Neuro Practice Questions

how long after having stroke so you have to get a CT?

20 min - do immediately

The school nurse notes a 6-year-old running across the playground with friends. The child stops in mid-stride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child? An absence seizure A complex seizure A partial seizure A tonic-clonic seizure

An absence seizure; Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness, during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. A generalized seizure involves the whole brain.

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? Visualization of a hemorrhage Aspiration of a brain abscess Access for intravenous (IV) fluids To assess visual acuity

Aspiration of a brain abscess; 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.

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

Avoiding flexion of the neck with use of a cervical collar; 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 client with a history of epilepsy has consecutive seizures lasting more than 5 minutes and is in status epilepticus. Which intervention should be included in this client's immediate treatment? Select all that apply a. Administer dexamethasone IV b. Administer oxygen and prepare for endotracheal intubation c. Prepare for immediate defibrillation d. Continue to protect the patient from injury e. Administer lorazepam IV Transfer to a facility with expertise in treating status epilepticus

B, D,E- medical emergency Ativan to stop seizure.

The client is in status epilepticus. Which interventions should be included in the client's immediate treatment? (Select all that apply) A. Administer dexamethasone intravenously B. Give oxygen and prepare for endotracheal intubation C. Obtain a defibrillator and prepare to use it immediately D. Remove nearby objects to protect the client from injury E. Administer lorazepam intravenously STAT

B,D,E; Status epilepticus is a medical emergency that increases the risk for brain hypoxia and permanent brain damage. The client will need additional oxygen and intubation secures the airway. Care should be taken to protect the client from injury during the seizure. Benzodiazepines (specifically lorazepam or diazepam) are administered initially to terminate the seizure because they can be administered more rapidly than phenytoin. Defibrillation is not indicated unless the client goes into ventricular fibrillation. Dexamethasone is an anti-inflammatory corticosteroid and is not indicated in status epilepticus.

The nurse is planning care for the client with a stage II pressure ulcer on the ball of the right foot. Which interventions should the nurse include in this client's plan of care? (Select all that apply) A. Obtain cultures of the wound daily B. Clean vigorously to remove dead tissue C. Cover with a protective dressing D. Reposition at least every 2 hours E. Elevate the right heel completely off the bed

C,D,E; Daily wound cultures are unnecessary since all wounds have bacteria. Only cleanse gently to prevent further trauma and encourage the building of granulation tissue. Covering the wound assists in keeping the wound bed moist, which promotes healing. Pressure ulcers left open to air are exposed to more contamination and potential injury. Clients should be turned at least every 2 hours (more quickly if tissue is compromised). Positioning devices help to keep the load/pressure off the wounds.

Which is the earliest sign of increasing intracranial pressure? Vomiting Change in level of consciousness Headache Posturing

Change in level of consciousness; The earliest sign of increasing intracranial pressure (ICP) is a change in level of consciousness. Other manifestations of increasing ICP are vomiting, headache, and posturing.

ventriculostomy is used to surgicaly treat what?

Cushing's triad(increased ICP)

The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client? Speaking loudly Establishing eye contact Avoiding the use of hand gestures Speaking in complete sentences

Establishing eye contact; The following strategies should be used by the nurse to encourage communication with a client with aphasia: face the client and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the client time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the client uses and handles an object, say what the object is. It helps to match the words with the object or action. Be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the client or make it difficult to sort out the message being spoken.

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

Every 15 minutes

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure? Jacksonian Absence Generalized Sensory

Generalized; The client typically falls to the ground, losing consciousness. The body stiffens (tonic phase) and then alternates between episodes of muscle spasm and relaxation (clonic phase). Tongue biting, incontinence, labored breathing, apnea, and cyanosis may also occur.

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

High in protein and low in carbohydrate; 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

A client is diagnosed with a traumatic brain injury. Which action will the nurse take to reduce this client's risk of increasing intracranial pressure (ICP)? Select all that apply. Keep head midline. Avoid rotation of the neck. Elevate the head 30 to 45 degrees. Assist to keep a position of hip flexion. Prevent compression of the jugular veins.

Keep head midline. Avoid rotation of the neck. Elevate the head 30 to 45 degrees Prevent compression of the jugular veins; Proper positioning helps reduce intracranial pressure (ICP). The client's head should be in a neutral or midline position. Rotation of the neck is to be avoided. Elevation of the head is to be maintained at 30 to 45 degrees. Compression of the jugular veins is to be avoided as this increases ICP. Extreme hip flexion is also avoided because this position causes an increase in intra-abdominal and intrathoracic pressures, which can produce an increase in ICP.

A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment? Limited attention span and forgetfulness Visual agnosia Lack of deep tendon reflexes Auditory agnosia

Lack of deep tendon reflexes

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? Diphenhydramine (Benadryl) Lioresal (Baclofen) Heparin Pregabalin (Lyrica)

Lioresal (Baclofen)

A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator? 50 to 100 mL/h 100 to 150 mL/h 150 to 200 mL/h More than 200 mL/h

More than 200 mL/h

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? Rising blood pressure and bradycardia Hypotension and bradycardia Hypotension and tachycardia Hypertension and narrowing pulse pressure

Rising blood pressure and bradycardia; Late cardiovascular indicators of increased ICP include rising blood pressure, bradycardia, and widening pulse pressure — known collectively as Cushing's triad

in what illness will CT/MRI be negative?

TIA

a hospitalization client diagnosed with seizures has a vagus nerve stimulation(VNS) device implanted. The nurse determines that the VNS is working properly when making which observation?

The client activates the VNS device to stop a seizure from occurring.

A client diagnosed with Huntington disease is on a disease-modifying drug regimen and has a urinary catheter in place. Which potential complication is the highest priority for the nurse while monitoring the client? Severe depression Choreiform movements Urinary tract infection Emotional apathy

Urinary tract infection

The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke? Weakness on one side of the body and difficulty with speech Severe headache and early change in level of consciousness Foot drop and external hip rotation Vomiting and seizures

Weakness on one side of the body and difficulty with speech; The main presenting symptoms for an ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; and trouble speaking or understanding speech.

Which of the following problems predisposed Jennie to develop meningitis? a muscle injury in her back a migraine HA a sore throat for 3 days vision changes

a sore throat for 3 days

the client who has expressive aphasia is having difficulty communicating with the nurse. Which action by the nurse would be most helpful? position the client facing the nurse enunciate directions very slowly use gestures and body language ask the client to point to needed objects

ask the client to point to needed objects

a burr hole, drain, or craniotomy is used to treat what complication?

herniation due to epidural hematoma

hemorrhagic transformation and cytotoxic edema are complications of what?

ischemic stroke

levodopa is used to treat what?

parkinson's disease(levodopa trial)

A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements? "A secondary headache is one for which no organic cause can be identified." "A secondary headache is located in the frontal area." "A secondary headache is associated with an organic cause, such as a brain tumor." "A migraine headache is an example of a secondary headache."

"A secondary headache is associated with an organic cause, such as a brain tumor."; A secondary headache is a symptom associated with an organic cause, such as a brain tumor or an aneurysm. A primary headache is one for which no organic cause can be identified. These types include migraine, tension, and cluster headaches. Secondary headaches can be located in all areas of the head.

A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse? "I will have progressive muscle weakness." "I will lose strength in my arms." "My children are at greater risk to develop this disease." "I need to remain active for as long as possible."

"My children are at greater risk to develop this disease."; There is no known cause for ALS, and no reason to suspect genetic inheritance. ALS usually begins with muscle weakness of the arms and progresses. The client is encouraged to remain active for as long as possible to prevent respiratory complications.

An elderly client with Parkinson's disease is prescribed levodopa and carbidopa (Sinement). Which point should a nurse include in the teaching plan for the client and spouse? a. The client is at increased risk for falls due to dizziness and orthostatic hypotension b. The client should stop taking multiple vitamins c. The medication should not be taken with food d. The medication has very few adverse effects

A- Levodopa is converted to dopamine in the CNS, serves as neurotransmitter. Carbidopa prevents Peripheral destruction of levodopa. Due t the dopamine agonist properties likely to experience dizzy and ortho hypotension= risk for falls. Many side effects= anxiety, memory loss, blurred vision, involuntary movements

The nurse overhears the client speaking with her husband about her new diagnosis of stage 1 breast cancer. Which statement by the client indicates that she does not fully understand the diagnosis? A. "I won't be here to see out daughter graduate this spring." B. "I understand that I will need either radiation or chemotherapy." C. "I will need surgery to remove the cancerous breast tissue." D. "The cancer is in an early stage and it is contained."

A; 90% of women with localized tumors (stage 1 and stage 2) can be expected to achieve long-term disease-free survival. This statement indicates she does not understand stage 1 breast cancer. Stage 1 indicates that the cancer is contained and not wide-spread.

Three days ago, the client received circumferential, partial, and full-thickness burns to 30% of the total body surface area of the chest and abdomen. The nurse monitors the client for restricted breathing due to which physiological response? A. Development of a layer of eschar B. Loss of elastin and collagen in the tissues C. Hypoxia and ischemia of the lungs' alveoli D. Fluid overload in the alveoli of the lungs

A; A layer of eschar or devitalized tissue commonly forms over partial- and full-thickness burns, which, when circumferential and when combined with increased fluid retention, can restrict circulation and lung expansion. Loss of elastin/collagen would not cause constriction (though it does occur in burns). Ischemia and hypoxia of the alveoli does not cause constriction (a mechanical process), though it does occur in inhalation burns. Fluid overload is a possibility, but unless combined with eschar formation, it will not cause mechanical constriction.

1. The nurse recognizes that patients with major changes in personality most likely have damage in which lobe of the brain? A. Frontal B. Occipital C. Parietal D. Temporal

A; The frontal lobe is responsible for voluntary motor movement, Broca's speech, personality, and behavior. The occipital lobe is primarily responsible for vision. The parietal lobe is responsible for sensory input and integration and spatial relationships. The temporal lobe is responsible for auditory sensation and perception, memory, and Wernicke's speech center.

Client Smith, a transgender woman who uses the pronouns "she/her," is on the unit status-post myocardial infarction. The nurse asks "can I get anything else for you, sir?" The client responds "I'm sorry, but my pronouns are 'she/her.'" What would be the best follow-up response for the nurse to make? A. "I'm sorry! Thank you for reminding me. Can I get anything else for you?" B. "I'm so sorry! I didn't mean to misgender you! I never make that mistake, really! That was such a horrible thing for me

A; When the nurse accidentally misgenders someone, make a brief and appropriate apology and thank the client for giving feedback. Don't belittle or ignore the client's feedback or give an excessive apology (this makes the client more uncomfortable). Use inclusive language that does not include third person pronouns (such as Mr. Mrs. sir, ma'am, etc.).

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP? Encourage coughing and deep breathing. Position the client with the head turned toward the side of the brain tumor. Administer stool softeners. Provide sensory stimulation.

Administer stool softeners; Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return. Coughing also increases ICP. Keeping the head in a midline position and avoiding extreme neck flexion prevents obstruction of venous outflow from the brain. Sensory stimulation and noxious stimuli can increase ICP.

A client seeks medical attention at an emergency department after experiencing left-sided weakness and slurred speech. The client receives a diagnosis with an ischemic stroke and is evaluated for treatment with thrombolytic therapy. Which finding would contraindicate this therapy? a. A normal CT scan of the brain b. A serious head injury 4 weeks earlier c. A history of diabetes mellitus The onset of neurological deficits 2 hours earlier

B- Risk for developing serious bleeding problems: cerebral hemorrhage. Negative ct and within 3 hours are indications to give

A nurse is caring for a group of clients on a medical unit in a rural hospital. Which client would the nurse be least likely to monitor for the potential complication of a brain abscess? a. Client with endocarditis b. Client with idiopathic epilepsy c. Client who has had a liver transplant Client with meningitis

B- brain abscess denotes collection of pus in the brain from infection. Idiopathic epilepsy has lowest risk for developing b/c an unknown cause does not have the risk of an active infection or impaired immune. A and D= infection, C=immune

Following an industrial accident in which a client sustained a severe craniocerebral trauma, the client develops the complication of diabetes insipidus (DI). A nurse suspects this complication is occurring when observing which symptom? a. Hyperglycemia b. Large amounts of urinary output c. Elevated urine specific gravity d. Decrease in level of consciousness

B- lack of ADH. Head injry can compress the pituitary gland = loss of adh. Will have diluted urine with low specific gravity. D is associated with swelling or bleeding from the trauma

The client with muscle weakness asks the nurse during the initial assessment if the symptoms suggest "Lou Gehrig's disease." Which is the nurse's most appropriate response? A. "Muscle weakness can occur from working too much. Avoid thinking the worst." B. "Tell me what has you thinking that you might have Lou Gehrig's disease." C. "Have you been having trouble remembering things along with this weakness?" D. "That is a good question. We will be doing tests to figure out what is going on."

B; Option B is the best response because it focuses on the client's concern, encourages verbalization, and solicits more information. Option A belittles the client's concerns and makes assumptions. Option C is incorrect as memory deterioration is not associated with ALS. Option D does not address the patient's concerns.

which of the following areas of the brain controls speech? left occipital lobe Broca's area midbrain brainstem

Broca's area

A nurse learns in report that a client admitted with a vertebral fracture has a halo external fixation device in place. Based on this information, for which intervention should the nurse plan? a. Ensure the weight with the traction is hanging b. Remove the vest at bedtime c. Perform pin site care Progressively loosen the pins in the skull each day

C- immobilization and stability to spinal cord

The nurse is taking care of four patients today. Patient Avery is postoperative day 1 from a total abdominal hysterectomy and requesting immediate pain medication. Patient Bennet is admitted for chemotherapy and complaining of nausea. Patient Clark is postoperative day 2 from an ovarian debulking surgery and needs drain care and wound teaching. Patient Dyer is postoperative day 0 from an abdominal myomectomy with a red saturated dressing and feels short of breath. In what order should the nurse

C; Patient Dyer should be the highest priority as her symptoms could be consistent with acute post-operative bleeding requiring immediate surgical intervention. Patient Avery's pain needs should be addressed next followed closely by patient Bennet's nausea complaints. Pain on postoperative day 1 should be under control so that the patient can ambulate and heal. Nausea with chemotherapy is common and should be addressed as needed. Drain care and wound teaching for patient Clark should be the lowest priority as this is a need for discharge and not an immediate care need.

The client, who has been prescribed sildenafil 2 weeks ago for erectile dysfunction, calls the clinic to report that nothing happens, despite taking his sildenafil orally and waiting for his erection to develop. Which fact should the nurse consider before responding to the client? A. In clinical trials, the sildenafil was effective only 20% of the time B. Sildenafil is not effective if taken orally and should be taken rectally C. In the absence of sexual stimuli, sildenafil will not cause an ere

C; Sildenafil (Viagra) enhances the normal erectile response to sexual stimuli by promoting smooth muscle relaxation of arterial and trabecular smooth muscle. The resultant arterial dilation causes engorgement of sinusoidal spaces in the corpus cavernosum. In the absence of sexual stimuli, however, nothing will happen. In clinical trials, this medication helps 70% of men reach erectile function.

1. A client with a deteriorating mental status after suffering a stroke has a rectal temperature of 102.3 F. For which reason should a nurse initiate interventions to bring the temperature to a normal level? a. A normal temperature will strengthen the client's immune system against infection b. Hyperthermia lowers the incidence of mortality c. A normal temperature will decrease the score on the Glasgow coma scale d. Hyperthermia increases the likelihood of a larger area of brain infarct

D- Temperature elevation is thought to be associate with dysfunction of hypothalamus. Temp elevation sin the client post stroke result in an increase in the size of the infarct. Hyperthermia associated with higher mortality and lowers Glasgow coma

The nurse is caring for the client with a leaking cerebral aneurysm. What early sign should prompt the nurse to notify the HCP of an increasing intracranial pressure (ICP)? A. Change in pupil size and reaction B. Sudden drop in the blood pressure C. Experiencing diminished sensation D. Change in the level of consciousness

D; A change in level of consciousness is the first sign of neurological deterioration and is often associated with the development of increased ICP. Pupillary changes and diminished sensation are late signs. A drop in BP is not directly associated with neurological deterioration, although a BP with a wide pule pressure is a late sign of increased ICP.

A client is demonstrating an altered level of consciousness from a traumatic brain injury. Which assessment will the nurse use as a sensitive indicator of neurologic function? Cerebellar function Glasgow Coma Scale Cranial nerve function Mental status evaluation

Glasgow Coma Scale; LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response. Cerebellar function, cranial nerve function, and mental status evaluation are all elements of the neurologic assessment.

chorea movement(rapid, jerky, involuntary and purposeless movement) is characteristic of what?

Huntington's disease

symmetrical atrophy on CT/MRI is indicative of what disease?

Huntington's disease

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is: Obesity Dyslipidemia Smoking Hypertension

Hypertension; Hypertension is the most modifiable risk factor for either ischemic or hemorrhagic stroke.

A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include thickened liquids. Which of the following is the priority nursing diagnosis for this client? Decreased Fluid Volume Risk Aspiration Risk Impaired Swallowing Malnutrition Risk

Impaired Swallowing; Impaired Swallowing was evident on the video fluoroscopy. Aspiration, Malnutrition, and Decreased Fluid Volume Risk can occur but are not the primary diagnosis at this point in time.

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? Decreased level of consciousness (LOC) Elevated blood pressure Increased urine output Decreased heart rate

Increased urine output; 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

An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy? International normalized ratio greater than 2 Two hour time period of the stroke Taking digoxin Surgery 6 weeks ago

International normalized ratio greater than 2; The client is at risk for further bleeding if the international normalized ratio is greater than 2. Thrombolytic therapy must be initiated within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetalol do not prohibit thrombolytic therapy.

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? Dextrose 5% in water (D5W) Half-normal saline (0.45% NSS) One-third normal saline (0.33% NSS) Lactated Ringer's

Lactated Ringer's; With increasing ICP, isotonic normal saline, lactated Ringer's, or hypertonic (3%) saline solutions are used to decrease swelling in the brain cells. D5W, 0.45% NSS, and 0.33% NSS are all hypotonic solutions that will move more fluid into the cells, worsening the ICP.

The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? Select all that apply. Loosening constrictive clothing Opening the patient's jaw and inserting a mouth gag Positioning the patient on his or her side with head flexed forward Providing for privacy Restraining the patient to avoid self injury

Loosening constrictive clothing Positioning the patient on his or her side with head flexed forward Providing for privacy; During a patient's seizure, the nurse should do the following. Loosen constrictive clothing. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions. Provide privacy, and protect the patient from curious onlookers. (The patient who has an aura [warning of an impending seizure] may have time to seek a safe, private place.) The nurse should not attempt to pry open jaws that are clenched in a spasm or attempt to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. No attempt should be made to restrain the patient during the seizure, because muscular contractions are strong and restraint can produce injury.

A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome? Attains desired fluid balance Displays no signs or symptoms of infection Maintains a patent airway Demonstrates optimal cerebral tissue perfusion

Maintains a patent airway; Maintenance of a patent airway is always a first priority. Loss of airway is a possible complication of increasing ICP, as well as aspiration from vomiting.

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?

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

A transcranial Doppler ultrasonography detects cerebral vasospasms in a client experiencing lethargy 8 days following a subarachnoid hemorrhage. The nurse anticipates which therapeutic intervention? Fluid restriction Nitroprusside IV Nimodipine PO Phenytoin IV

Nimodipine PO; Medication may be effective in the treatment of vasospasm. Based on one theory, that vasospasm is caused by an increased influx of calcium into the cell, medication therapy may be used to block or antagonize this action and prevent or reverse the action of vasospasm if already present. The most frequently used calcium channel blocker is nimodipine. The other interventions and medications are not used to treat vasospasms.

A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate? Give the patient some mouthwash to gargle with. Request an antihistamine for the postnasal drip. Ask the patient to cough to observe the sputum color and consistency. Notify the physician of a possible cerebrospinal fluid leak.

Notify the physician of a possible cerebrospinal fluid leak; Any sudden discharge of fluid from a cranial incision is reported at once, because a large leak requires surgical repair. Attention should be paid to the patient who complains of a salty taste or "postnasal drip," because this can be caused by cerebrospinal fluid trickling down the throat.

A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, benztropine, and selegiline. The nurse knows that most likely, the client has a diagnosis of: Parkinson disease. Huntington disease. seizure disorder. multiple sclerosis.

Parkinson disease

A nurse is admitting a client with a diagnosis of meningitis. Which of the nurse's assessment findings support this diagnosis? Select all that apply a. Nuchal rigidity b. Severe Headache c. Pill-rolling tremor d. Photophobia e. Fever f. Micrographia

answer: A, B, D,E- Meningitis is inflammation affecting arachnoid and pia mater covering brain and spinal cord. C and F are associated with parkinsons

A client is seen by a primary care provider because of difficulty walking. A neurological assessment is done. A nurse informs the client that which assessment procedure was done to test the functioning of the cerebellum? a. Ask the client to shut the eyes and distinguish whether the touch is with a sharp or dull object b. Ask the client to hold hands with palms up perpendicular to the body with eyes closed c. As the client to grasp and squeeze 2 fingers of each of the examiner's hands d. Ask the

answer: D(repetitive, alternating motion tests the client's coordination); a. Sharp or dull- peripheral nerve function b. Pronator rift- muscle weakness due to cerebral or brainstem dysfunction c. Hand grasps compares equality of muscle strength bilaterally

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 dipyridamole. aspirin. clopidogrel. ticlopidine.

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

the urse is caring for the client with a C6 SCI. which findings support the nurse's conclusion that the client may be experiencing autonomic dysreflexia? select all that apply. blurred vision BP 198/102 mm Hg HR 150 bpm extreme headache sweaty face and arms

blurred vision BP 198/102 mm Hg extreme headache sweaty face and arms; blurred vision results from the hypertension occuring with autonomic dysreflexia. hypertension is a symptom due to overstimulation of sympathetic nervous system(SNS). bradycardia(not tachycardia) results form autonomic dysreflexia. sweating results from the sympathetic stimulation above the level of injury

jason is admitted following a T4 soinal injury. When taking his morning VS, you note that he appears restless and his bp is elevated. Which of the following actions is appropriate? recheck his bp in an hour no action is necessary check for a full bladder encourage him to express his anxiety

check for a full bladder

the client hospitalized with a vertebral fracture has a halo external fixation device in place. Which interventions should the nurse plan? ensure the traction weight hangs freely remove the vest from the device at bedtime cleanse the site where the pins enter the skull screw the pins in the skull daily to tighten

cleanse the site where the pins enter the skull

what should you not do after administering T-PA for ischemic stroke?

complication is bleeding, so avoid inserting anything 24 hours post administration such as NGT, foley, etc.

chronic traumatic encephalopathy is a result of repeated incidents of what?

concussions

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

dehydrate the brain and reduce cerebral edema; 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.

how do you know there might be possible herniation in epidural hematoma?

dilation/fixation of pupil or paralysis of extremity

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: pupillary changes. diminished responsiveness. decreasing blood pressure. elevated temperature.

diminished responsiveness.; Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later. Increased ICP causes systolic blood pressure to rise. Temperature changes vary and may not occur even with a severe decrease in responsiveness.

the nurse is implementing interventions for the client who has increased ICP. the nurse knows that which result will occur if increased ICP is left untreated? displacement of brain tissue increase in cerebral perfusion increase in serum pH level leakage of CSF

displacement of brain tissue

herpes simplex is the main cause of what disease?

encephalitis

the client is in status epilepticus. Which interventions, if prescribed, should be included in the client's immediate treatment? select all that apply. administer dexamethasone IV give oxygen and prepare for endotracheal intubation obtain a defibrillator and prepare to use it immediately remove nearby objects to protect the client from injury administer lorazepam IV stat

give oxygen and prepare for endotracheal intubation remove nearby objects to protect the client from injury administer lorazepam IV stat; why? status epilepticus is a medical emergency. The client is at risk for brain hypoxia and permanent brain damage. The client needs additional O2, and intubation will secure the airway. Care is taken to protect the client from injury during the seizure. Either lorazepam(Ativan) or diazepam(valium) is administered initially to terminate the seizure bc they can be administered more rapidly than phenytoin.

the client with MS tells the nurse about extreme fatigue. which assessment findings should the nurse identify as a contributing factor to the client's fatigue? select all that apply hemoglobin 9.5 g/dL and hematocrit is 31.8% taking baclofen 15 mg 3 times per day working 4-8 hours per week in the family business presence of cardiac murmur at the tricuspid valve bilateral leg weakness noted when walking in room

hemoglobin 9.5 g/dL and hematocrit is 31.8% taking baclofen 15 mg 3 times per day presence of cardiac murmur at the tricuspid valve bilateral leg weakness noted when walking in room; why? the lower than normal hgb and hct indicate anemia. Inadequate cell oxygenation contributes to fatigue. Baclofen(Lioresal), a skeletal muscle relaxant used to relieve spasms, has the adverse effects of drowsiness and fatigue. working 4-8 hours per week is limited number of hours and should not contribute to client's fatigue. the client has stopped anitriptyline, an antidepressant, and may be clinically depressed, and fatigue is a major symptoms of depression. a tricuspid murmur indicates an incompetent cardiac valve, which will decrease the amount of oxygenated blood reaching the tissue. The increased energy expenditure with ambulation can increase fatigue.

in what illness should you check for carotid bruits?

ischemic stroke

nuchal rigidity, positive kernig's and brudzinski's, and photophobia are common clinical manifestations of what?

meningitis

To meet the sensory needs of a client with viral meningitis, the nurse should: minimize exposure to bright lights and noise. promote an active range of motion. increase environmental stimuli. avoid physical contact between the client and family members.

minimize exposure to bright lights and noise; Photophobia and hypersensitivity to environmental stimuli are the common clinical manifestations of meningeal irritation and infection. Therefore, the nurse should provide a calm environment with less stressful stimuli. Physical activity may worsen symptoms; therefore, physical activity should be reduced. Family members do not need to be avoided. People diagnosed with viral meningitis should be instructed to thoroughly wash hands frequently.

interferon beta is given for what ? and what route?

multiple sclerosis - subQ every other day to reduce frequency of attacks

the nurse is assessing the client with tentative diagnosis of meningitis. Which findings should the nurse associate with meningitis? Select all that apply nuchal rigidity severe HA pill-rolling tremor photophobia lethargy

nuchal rigidity severe HA photophobia lethargy

A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like part B(deceberate) of the accompanying image. Based on this initial observation, what would the nurse predict about this patient's prognosis? good poor excellent fatal

poor; An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. Decerebrate posturing indicates deeper and more severe dysfunction than does decorticate posturing; it implies brain pathology, which is a poor prognostic sign. Decorticate posture is the flexion and internal rotation of forearms and hands. Decerebrate posture is extension and external rotation. Flaccidity is the absence of motor response and the most severe neurologic impairment.

which of the following systems should take priority when doing a nursing assessment for a pt. with ALS? skin assessment bowel function assessment bladder function assessment respiratory assessment

respiratory assessment

the nurse is administering mannitol IV to decrease the client's ICP following craniotomy. Which lab test results should the nurse monitor during the client's treatment with mannitol? serum osmolarity WBC count serum cholesterol erythrocyte sedimentation rate(ESR)

serum osmolarity

Bells palsy is a disorder of which cranial nerve? third fifth seventh ninth

seventh

autonomic dysreflexia is a complication of what?

spinal cord injury

the nurse asseses the client injured in a diving accident 2 hours earlier. The l=client breathes independently but has no movement or muscle tone below the injured area. A CT scan reveals a C4 cervical vertebra fracture. The nurse should plan interventions for which problem? complete spinal cord transection spinal shock an upper motor neuron injury quadriplegia

spinal shock; the client is experiencing spinal shock that manifests within a few hours after the injury. Hypotension, flaccid paralysis, and absence of muscle contractions occur.

the nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the:

supine position with the head slightly elevated; After surgery, the nurse should place the client in either a supine position with the head slightly elevated or a side-lying position on the unaffected side. The dorsal recumbent, Trendelenburg, and prone positions can increase intracranial pressure.

Karesa comes to the clinic complaining of a burning pain on her right cheek. Which of the following findings further supports a diagnosis of trigeminal neuralgia? tearing of the eye inability to close the affected eye asymmetry of facial expressions lack of pupillary response

tearing of the eye

the client, diagnosed with an ischemic stroke, is being evaluated for thrombolytic therapy. Which assessment finding should promptthe nurse to withhold thrombolytic therapy? brain CT scan results show no bleeding the client had a serious head injury 4 weeks ago the client has a history of type 1 diabetes mellitus neurological deficits started 2 hours ago

the client had a serious head injury 4 weeks ago; why? contraindications to thrombolytic therapy for the client with an ischemic stroke include a serious head injury within the previous 3 months. This would put the client at risk for developing serious bleeding problems, specifically cerebral hemorrhage.

the nurse is caring for a client who, 6 weeks after an MVA, was diagnosed with a mild TBI. Which information in the client's history if the injury should the nurse associate with TBI? select all that apply. the client has had not episodes of vomiting after the incident the client remembers events before and right after the accident the client has had headache and dizziness daily since the accident the client has difficulty concentrating and focusing while at work the client lost consciousness mo

the client has had headache and dizziness daily since the accident the client has difficulty concentrating and focusing while at work the client lost consciousness momentarily at the time of injury.

The nurse is assessing the client after sustaining a closed head injury. When applying nailbed pressure, the client's body stiffens suddenly, the eye roll upward, and there is increased salivation and a loss of swallowing reflex. Which observation should the nurse document?

tonic seizure activity observed

A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure? unequal response equal response rapid response constricted response

unequal response; In increased ICP, the pupil response is unequal. One pupil responds more sluggishly than the other or becomes fixed and dilated.

A client suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure? vasodilation vasoconstriction hypertension increased PaO

vasodilation; Hypotension and hypoxia lead to vasodilation, which contributes to increased ICP, compressing blood vessels and leading to cerebral ischemia. As ICP continues to rise, autoregulatory mechanisms can become compromised; hypotension and hypoxia lead to vasodilation, which contributes to increased ICP.

how is T-PA given?

weight determines the dose; 10% 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(drip)