1020 Intracranial Regulation
Which assessment finding indicates that a client has had a stroke? Select all that apply. One, some, or all responses may be correct. 1 Lopsided smile 2 Unilateral vision 3 Incoherent speech 4 Unable to raise right arm 5 Symptoms started 2 hours ago
1 Lopsided smile 2 Unilateral vision 3 Incoherent speech 4 Unable to raise right arm 5 Symptoms started 2 hours ago The signs of a stroke follow the acronym FAST. The F stands for facial drooping (a lopsided smile); A for arm weakness (inability to raise the right arm); and S for speech difficulties (incoherent speech) The T stands for time, as the signs and symptoms need to be evaluated as soon as possible. Tissue plasminogen activator (TPA) can be administered to reestablish blood flow if treatment is initiated within 4½ hours of stroke onset.
A client is admitted to the hospital with a tonic-clonic seizure after his seizures had been well controlled by phenytoin for 6 months. The client says to the nurse, "I am so upset. I didn't think I was going to have more seizures." Which response would the nurse make? 1 "Did you forget to take your medication?" 2 "You are worried about having more seizures?" 3 "You must be under a lot of stress right now." 4 "Don't be concerned; your medication can be increased."
2 "You are worried about having more seizures?" The response "You are worried about having more seizures?" addresses the client's feelings and encourages communication. The question "Did you forget to take your medication?" sounds accusatory; it ignores the client's feelings and discourages communication. Although the statement "You must be under a lot of stress right now" may be true, it does not encourage further communication concerning the seizure. The statement "Don't be concerned, your medication can be increased" negates the client's feelings and discourages communication.
Which assessment finding alerts the nurse to suspect increasing intracranial pressure in an infant? 1 Sunken eyes 2 Projectile vomiting 3 Depressed fontanels 4 Narrowing pulse pressure
2 Projectile vomiting Increased intracranial pressure exerts pressure on the vomiting center in the brain, resulting in projectile vomiting unrelated to feeding. The eyeballs will show signs of increased fluid volume in the skull and will be pushed forward, pulling the lids taut. The fontanels will show signs of increased fluid volume in the skull and will bulge. With increased intracranial pressure the systolic pressure is increased, and the diastolic pressure is the same or decreased, creating a widening, not narrowing, of pulse pressure.
A client who sustains a stroke has a loss of proprioception and fine touch. Which artery would the nurse suspect is damaged? 1 Lateral cerebral 2 Middle cerebral 3 Anterior cerebral 4 Posterior cerebral
3 Anterior cerebral Damage to the anterior cerebral artery can lead to a loss of proprioception and fine touch. Damage to the vertebral artery can cause dysphagia and dysarthria. Injury to the middle cerebral artery can cause motor and sensory deficits. Posterior cerebral artery damage can cause visual hallucinations and hemianopsia. There is no artery called lateral cerebral.
A client who sustained a head injury reports bland taste of food. Upon examination, the nurse finds that there is loss of taste perception from the anterior two-thirds region of the tongue. Which origin of the brain is associated with the involved nerve? 1 Medulla 2 Midbrain 3 Inferior pons 4 Cerebrum
3 Inferior pons Loss of taste perception from the anterior two-thirds of the tongue indicates injury to the facial nerve, which originates from the inferior pons. The medulla is the site of origin for the glossopharyngeal, vagus, accessory, and hypoglossal nerves. The optic nerve and oculomotor nerve originate from the midbrain. The site of origin for the olfactory nerve is the olfactory bulb in the anterior ventral cerebrum.
Which clinical indicator is most commonly present in the assessment of a client with a ruptured cerebral aneurysm? 1 Tonic-clonic seizures 2 Decerebrate posturing 3 Narrowed pulse pressure 4 Sudden, severe headache
4 Sudden, severe headache Bleeding into the enclosed cavity of the skull creates pressure, causing pain. Seizures are not directly related to the hemorrhage; they result from abnormal electrical charges that may eventually develop as a consequence of tissue ischemia. Decerebrate posturing (extension posturing) indicates caudal deterioration with damage to the midbrain and pons. As the systolic pressure increases, widening of the pulse pressure occurs because of compression of vasomotor centers.
The nurse is reviewing the cerebrospinal fluid (CSF) laboratory findings of four clients. Which client would the nurse suspect has had a previous meningeal hemorrhage? Appearance in CFS Client A--->yellow Client B --> brown Client C--> unclear or hazy Client D--> pink-red to orange
Client B --> brown The brown color of the CSF indicates the client has had a meningeal hemorrhage. A yellow color of the CSF is due to hemolysis of red blood cells (RBC) leading to increased bilirubin. An unclear or hazy appearance of the CSF indicates an elevated white blood cell count. A pink-red to orange color indicates the presence of RBCs in the CSF.
Which action is the priority for a client who is admitted to the hospital with a severe head injury? 1 Maintain ventilation. 2 Prevent contractures. 3 Preserve skin integrity. 4 Monitor blood pressure.
1 Maintain ventilation. The brain requires continuous, large quantities of oxygen to function; maintaining the airway and ensuring respiratory exchange and ventilation are the priorities. Although preserving skin integrity and preventing contractures is a concern, those are not the priority at this time. Although monitoring the blood pressure is done because a widening pulse pressure may indicate increasing intracranial pressure, it is not a higher priority than maintaining ventilation.
Which action would the nurse take when caring for a client who has a possible skull fracture as a result of trauma? 1 Monitor the client for signs of brain injury. 2 Check for hemorrhaging from the oral cavity. 3 Elevate the foot of the bed if the client develops symptoms of shock. 4 Observe for indicators of decreased intracranial pressure and temperature.
1 Monitor the client for signs of brain injury. Head injuries can cause trauma to the brain, and the client should be monitored for symptoms of increased intracranial pressure (e.g., headache, dizziness, and visual disturbances). Checking for hemorrhaging from the oral cavity is not indicated in this situation. Elevating the lower extremities should be avoided because it will increase intracranial pressure. The intracranial pressure may increase after trauma because of bleeding and edema. The temperature may increase because of injury to or pressure on the hypothalamus.
Which action would the nurse take for an older resident in a nursing home with Alzheimer disease who hoards leftover food and other seemingly valueless articles and stuffs them into pockets "so the others won't steal them"? 1 Remove the resident's unsafe and soiled articles during the night. 2 Give the resident a small bag in which to place selected personal articles and food. 3 Explain to the resident why the nursing home's policy for cleanliness and safety must be followed. 4 Tell the resident that the staff is required to keep harmful objects out of reach in the resident's closet.
2 Give the resident a small bag in which to place selected personal articles and food. The nurse would give the resident a small bag in which to place selected personal articles and food. This action allows the client to exercise the right to decide which articles to keep and helps ensure safety and cleanliness. Removing the resident's unsafe and soiled articles during the night deceives the client and will create mistrust toward the staff. Because of the client's decreased attention span and memory, explanations alone will not help ensure safety or meet this client's needs. Telling the resident that the staff is required to keep harmful objects out of reach in the resident's closet does not address the client's needs and with the loss of short-term memory, this may be futile; no data indicate that the resident is hoarding harmful objects.
Which assessment would the nurse perform specific to the safe administration of intravenous mannitol? 1 Body weight daily 2 Urine output hourly 3 Vital signs every 2 hours 4 Level of consciousness every 8 hours
2 Urine output hourly Mannitol, an osmotic diuretic, increases the intravascular volume that must be excreted by the kidneys. The client's urine output should be monitored hourly to determine the client's response to therapy. Although mannitol results in an increase in urinary excretion that is reflected in a decrease in body weight (1 L of fluid is equal to 2.2 pounds [1 kg]), a daily assessment of the client's weight is too infrequent to assess the client's response to therapy. Urine output can be monitored hourly and is a more frequent, accurate, and efficient assessment than is a daily weight. Vital signs should be monitored every hour considering the severity of the client's injury and the administration of mannitol. Although the level of consciousness should be monitored with a head injury, conducting assessments every 8 hours is too infrequent to monitor the client's response to therapy.
Which clinical indicators would the nurse expect to find when assessing a client with Parkinson disease? Select all that apply. One, some, or all responses may be correct. 1 Resting tremors 2 Flattened affect 3 Muscle flaccidity 4 Tonic-clonic seizures 5 Slow voluntary movements
Resting tremors Flattened affect Slow voluntary movements Resting (nonintentional) tremors, commonly accompanied by pill-rolling movements of the thumb against the fingers, are associated with destruction of the neurons of the basal ganglia and substantia nigra. Destruction of the neurons of the basal ganglia and substantia nigra results in decreased muscle tone. The masklike appearance, unblinking eyes, and monotonous speech patterns can be interpreted as a flat affect. Slow voluntary movements (bradykinesia) are associated with this disorder. Muscle flaccidity is not associated with Parkinson disease. Rigidity is caused by sustained muscle contractions. Movement is jerky in quality (cogwheel rigidity). Tonic-clonic seizures are not associated with Parkinson disease.