Patho Prep U Ch 37 Brain Disorders
Global or diffuse brain injury is manifested by changes in the level of consciousness. True False
true
As the nurse is performing a physical assessment of a client, the client begins to have seizure activity including loss of consciousness and limb jerking. The nurse's priority is to: -protect the client from injury. -stop the seizure. -preserve brain functioning. -treat underlying disease.
-protect the client from injury
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 Explanation: Severe brain injury that results in seriously compromised brain function can result in brain death.
A teenager, exposed to West Nile virus a few weeks ago while camping with friends, is admitted with headache, fever, and nuchal rigidity. The teenager is also displaying some lethargy and disorientation. The nurse knows which medical diagnosis listed below may be associated with these clinical manifestations? -Rocky mountain spotted fever -Lyme disease -Encephalitis -Spinal infection
-Encephalitis Explanation: Encephalitis represents a generalized infection of the parenchyma of the brain or spinal cord. A virus, such as West Nile virus, usually causes encephalitis, although it may be caused by bacteria, fungi, and other organisms. Encephalitis is characterized by fever, headache, and nuchal rigidity. However, more often, people also experience neurologic disturbances, such as lethargy, disorientation, seizures, focal paralysis, delirium, and coma.
An emergency room nurse receives a report that a client's Glasgow Coma Scale (GCS) is 3. The nurse prepares to care for a client with which of the following? -Spontaneous eye opening -Flaccid motor response -Normal flexion -Confused conversation
-Flaccid motor response Explanation: A score of 3 on the Glasgow Coma Scale indicates the lowest possible score in each of the three scoring categories (eye opening, motor response, and verbal response) and includes flaccid or no motor response, no verbal response and the inability to open the eyes.
A client is admitted for cardioembolic stroke. Which therapy to best prevent recurrence of embolic stroke should the nurse monitor for effectiveness? -Anticoagulation therapy -Blood pressure management -Correction of dyslipidemia -Antiarrhythmic therapy
Anticoagulation therapy Explanation: The risk of stroke recurrence is highest in the first week after stroke, and the use of anticoagulation in cardioembolic stroke is imperative.
The spouse of a patient diagnosed with Alzheimer's disease asks the nurse why the patient often neglects to take a shower. The spouse states that the patient was always diligent with hygiene in the past; however, over the past few months that has not been the case. Which of the following is the nurse's best response? "The patient just does not care anymore." "The patient would be fine without showering." "The patient is experiencing a temporary relapse." "You should remind the patient to shower."
"You should remind the patient to shower." Explanation: The patient should be reminded to shower because most likely he or she has difficulty remembering to do so. In the moderate stage of Alzheimer's disease, which can last for several years, it is not unusual for hygiene to be neglected because the person may just not remember if he or she did or did not shower. There is no information in the question to support the remaining responses.
A client reports "the worst headache" of her life with associated blurred vision. Subsequent diagnostic testing has resulted in a diagnosis of an intra-axial brain tumor. What other clinical manifestations would be consistent with this diagnosis? Select all that apply. -Tinnitus and earaches, with no accompanying signs of infection -Recurrent epistaxis (nosebleeds) -Cognitive and personality changes -Seizure activity -Nausea and vomiting
- Cognitive and personality changes -seizure activity -nausea and vomiting Explanation: The clinical manifestations of brain tumors depend on the size and location of the tumor. General signs and symptoms include headache, nausea, vomiting, mental changes, papilledema, visual disturbances (e.g., diplopia), alterations in sensory and motor function, and seizures. Tinnitus, ear pain, and epistaxis are not among the more common signs and symptoms of a brain tumor.
A client with a traumatic brain injury has developed extreme cerebral edema. Which clinical manifestations of brain herniation correlate to upward herniation of the midbrain known as uncal herniation? Select all that apply. -Deep coma -Rhythmic movement of arms and legs -Respiratory rate of 8 with intermittent sighs -Intracranial bleeding from nose and ears -Bilateral small, fixed pupils
- Deep coma - Respiratory rate of 8 with intermittent sighs - Bilateral small, fixed pupils Explanation: Infratentorial herniation results from increased pressure in the infratentorial compartment. Herniation may occur superiorly (upward) through the tentorial incisura or inferiorly (downward) through the foramen magnum. The most prominent signs of upward (uncal) herniation include immediate onset of deep coma; small equal, fixed pupils; and abnormal respirations (slow rate with intermittent sighs or ataxia) and other vital signs. Downward displacement of the midbrain through the tentorial notch (or of the cerebellar tonsils through the foramen magnum) can interfere with medullary functioning and cause cardiac or respiratory arrest. Tissue infarction and intracranial bleeding are causes of cerebral edema, rather than an outcome of herniation. Rhythmic movement of arms and legs could be caused by many things and is not specific to infratentorial herniation.
A male client has smoked cigarettes for decades and currently drinks around 10 beers a day. His diet is high in fat and low in fiber. This morning he has arrived at the emergency department with weakness on his left side and an inability to speak. What is most likely causing his symptoms? -A transient ischemic attack (TIA) -A hemorrhagic stroke -An ischemic stroke involving the middle cerebral artery -An ischemic stroke involving the anterior cerebral artery
-An ischemic stroke involving the middle cerebral artery Explanation: A stroke in the territory of the middle cerebral artery is the most common aphasia-producing stroke, causing this sign more commonly than a hemorrhagic stroke or a TIA. The middle cerebral artery feeds blood to the language centers. The posterior, basilar, and anterior arteries feed different regions of the brain and a stroke in these arteries would produce different symptoms.
The nurse is caring for a client with a brain tumor when the client begins to vomit. Which intervention should the nurse do first? -Assess for other signs/symptoms of increased intracranial pressure. -Assess for signs/symptoms of cerebrovascular accident (stroke). -Contact physician for anti-nausea medication orders. -Document the finding as it is an expected symptom.
-Assess for other signs/symptoms of increased intracranial pressure. Explanation: The tumor may be causing increased intracranial pressure. Vomiting, with or without nausea, is a common symptom of increased intracranial pressure and/or brain stem compression. The nurse's first action is to assess for other signs/symptoms of increased intracranial pressure. Once the assessment is completed, the nurse should contact the physician if indicated by the findings.
An elderly client is brought to the emergency department after experiencing some confusion, slurred speech, and a weak arm. Now she is back to her normal self. Suspecting a transient ischemic attacks (TIAs), the health care provider will order 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 Explanation: The traditional definition of TIAs as a neurologic deficit resolving within 24 hours was developed before the mechanisms of ischemic cell damage and the penumbra were known and before the newer, more advanced methods of neuroimaging became available. A more accurate definition now is a transient deficit without time limits, best described as a zone of penumbra without central infarction. TIAs are important because they may provide warning of impending stroke. The causes of TIAs are the same as those of ischemic stroke, and include atherosclerotic disease of cerebral vessels and emboli. The most common predisposing factors for cerebral hemorrhage are advancing age and hypertension; other causes include aneurysm rupture. Cerebral electrical malfunctions usually occur with seizure activity.
When the suspected diagnosis is bacterial meningitis, what assessment techniques can assist in determining if meningeal irritation is present? -Kernig sign and Chadwick sign -Brudzinski sign and Kernig sign -Brudzinski sign and Chadwick sign -Chvostek sign and Guedel sign
-Brudzinski sign and Kernig sign Explanation: Two assessment techniques can help determine whether meningeal irritation is present. Kernig sign is resistance to extension of the knee while the person is lying with the hip flexed at a right angle. Brudzinski sign is elicited when flexion of the neck induces flexion of the hip and knee.
The nurse is planning care for a client in the acute recovery phase after an ischemic stroke. What interventions will the nurse prioritize when planning care? Select all that apply. -Deep vein prophylaxis -Falls prevention -Swallowing precautions -Reorientation exercises -Stroke prevention education
-Deep vein prophylaxis -Falls prevention -Swallowing precautions Explanation: Early hospital care for the client with ischemic stroke requires careful prevention of aspiration, deep vein thrombosis, and falls. Most clients with stroke are not disoriented. Stroke prevention education would be a priority closer to the time of discharge rather than in the acute phase of recovery.
The nurse planning a community education class on brain tumors and their prevention should include which risk factors in the presentation? Select all that apply. -High dose irradiation exposure -Acquired immune suppression -Polyvinyl chloride exposure -Head trauma
-High dose irradiation exposure -polycinyl chlroide exposure Explanation: Risk factors for brain tumors include high-dose irradiation and acquired immune suppression and should be included by the nurse when discussing brain tumor prevention. Polyvinyl chloride exposure and head trauma have not been convincingly demonstrated to increase the risk of brain tumors.
A client arrives at the emergency department with symptoms of stroke. What evidence should the nurse gather to determine if the client is a candidate for thrombolytic therapy? Select all that apply. -History of stroke -Age -Blood pressure -Heart rate -Time of symptom onset
-History of stroke -Time of onset -blood pressures Prior stroke or head injury within 3 months, a blood pressure greater than 185/110 mm Hg, or symptoms that have been present for greater than 4.5 hours exclude the client as a candidate for thrombolytic therapy. Neither age nor heart rate are part of thrombolytic therapy treatment criteria.
The emergency room doctor suspects a client may have bacterial meningitis. The most important diagnostic test to perform would be: -Lumbar puncture -Blood cultures -CT of the head -Sputum culture
-Lumbar puncture Explanation: The diagnosis of bacterial meningitis is confirmed with abnormal CSF findings. Lumbar puncture findings, which are necessary for accurate diagnosis, include a cloudy and purulent CSF under increased pressure. The other options do not confirm the diagnosis.
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. Explanation: Vasogenic brain edema occurs with conditions that impair the function of the blood-brain barrier and allow the transfer of water and protein from the vascular space into the interstitial space. Increased production of CSF and decreased absorption result in hydrocephalus. It occurs in conditions such as hemorrhage, brain injury, and infectious processes.
The nurse is performing passive range-of-motion exercises with a client who suffered an ischemic stroke 2 weeks ago and has hemiparesis. The client says, "What is the point of doing these exercises if I will never be able to use that arm again?" What should the nurse include when responding to the client? Select all that apply. - You may still regain use of this arm, and these exercises may help with this recovery. - These exercises help to prevent painful shoulder complications after a stroke. - Doing these exercises helps to prevent blood clots from forming in the arteries of your arm. - It is important for you to keep a positive outlook as it will help with your recovery. - We want to ensure your shoulder joint remains flexible while you recover.
-You may still regain use of this arm, and these exercises may help with this recovery. -These exercises help to prevent painful shoulder complications after a stroke. -We want to ensure your shoulder joint remains flexible while you recover. Explanation: Passive range-of-motion exercises help to maintain joint function and to prevent edema, shoulder subluxation, and muscle atrophy. They also may help to reestablish motor patterns. Recovery of motor function can continue over the first few months of stroke, so the level of disability is not yet known for this client. Telling the client to be positive is dismissive of the feelings being expressed. Arterial occlusion is not prevented by doing range-of-motion exercises.
Manifestations of brain tumors are focal disturbances in brain function and increased ICP. What causes the focal disturbances manifested by brain tumors? -Tumor infiltration and increased blood pressure -Brain compression and decreased ICP -Brain edema and disturbances in blood flow -Tumor infiltration and decreased ICP
Brain edema and disturbances in blood flow Explanation: Intracranial tumors give rise to focal disturbances in brain function and increased ICP. Focal disturbances occur because of brain compression, tumor infiltration, disturbances in blood flow, and brain edema. Blood pressure, either increased or decreased, is not a manifestation of a brain tumor.
