause, and strokes from other causes, such as illicit drug use (cocaine), coagulopathies, migraine, or spontaneous dissection of the carotid or vertebral arteries.

For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to: A. lower arterial pH. B. promote carbon dioxide elimination. C. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg. D. prevent respiratory alkalosis.

B. promote carbon dioxide elimination Rationale: The goal of treatment for ICP is to prevent acidemia by eliminating carbon dioxide because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this client. It isn't necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients.

Which is a true statement regarding pharmacologic aspects of aging? A. Elderly have a decreased percentage of body fat. B. Potential for drug-drug reactions decreases with the number of drugs prescribed. C. Absorption may be affected by changes in gastric pH. D. Medication compliance is a single-faceted issue among the elderly.

C. Absorption may be affected by changes in gastric pH. Rationale: During the aging process, absorption may be affected by changes in gastric pH. The elderly have an increased percentage of body fat. The potential for drug-drug interaction increases with the number of drugs prescribed. The aged population tends to be less compliant with their medication regimen because of several factors, such as cost, vision changes, mobility issues, and education.

The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention? A. Assess for weight loss. B. Give acetaminophen per orders. C. Administer corticosteroids as ordered. D. Document signs and symptoms of inflammation.

C. Administer corticosteroids as ordered Rationale: Cranial arteritis is caused by inflammation, which can lead to visual impairment or rupture of the vessel. Administering the corticosteroid as ordered can decrease the chance of losing vision or vessel rupture. The client should receive an analgesic (acetaminophen) for the pain, but the corticosteroid should help decrease the pain and prevent complications. The nurse should assess for weight loss, but that can be determined after the medication is administered. Signs and symptoms of inflammation should be documented by the nurse after measures have been taken to decrease complications.

The nurse is aware that burr holes may be used in neurosurgical procedures. Which of the following is a reason why a neurosurgeon may choose to create a burr hole in a patient? A. Access for intravenous (IV) fluids B. To assess visual acuity C. Aspiration of a brain abscess D. Visualization of a hemorrhage

C. Aspiration of a brain abscess Rationale: Burr holes may be used in neurosurgical procedures to make a bone flap in the skull, to aspirate a brain abscess, or to evacuate a hematoma.

When administering medications to an older adult patient, which medication does the nurse understand may remain in the body longer due to increased body fat? A. Anticoagulants B. Diuretics C. Barbiturates D. Digitalis glycosides

C. Barbiturate Rationale: Proportion of body fat increases with age, resulting in increased ability to store fat-soluble medications, including barbiturates; this causes drug accumulation, prolonged storage, and delayed excretion. The other medications listed are not fat-soluble.

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? A. Elevated no more than 10 degrees B. Turned onto the operative side C. Elevated 30 degrees D. Flat

C. Elevated 30 degrees Rationale: After supratentorial surgery, the nurse should elevate the client's head 30 degrees to promote venous outflow through the jugular veins. The nurse would keep the client's head flat after infratentorial, not supratentorial, surgery. However, after supratentorial surgery to remove a chronic subdural hematoma, the neurosurgeon may order the nurse to keep the client's head flat; typically, the client with such a hematoma is older and has a less expandable brain. A client without a bone flap can't be positioned with the head turned onto the operative side because doing so may injure brain tissue. Elevating the head 10 degrees or less wouldn't promote venous outflow through the jugular veins.

A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. While assessing the client, the nurse expects which of the following findings? A. Oliguria and decreased urine osmolality B. Oliguria and serum hyperosmolarity C. Excessive urine output and decreased urine osmolality D. Excessive urine output and serum hypo-osmolarity

C. Excessive urine output and decreased urine osmolarity Rationale: Diabetes insipidus is the result of decreased secretion of antidiuretic hormone (ADH). The client has excessive urine output, decreased urine osmolality, and serum hyperosmolarity.

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? A. Ischemic Stroke B. Systolic blood pressure less than or equal to 185 mm Hg C. Intracranial hemorrhage D. Age 18 years or older

C. Intracranial hemorrhage Rationale: Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA. Clinical diagnosis of ischemic stroke, age 18 years or older, and a systolic blood pressure less than or equal to 185 mm Hg are eligibility criteria.

An elderly female client has been taking prednisone for breathing problems for many years. The nurse notes that the client's current height is 64 inches. Two years ago, her height was 66 inches. The nurse assesses this loss in height is most likely the result of A. Decreased muscle mass and joint cartilage B. Degeneration in the efficiency of bone joints C. Loss of bone density D. The client's failure to exercise

C. Loss of bone density Rationale: Elderly clients experience decreased bone density; they also may experience a loss of bone density from insufficient exercise. For this client, however, additional information indicates that she is taking prednisone, which may induce osteoporosis (loss of bone density). No information indicates that the client is not exercising or has experienced degeneration of bone joints. Degeneration in the efficiency of the bone joints and decreased muscle mass and joint cartilage would have more of an effect on increased pain than on decreased height.

A client with a T4-level spinal cord injury (SCI) reports severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp and suspects autonomic dysreflexia. What is the first thing the nurse will do? A. Notify the physician. B. Lay the client flat. C. Place the client in a sitting position. D. Apply antiembolic stockings.

C. Place the client in sitting position Rationale: The nurse immediately places the client in a sitting position to lower blood pressure. Next, the nurse will do a rapid assessment to identify and alleviate the cause, and then check the bladder and bowel. The nurse will examine skin for any places of irritation. If no cause can be found, the nurse will give an antihypertensive as ordered and continue to look for cause. He or she watches for rebound hypotension once cause is alleviated. Antiembolic stockings will not decrease the blood pressure.

A department of nursing within a health care organization is adopting the Functional Consequences Theory when caring for older adults. Which action would the nurse take to facilitate using this theory when caring for a client? A. Establish improvement of cognitive function as the overall goal of care. B. Identify reasons for changes in musculoskeletal function. C. Plan interventions to address consequences of age-related changes. D. Recognize that immune system changes cannot be altered.

C. Plan interventions to address consequences of age-related changes. Rationale: The Functional Consequences Theory encourages nurses to consider the effects of normal age-related changes and the damage caused by disease or environment and behavioral risk factors when planning care. This theory suggests that nurses can alter the outcome for clients through nursing interventions that address the consequences of these changes. The Functional Consequences Theory does not focus specifically on musculoskeletal function, immunity, or cognitive functioning.

When caring for a patient in hypovolemic shock who is receiving large volumes of IV isotonic fluids, the nurse should monitor symptoms of? A. Hyperthermia B. Pain C. Pulmonary edema D. Tachycardia

C. Pulmonary Edema Rationale: The nurse should monitor for circulatory overload and pulmonary edema when large volumes of fluids are administered intravenously. Hypothermia may occur with large volumes of fluids that are not warmed Pain would not be seen in hypovolemic shock, but may occur with cardiogenic shock Tachycardia would be expected in hypovolemic shock

When assessing an older adult, the nurse anticipates an increase in which component of respiratory status? A. Gas exchange and diffusing capacity B. Vital capacity C. Residual lung volume D. Cough efficiency

C. Residual lung volume Rationale: With an increase in residual lung volume the client experiences fatigue and breathlessness with sustained activity. The nurse anticipates decreased vital capacity. The nurse anticipates decreased gas exchange and diffusing capacity resulting in impaired healing of tissues due to decreased oxygenation. The nurse anticipates difficulty coughing up secretions due to decreased cough efficiency.

Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch? A. Akathisia B. Ataxia C. Spasticity D. Myoclonus

C. Spasticity Rationale: Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes. Akathisia refers to restlessness, an urgent need to move around, and agitation. Ataxia refers to impaired ability to coordinate movement. Myoclonus refers to spasm of a single muscle or group of muscles.

The following information is documented on the assessment form for an older adult: Kyphosis Dry mucous membranes Decreased respiratory excursion Urinary incontinence The nurse is reviewing the information and reports which finding to the physician? A. Dry mucous membranes B. Kyphosis C. Urinary incontinence D. Decreased respiratory excursion

C. Urinary incontinence Rationale: Urinary incontinence is not a normal age-related change. Kyphosis, dry mucous membranes, and decreased respiratory excursion are considered normal age-related changes.

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to A. control shivering. B. control fever C. dehydrate the brain and reduce cerebral edema. D. reduce cellular metabolic demand

C. dehydrate the brain and reduce cerebral edema Rationale: Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid. Antipyretics and a cooling blanket are used to control fever in the client with increased ICP. Chlorpromazine may be prescribed to control shivering in the client with increased ICP. Medications such as barbiturates are given to the client with increased ICP to reduce cellular metabolic demands.

A client diagnosed with a stroke is ordered to receive warfarin. Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is A. dipyridamole. B. ticlopidine C. clopidogrel. D. aspirin.

D. aspirin Rationale: If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.

A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is higher than: A. 190 mm Hg/120 mm Hg B. 175 mm Hg/100 mm Hg C. 170 mm Hg/105 mm Hg D. 185 mm Hg/110 mm Hg

D. 185 mm Hg/110 mm Hg Rationale: Elevated blood pressure (systolic >185; diastolic >110 mm Hg) is a contraindication to tPA.

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? A. 8.3 mg B. 7.5 mg C. 10 mg D. 6.3 mg

D. 6.3 mg Rationale: A person who weighs 154 lbs weighs 70 kg. To calculate total dosage, multiply 70 × 0.9 mg/kg = 63 mg. Ten percent of the calculated dose is given as an IV bolus over 1 minute. The remaining dose (90%) is given IV over 1 hour via an infusion pump. So initially the nurse gives 10% (6.3 mg) over 1 minute.

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? A. 60 mm Hg B. 50 mm Hg C. 80 mm Hg D. 70 mm Hg

D. 70 mm Hg Rationale: Changes in ICP are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). For example, if the MAP is 100 mm Hg and the ICP is 15 mm Hg, then the CPP is 85 mm Hg. The normal CPP is 70 to 100 mm Hg (Hickey, 2009).

Which is a late sign of increased intracranial pressure (ICP)? A.Slowed Speech. B. Irritability C. Headache D. Altered respiratory patterns

D. Altered Respiratory patterns Rationale: Altered respiratory patterns are late signs of increased ICP and may indicate pressure or damage to the brainstem. Headache, irritability, and any change in LOC are early signs of increased ICP. Speech changes, such as slowed speech or slurring, are also early signs of increased ICP.

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode? A. Recent stress level B. Recent weight gain or loss C. The type of anticonvulsant prescribed to manage the epileptic condition D. Compliance with the prescribed medication regimen

D. Compliance with prescribed medication regimen Rationale: The most common cause of status epilepticus is sudden withdraw of anticonvulsant therapy. The type of medication prescribed, the client's stress level, and weight change don't contribute to this condition.

The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop? A. Damage to the facial nerve B. Damage to the olfactory nerve C. Damage to the vagal nerve D. Damage to the optic nerve

D. Damage to the optic nerve Rationale: Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing. Sequelae to meningitis do not include damage to the vagal nerve, the olfactory nerve or the facial nerve.

A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes? A. Decreased norepinephrine level B. Increased norepinephrine level C. Increased acetylcholine level D. Decreased acetylcholine level

D. Decreased acetylcholine level

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? A. Lack of deep tendon reflexes B. Hemiplegia or hemiparesis C. Visual and auditory agnosia D. Limited attention span and forgetfulness

D. Limited attention span and forgetfulness Rationale: Damage to the frontal lobe may impair learning capacity, memory, or other higher cortical intellectual functions. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation. Damage to the motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes. Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia.

Which condition occurs when blood collects between the dura mater and arachnoid membrane? A. Epidural hematoma B. Intracerebral hemorrhage C. Extradural hematoma D. Subdural hematoma

D. Subdural hematoma Rationale: A subdural hematoma is a collection of blood between the dura mater and brain, space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with the displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hematoma.

A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize? A. "You must lie flat for 24 hours after surgery." B. "You must report ringing in your ears immediately." C. "You must restrict your fluid intake." D. "You must avoid coughing, sneezing, and blowing your nose."

D. You must avoid coughing, sneezing, and blowing your nose. Rationale: After a transsphenoidal hypophysectomy, the client must refrain from coughing, sneezing, and blowing the nose for several days to avoid disturbing the surgical graft used to close the wound. The head of the bed must be elevated, not kept flat, to prevent tension or pressure on the suture line. Within 24 hours after a hypophysectomy, transient diabetes insipidus commonly occurs; this calls for increased, not restricted, fluid intake. Visual, not auditory, changes are a potential complication of hypophysectomy.

Which of the following is a potential cause of transient incontinence? Select all that apply. Stool impaction Atrophic vaginitis Delirium Restricted activity Infection of urinary tract

Potential causes of transient incontinence include delirium, restricted activity, infection of the urinary tract, atrophic vaginitis, and stool impaction.

The earliest sign of increasing ICP is a change in LOC. True or false?

True Rationale: Earliest sign of increasing ICP is a change in LOC. Slowing of speech and delay in response to verbal suggestions are other early indicators

The Sympathetic Nervous System is activated during Stress? True or False?

True: Rationale: The sympathetic nervous system is activated during stress and elicits responses such as decreased gastric secretions, bronchiole dilation, increased pupil rate, and pupil dilation