NRSG 305: Chapter 16 Review

What are risk factors contributing to a stroke?

-Family Hx. -Smoking -HTN -DM -Hyperlipidemia -Asymptomatic carotid stenosis -sickle cell -afib

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

-Subarachnoid hemorrhage

The parent of an infant who developed hydrocephalus while in utero is very concerned that the child will have significant intellectual dysfunction. The best response to the parent would be: -"Because the skull sutures are not fused there may be no brain damage." -"Infants never have symptoms from hydrocephalus." -"Unfortunately, there usually is significant brain dysfunction." -"The cranial sutures are fused and decrease brain damage."

"Because the skull sutures are not fused there may be no brain damage."

Aneurysmal subarachnoid hemorrhage: -def -causes: CACHE

-bleeding into the subarachnoid space C-congenital defects A- Acute ICP C- Cigarette smoking H- HTN E- Excessive alcohol intake

A client has sustained a severe, diffuse brain injury that resulted in seriously compromised brain function. The client is at greatest risk for: -Brain death -Paraplegia -Confusion -Amnesia

-brain death

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

-muscle atrophy

Global and focal brain injuries manifest differently. What is almost always a manifestation of a global brain injury? -Altered level of consciousness -Change in behavior -Respiratory instability -Loss of eye movement reflexes

Altered LOC

Which intracranial volume is most capable of compensating for increasing intracranial pressure? -Brain cell tissue -Intravascular blood -Surface sulci fluid -Cerebrospinal fluid

CSF

Cerebral Edema: -Vasogenic edema -cytotoxic edema

Cerebral edema: increase in water and Na+ which increases brain volume = increased ICP -Vasogenic edema: extracellular accumulation -Cytotoxic: intracellular accumulation which impairs waste remove = increased toxicity

Brain injuries: -Common causes -S&S: Diminution of LOC -Primary v Secondary brain injury -Focal v diffuse brain injury -Counter-coup brain injury

Common Causes: trauma/infxn/tumor/stroke/degenerative diseases/metabolic derangements Diminution of LOC: -Early: inattentive, mild confusion, disoriented, blunt responses -late: lethargic & agitated -> obtunded -> stupor and coma Additional S&S: abnormal flexion/extension/posture, yawning/sighing/cheyne-stokes breathing Primary: direct brain impact Secondary: subsequent brain swelling from infxn/hypoxia Focal: one location & diffuse: spreads/multi-location Counter-coup: rebound injury on opposing side of brain from intimal injury

Describes the 2 main mechanisms for brain injury: Hypoxia and Ischemia

Hypoxia: decreased o2 perfusion with sustained blood flow (commonly seen in CO2 poisoning or anemia) -Aerobic metabolism STOPS = less ATP, Increase intracellular Na+ -> swelling -> lysis -Anaerobic metabolism TAKES OVER = high lactic acid -> low pH = cell damage Ischemia: reduced or interrupted blood flow causes poor o2 perfusion, waste removal, etc.

Encephalitis: -Def -Causes -S&S

Local necrotizing hemorrhage and nerve degeneration of the brain parenchyma -causes: HSV, WNV, Bacteria, & fungi -S&S: severe meningitis S&S + lethargy, seizure, coma

Seizure: Types and subtypes -Partial/focal (2 subtypes) -unclassified -Generalized (5 subtypes)

Partial/focal- specific function affected (mainly LOC) -Simple: awareness unaffected -Complex: impaired consciousness Unclassified: insufficient data Generalized -Absent: no convulsions but decreased LOC -Atonic: sudden tone loss "flaccid/drop attacks" -Myoclonic: jerky motions -Tonic: increased muscle tone = rigidity -Tonic-colonic: stiff and jerky

A client's emergency magnetic resonance imaging (MRI) has been examined by the physician and tissue plasminogen activator (tPA) has been administered to the client. What was this client's most likely diagnosis? -Status epilepticus -Subarachnoid hemorrhage -Ischemic stroke -Encephalitis

ischemic stroke

What is the normal range for ICP?

0-15mmHg

The nurse working in an emergency room is caring for a client who is exhibiting signs and symptoms of a stroke. What does the nurse anticipate that the physician's orders will include? -CT scan -MRI -Intravenous antibiotics -Pain medication

-Ct scan

What is post concussion syndrome?

persistence of symptoms after a concussion: headache/irritable/insomnia/difficulty remembering (Initial concussion: acute/immediate loss of consciousness with brief amnesia, normal recovery is withing 24Hr)

The nurse taking a report on a client coming into the emergency room plans care for a client with brain dysfunction based on which symptom? -Stupor -Pupils that react to light -Wheezing -Chest pain

stupor

The nurse is caring for a client admitted to the emergency room with suspected meningitis. The nurse prepares to perform which nursing intervention upon physician orders, while diagnostic testing is being completed? -Administration of antibiotics -Administration of TPN -Administration of oxygen -Administration of pain medication

-Administration of antibiotics

The nurse caring for a client with an epidural hematoma recognizes the bleeding is associated with which physiological finding? -Skull fracture -Cerebral edema -Berry aneurysm rupture -Arterial tear

-Arterial tear

An older adult is brought to the emergency department after experiencing some confusion, slurred speech, and a weak arm. Now the client is back to acting normally. Suspecting a transient ischemic attack (TIA), the health care provider prescribes diagnostic testing looking for which cause of this episode? -Aneurysm leakage -Minor residual deficits -Diffuse cerebral electrical malfunctions -Atherosclerotic lesions in cerebral vessels

-Atherosclerotic lesions in cerebral vessels

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

-Thrombolysis

A client has been diagnosed with a cerebral aneurysm and placed under close observation before treatment commences. Which pathophysiologic condition has contributed to this client's diagnosis? -Weakness in the muscular wall of an artery -Impaired synthesis of clotting factors -Deficits in the autonomic control of blood pressure -Increased levels of cerebrospinal fluid

-Weakness in the muscular wall of an artery

A client suffering global cerebral ischemia a week after a suicide attempt by hanging is in the intensive care unit receiving treatment. The parent asks the nurse why it is necessary to keep the client paralyzed with medications and on the ventilator. The most appropriate response would be that these therapies: -decrease metabolic needs and increase oxygenation. -decrease the client's ability to attempt suicide again. -decrease intracranial fluid volumes and pressures. -increase oxygen demands and metabolic needs.

-decrease metabolic needs and increase oxygenation.

Describe the types of hematomas: -Epidural -Subdural -Traumatic intracerebellar

Epidural: head injury with a skull fracture leading to bleeding btwn the skull and dura -usually a torn artery: rapid and serious Subdural: tear of a vein btwn the dura and arachnoid space Traumatic intracerebellar: direct damage to brain tissue -single/multiple & in any lobe -Common in older adults and alcoholics

Meningitis: -def -S&S -Dx -Tx

Inflammation of CSF filled areas (meninges) -S&S: fever, chills, headache, stiff neck/back, extremity pains, N/V -Dx: Hx + physical confirmation must have LP (cloudy w/ neutrophils & protein -Tx: antibiotics, palliative care, corticosteroids

Types and subtypes of strokes

Ischemic: interrupted flow by clot, most common -Thrombotic: plaque thrombus blockage that narrows lumen -Lacunar: small and deep within the brain -Embolic: clot dislodges and travels to brain -Transient ischemic attack: self-resolving and temporary Hemorrhagic: Vessel rupture and severe bleeding, most serious

A nurse in the emergency room is assessing a client who appears very drowsy but is able to follow simple commands and respond to painful stimuli appropriately. Which documentation is most accurate regarding this client's level of consciousness? -Confusion -Lethargy -Obtundation -Stupor

obtundation

Severe head trauma from a coup-contrecoup injury may result in which type of brain injury? -cerebral hematoma -cerebrovascular infarction -arteriovenous malformation -development of ataxia

cerebral hematoma

A nurse at a long-term care facility provides care for a client who has had recent transient ischemic attacks (TIAs). What significance should the nurse attach to the client's TIAs? -TIAs result in an accumulation of small deficits that may eventually equal the effects of a CV. -TIAs are relatively benign phenomena that necessitate monitoring, but not treatment. -TIAs, by definition, resolve rapidly, but they constitute an increased risk for stroke. -The small bleeds that define TIAs can be a warning sign of an impending stroke.

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

What is hydrocephalus and what are the 2 types?

accumulation of CSF in the vessels causing expansion = increased ICP Communicating: low CSF in bloodstream non-communicating: CSF overproduction

The nurse is explaining to a client's family how vasogenic brain edema occurs. The most appropriate information for the nurse to provide would be: -The blood-brain barrier is disrupted, allowing fluid to escape into the extracellular fluid. -There is an increase in the production of cerebrospinal fluid volume. -Normal physiologic circumstances result in decreased adsorption of CSF. -There is a decrease in the amount of fluid volume in the brain.

-The blood-brain barrier is disrupted, allowing fluid to escape into the extracellular fluid.

A teenager has been in a car accident and experienced an acceleration-deceleration head injury. Initially, the client was stable but then started to develop neurological signs/symptoms. The nurse caring for this client should be assessing for which type of possible complication? -Brain contusions and hematomas -TIAs and cerebrovascular infarction -Momentary unconsciousness -Status epilepticus

Brain contusions and hematomas

The nurse is caring for a client experiencing a seizure. During the seizure the nurse notes that the client repetitively rubs his/her clothing. When contacting the client's physician, the nurse notes that the client exhibited: -automatisms. -aura. -myoclonic activity. -hallucination.

-Automatism

The nurse is assessing a client and notes the client is now displaying decerebrate posturing. The position would be documented as: -rigidity of the arms with palms of the hands turned away from the body and with stiffly extended legs and plantar flexion of the feet. -prone position with arms placed above the head and legs elevated; deep tendon reflexes showing hyperreflexia. -flexion of the arms, wrists, and fingers, with abduction of the upper extremities, internal rotation, and plantar flexion of the lower extremities. -active range of motion with increased strength in the upper extremities when painful stimulation applied.

-rigidity of the arms with palms of the hands turned away from the body and with stiffly extended legs and plantar flexion of the feet.

A client with a history of a seizure disorder has been observed suddenly and repetitively patting his knee. After stopping this repetitive action, the client appears confused—he is oriented to person and place but not time. What type of seizure did this client most likely experience? -Tonic-clonic seizure -Atonic seizure -Myoclonic seizure -Focal seizure with impairment to consciousness

Focal seizure with impairment to consciousness