ch 16
A client begins to exhibit signs and symptoms of a stroke at a community health fair. Emergency care for the client includes:
going to the nearest stroke center.
Based on assessment parameters for motor response on the Glasgow Coma Scale, to which client should the nurse assign a score of 5?
Localizes pain
According to the Glasgow Coma Scale, opening one's eyes to only painful stimuli would receive which score?
2 Only opening eyes to painful stimulation is scored as a 2. Spontaneously opening eyes is scored as a 4; opening eyes to speech is scored as a 3; no opening is scored as a 1.
A 26 year-old female is resting after a one-minute episode during which she lost consciousness while her muscles contracted and extremities extended. This was followed by rhythmic contraction and relaxation of her extremities. On regaining consciousness, she found herself to have been incontinent of urine. What has the woman most likely experienced?
A tonic-clonic seizure. A tonic-clonic seizure often begins with tonic contraction of the muscles with extension of the extremities and immediate loss of consciousness. Incontinence of bladder and bowel is common. Cyanosis may occur from contraction of airway and respiratory muscles. The tonic phase is followed by the clonic phase, which involves rhythmic bilateral contraction and relaxation of the extremities.
The nurse is conducting a staff inservice on increased intracranial pressure. The nurse determines that the participants are understanding the information when they identify that blood pressure increases in increased intracranial pressure because of which of the following?
An attempt to increase cerebral perfusion Blood pressure increases in increased intracranial pressure due to the body's attempt to increase tissue perfusion. When the pressure in the cranial cavity approaches or exceeds the mean arterial pressure, tissue perfusion becomes inadequate.
The nurse caring for a client with a newly diagnosed intracranial tumor anticipates that the neoplasm will be which of the following?
Astrocytic neoplasms Collectively, astrocytic neoplasms are the most common type of primary brain tumor in adults; therefore the nurse anticipates that this is the cause of the client's intracranial tumor.
Following a collision while mountain biking, the diagnostic work up of a 22 year-old male has indicated the presence of an acute subdural hematoma. Which of the following pathophysiological processes most likely underlies his diagnosis?
Blood has accumulated between the man's dura and subarachnoid space. A subdural hematoma develops in the area between the dura and the arachnoid space while epidural hematomas exist between the skull and dura.
A client has sustained a severe, diffuse brain injury that resulted in seriously compromised brain function. The client is at greatest risk for: · Confusion · Brain death · Amnesia · Paraplegia
Brain death Severe brain injury that results in seriously compromised brain function can result in brain death.
A soccer player has been diagnosed with a brain contusion after being injured in a game. The best explanation of the injury by the nurse would be:
Bruising on the surface of the brain occurred. Contusions represent bruising on the surface of the brain, and lacerations are a tearing of brain tissue.
A patient with Alzheimer's disease (AD) is forgetful and has started to lose interest in social activities. Which of the following treatment routines would be beneficial for the patient?
Donepezil (Aricept) The cholinesterase inhibitor donepezil (Aricept) has been effective in slowing cognitive decline in early stages of AD.
The nurse assessing for the doll's head response (doll's eye response) in an unconscious client documents which of the following as an abnormal response?
Eyes turn right when head is turned right
Which of the following clients' signs and symptoms would allow a clinician to be most justified in ruling out stroke as a cause? An adult:
Has had a gradual onset of weakness, headache and visual disturbances over the last two days. A cardinal trait of the manifestations of stroke is that the onset is sudden, and a gradual onset of symptoms over two days would suggest an alternative etiology.
A patient with memory loss is concerned about the possibility that it may be inherited. Which of the following disorders is an inherited dementia?
Huntington's disease Huntington's disease is an inherited disorder with chorea and dementia.
A patient admitted to the emergency department with a change in mental status and a history of AIDS and primary central nervous system (CNS) lymphoma becomes extremely combative with the medical personnel. A family member is very upset with the patient's behavior. The nurse explains that these behaviors are most likely caused by which of the following?
Recurrence of primary CNS lymphoma
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. · The small bleeds that define TIAs can be a warning sign of an impending stroke. · TIAs are relatively benign phenomena that necessitate monitoring, but not treatment. · TIAs, by definition, resolve rapidly, but they constitute an increased risk for stroke.
TIAs, by definition, resolve rapidly, but they constitute an increased risk for stroke.
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 The risk of stroke recurrence is highest in the first week after stroke, and the use of anticoagulation in cardioembolic stroke is imperative.
The nurse caring for a client with an aneurysmal subarachnoid hemorrhage understands that the most common cause of this condition is which of the following?
Berry aneurysm Aneurysmal subarachnoid hemorrhage is a type of hemorrhagic stroke caused by the rupture of a cerebral aneurysm and resultant bleeding into the subarachnoid space. Most of these aneurysms are small saccular aneurysms, called berry aneurysms.
An 80-year-old patient with a history of heavy alcohol use is being seen by his provider for drowsiness, confusion, and headache. His family states that he fell and hit his head "several weeks ago." Which type of hematoma does the provider suspect?
Chronic subdural
Which of the following clients is at least risk for rapid bleeding? · Client with spontaneous subarachnoid hemorrhage · Client with a epidural hematoma · Client with a red stroke · Client with a subdural hematoma
Client with a subdural hematoma A subdural hematoma develops in the area between the dura and arachnoid space and is usually the result of a tear in small bridging veins that connect the surface of the cortex to dural sinuses. This is a venous source of bleeding and a subdural hematoma develops more slowly than the arterial bleeding in an epidural hematoma Rapid bleed with an epidural hematoma, red stroke, and/or subarachnoid hemorrhage.
The most common cause of an ischemic stroke is which of the following? · Cardiogenic embolus · Thrombosis · Intracerebral arterial vasculitis · Vasospasm
Thrombosis Thrombi are the most common cause of ischemic strokes, usually occurring in atherosclerotic blood vessels. 20% large vessels; 25% small (cardiogenic = 20%)
Global or diffuse brain injury is manifested by changes in the level of consciousness. True False
True
Global or diffuse brain injury is manifested by changes in the level of consciousness.
True Global brain injury nearly always results in altered levels of consciousness, ranging from inattention to stupor or coma.
Which symptoms would support the diagnosis of a stroke involving the posterior cerebral artery? Select all that apply.
• Loss of central vision • Repeating of verbal responses Posterior cerebral artery stroke would produce visual defects and the repeat of verbal and motor responses.
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 which of the following? · "The cranial sutures are fused and decrease brain damage." · "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."
"Because the skull sutures are not fused there may be no brain damage." When hydrocephalus develops in utero, before the cranial sutures have fused, the head can swell and decrease intracranial pressure, thereby decreasing the amount of brain tissue that is compressed.
A nurse on a neurology unit is assessing a female brain-injured client. The client is unresponsive to speech, and her pupils are dilated and do not react to light. She is breathing regularly but her respiratory rate is 45 breaths per minute. In response to a noxious stimulus, her arms and legs extend rigidly. What is her level of impairment?
Coma
Generalized convulsive status epilepticus is a medical emergency caused by a tonic-clonic seizure that does not spontaneously end, or recurs in succession without recovery. What is the first-line drug of choice to treat status epilepticus?
Intravenous lorazepam
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? · Subarachnoid hemorrhage · Status epilepticus · Encephalitis · Ischemic stroke
· Ischemic stroke
There are several types of brain injuries that can occur. What are the primary (or direct) brain injuries? (Select all that apply.)
• Focal lesions of laceration • Contusion • Diffuse axonal • Hemorrhage
The nurse assessing a patient with a traumatic brain injury assesses for changes in which of the following? Select all that apply.
• Sensory function • Motor function • Cognition • Level of consciousness Brain injuries can cause changes in level of consiousness and alterations in cognition, motor, and sensory function; therefore, the nurse assessing a patient with a traumatic brain injury should assess for changes in these areas.
For seizure disorders that do not respond to anticonvulsant medications, the option for surgical treatment exists. What is removed in the most common surgery for seizure disorders?
Amygdala The most common surgery consists of removal of the amygdala and an anterior part of the hippocampus and entorhinal cortex, as well as a small part of the temporal pole, leaving the lateral temporal neocortex intact. Only a portion of the hippocampus and entorhinal cortex, and temporal pole are removed.
A teenager has been in a car accident and experienced 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? · TIAs and cerebrovascular infarction · Brain contusions and hematomas · Momentary unconsciousness · Status epilepticus
Brain contusions and hematomas Contusions (focal brain injury) cause permanent damage to brain tissue. The bruised, necrotic tissue is phagocytized by macrophages, and scar tissue formed by astrocyte proliferation persists as a crater. The direct contusion of the brain at the site of external force is referred to as a acceleration injury, whereas the opposite side of the brain receives the deceleration injury from rebound against the inner skull surfaces. As the brain strikes the rough surface of the cranial vault, brain tissue, blood vessels, nerve tracts, and other structures are bruised and torn, resulting in contusions and hematomas.
Intracranial aneurysms that rupture cause subarachnoid hemorrhage in the client. How is the diagnosis of intracranial aneurysms and subarachnoid hemorrhage made? · Loss of cranial nerve reflexes · CT scan · MRI · Venography
CT scan The diagnosis of subarachnoid hemorrhage and intracranial aneurysms is made by clinical presentation, CT scan, and angiography.
A patient 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 patient paralyzed with medications and on the ventilator. The most appropriate response would be that these therapies do which of the following?
Decrease metabolic needs and increase oxygenation The general goal of treatment with global cerebral ischemia is to decrease metabolic needs and increase oxygenation to the injured cerebral tissue. Artificial ventilation provides appropriate oxygenation; keeping the patient paralyzed decreases the body's metabolic needs.
A child is being seen in the emergency department (ED) after ingesting crayons with lead in them. He is disoriented and having seizures. The provider suspects he has which of the following? · Bacterial meningitis · Viral meningitis · Encephalitis · Meningioma
Encephalitis Less frequent causes of encephalitis include ingesting toxic substances such as lead. People experience neurologic disturbances such as lethergy, disorientation, seizures, focal paralysis, delirium and coma.
A parent brought her 8-year-old child to the emergent care center to be examined following a fall off a playground set, resulting in a head injury. On discharge, the nurse explains to the parent that some symptoms may continue, including the inability to remember what happened before the fall. Which of the following terms best describes the diagnosis?
Retrograde amnesia The loss of memory following a concussion can be part of the postconcussion syndrome. The term for loss of memory before the accident is retrograde amnesia.
The MRA scan of a client with a suspected stroke reports ruptured berry aneurysm. The nurse plans care for a client with which of the following? · Lacunar infarct · Encephalitis · Thrombotic stroke Subarachnoid hemorrhage
Subarachnoid hemorrhage The rupture of a berry aneurysm leads to a subarachnoid hemorrhage (SAH).
The nurse observes a new nurse performing the test for Kernig's sign on a client. The new nurse performs the test by providing resistance to flexion of the knees while the client is lying with the hip flexed at a right angle. The nurse should explain to the new nurse that: · the sign elicited was the obturator sign. · the sign elicited was the Brudzinski sign. · the client should be in a sitting position. · resistance should be provided with the knee in a flexed position.
resistance should be provided with the knee in a flexed position. The test for Kernig's sign for meningeal irritation is performed by providing resistance to flexion of the knees while the client is lying with the hip flexed at a right angle. Brudzinski sign is when flexion of the neck induces flexion of the hip and knee
Which intracranial volume is most capable of compensating for increasing intracranial pressure? · Intravascular blood · Surface sulci fluid · Brain cell tissue · Cerebrospinal fluid
· Cerebrospinal fluid most able to compensate for changes in ICP. blood volume limited ability due to small amount of blood in the cerebral circulation Volume 80% brain 10% blood 10% CSF
The nurse is caring for a client who has received tissue plasminogen activator (tPA). The nurse's plan of care should include education relating to which of the following? Select all that apply.
• Warfarin (Coumadin) therapy • Reduction of risk factors • Signs and symptoms of occurrence
A patient is having difficulty with sleeping and has also been experiencing marital difficulties over the past couple of months. The patient tells the nurse at the physician's office that all this started after he had a car accident earlier that year. Which of the following would be the most important question for the nurse to ask?
"Did you sustain any injuries in the accident?" Postconcussion syndrome can interfere with daily living and also with relationships and can continue for months. The syndrome can include amnesia, insomnia, headache, difficulty concentrating, and irritability. In this situation, it would be very important to determine if the patient sustained a head injury to rule out postconcussion syndrome.
A patient discharged from the hospital 5 days ago following a stroke has come to the emergency department with facial droop that progressed with hemiplegia and aphasia. The patient's spouse is extremely upset because the physician stated that the patient cannot receive thrombolytic medications to reestablish cerebral circulation and the spouse asks the nurse why. Which of the following is the nurse's most accurate response? · "The stroke is hemorrhagic, not thrombotic." · "All the brain tissue damage is already done." · "Thrombolytics may cause cerebral hemorrhage." · "The medications do not work with subsequent strokes."
"Thrombolytics may cause cerebral hemorrhage." A previous stroke, occurring within 3 months of the administration of thrombolytics, significantly increases the risk of intracranial hemorrhage.
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." 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.
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 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 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 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
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 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.
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
-Falls prevention -Swallowing precautions -Deep vein prophylaxis 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.
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 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 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. 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.
A nurse is monitoring the intracranial pressure (ICP) of a client. The nurse would consider the client to have a normal reading when the results identify:
0 to 15 mm Hg The cranial cavity contains blood, CSF, and brain tissue. Each of these three volumes contributes to ICP, which is normally maintained within a range of 0 to 15 mm Hg when measured in the lateral ventricles.
The regulation of cerebral blood flow is accomplished through both autoregulation and local regulation. This allows for the brain to meet its metabolic needs. What is the low parameter for arterial blood pressure before cerebral blood flow becomes severely compromised?
60 mm Hg
The regulation of cerebral blood flow is accomplished through both autoregulation and local regulation. This allows for the brain to meet its metabolic needs. What is the low parameter for arterial blood pressure before cerebral blood flow becomes severely compromised?
60 mm Hg If blood pressure falls below 60 mm Hg, cerebral blood flow becomes severely compromised, and if it rises above the upper limit of autoregulation, blood flow increases rapidly and overstretches the cerebral vessels.
A client has developed hydrocephalus and asks the nurse what may have caused this to occur. The best response would be :a. Overproduction of cerebrospinal fluid b. Deficient cerebrospinal fluid c. Excessive CSF flow in the ventricular system d. Increased reabsorption of cerebrospinal fluid
:A. Overproduction of cerebrospinal fluid Hydrocephalus represents a progressive enlargement of the ventricular system due to an abnormal increase in CSF volume. It can result because of overproduction of CSF, impaired reabsorption of CSF, or obstruction of CSF flow in the ventricular system.
The family of an older adult reports increasing inability to perform basic activities of daily living. After evaluation, the client is diagnosed with Alzheimer's disease. What intervention will be implemented to slow cognitive decline?
Acetylcholinesterase inhibitors
A client is brought to the emergency department and is diagnosed with an ischemic stroke confirmed by CT scan. The most important treatment for this client would be to:• monitor vital signs closely for improvement. • administer analgesics for the relief of pain. • administer IV tissue plasminogen activator (tPA). • prepare the client for emergency surgery.
Administer IV tissue-type plasmin activator (tPA)
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 oxygen · Administration of pain medication · Administration of antibiotics · Administration of TPN
Administration of antibiotics The nurse should prepare to administer antibiotics as ordered by the physician while the diagnostic tests are being completed. Delay in initiation of antimicrobial therapy, most frequently due to medical imaging prior to lumbar puncture or transfer to another medical facility, can result in poor client outcomes.
Global and focal brain injuries manifest differently. What is almost always a manifestation of a global brain injury? · Loss of eye movement reflexes · Change in behavior · Respiratory instability · Altered level of consciousness
Altered level of consciousness
A nurse is teaching a client newly diagnosed with a seizure disorder about medications. The most important information for the nurse to provide would be:
Antiepileptic medications should never be discontinued abruptly. Consistency in taking seizure medications is essential to obtaining and maintaining therapeutic blood levels of the medication. Abrupt withdrawal can cause seizure recurrence. Monitoring and assessment of drug levels are important.
What medication teaching should be done for a woman of childbearing age with a seizure disorder? · Antiseizure drugs increase the risk for congenital abnormalities. · Some antiseizure drugs can interfere with vitamin K metabolism. · Antiseizure drugs do not interact with oral contraceptives. · All women of childbearing age should be advised to take a vitamin C supplement.
Antiseizure drugs increase the risk for congenital abnormalities. For women with epilepsy who become pregnant, antiseizure drugs increase the risk for congenital abnormalities and other perinatal complications. (also interfere with contraceptives, should take folic acid, some interfere with Vit D metabolism and increase osteoporosis)
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 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.
Assess for other signs/symptoms of increased intracranial pressure. 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 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.
A teenager has been in a car accident and experienced 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
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 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.
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 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 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? · Pain medication · MRI · CT scan · Intravenous antibiotics
CT scan The nurse should anticipate that the client will be ordered a CT scan to rule out hemorrhagic stroke that would preclude the administration of tissue plasminogen activator (tPA).
The nurse is conducting a community education program on concussions. The nurse will include that the brain is protected from external physical forces by which part of the nervous system? · blood-brain barrier · cerebral cortex · reticular formation · cerebrospinal fluid
Cerebral spinal fluid The brain is protected from external forces by the rigid confines of the skull and the cushioning afforded by the cerebrospinal fluid.
A client has suffered a stroke that has affected his speech. The physician has identified the client as having expressive aphasia. Later in the day, the family asks the nurse to explain what this means. The most accurate response would be aphasia that is: · nearly normal speech except for difficulty with finding singular words. · manifested as impaired repetition and speech riddled with letter substitutions, despite good comprehension, and fluency. · characterized by an inability to comprehend the speech of others or to comprehend written material. · characterized by an inability to communicate spontaneously with ease or translate thoughts or ideas into meaningful speech or writing. P. 431
Characterized by an inability to easily communicate spontaneously or translate thoughts or ideas into meaningful speech or writing Expressive or nonfluent aphasia - inability to easily communicate spontaneously or translate thoughts or ideas into meaningful speech or writing. Wernicke aphasia - inability to comprehend speech of others or written material Anomic aphasia - difficulty with finding singular words Conduction aphasia - impaired repetition & speech riddled with letter substitutions
The nurse is working in the emergency room. One client's presenting symptoms include the worst headache ever, nuchal rigidity and nausea. Another client's presenting symptoms include fever, stiff back, and positive Kernig's sign. Which client should the nurse assess first? · Client with fever, stiff back, and positive Kernig sign · Client with the worst headache, nuchal rigidity, and nausea
Client with the worst headache, nuchal rigidity and nausea The nurse should assess the client with presenting symptoms of worst headache ever, nuichal rigidity and nausea because these are presenting signs of aneurysmal subarachnoid hemorrhage from a ruptured cerebral aneurysm. The client with the presenting symptoms of fever, stiff back, and positive Kernig's sign is experiencing symptoms of meningitis. Ruptured cerebral aneurysm is a medical emergency with a higher priority than meningitis.
A nurse on a neurology unit is assessing a client with a brain injury. The client is unresponsive to speech, with dilated pupils that do not react to light. The client is breathing regularly with a respiratory rate is 45 breaths per minute. In response to a noxious stimulus, the client's arms and legs extend rigidly. What is the client's level of impairment? · Brain death · Delirium · Coma · Vegetative state
Coma= fixed, dilated pupils; and abnormal motor posturing; Does not respond appropriately to stimuli; sleeplike state with eyes closed; does not make any verbal sounds Vegetative: - Reflex & vegetative functions remain, sleep-wake cycles = spontaneous eye opening, no awareness or reactions Obtundation= Responds verbally with a word; arousable with stimulation; responds appropriately to painful stimuli; follows simple commands; appears very drowsy Stupor Unresponsive except to vigorous and repeated stimuli; responds appropriately to painful stimuli; lies quiet with minimal spontaneous movement; may have incomprehensible sounds and/or eye opening
Which type of seizure begins in a localized area of the brain but may progress rapidly to involve both hemispheres?
Complex partial Complex partial type seizures begin in a localized area of the brain but may progress rapidly to involve both hemispheres.
A patient who is diagnosed with seizures describes feeling a strange sensation before losing consciousness. The family members report that the patient has been smacking their lips prior to having a seizure. Which type of seizure disorder presents with these symptoms?
Complex partial or focal seizure with impairment of consciousness
Wernicke-Korsakoff syndrome is a dementia that is associated with chronic alcoholism. It is caused by a deficiency in thiamine (vitamin B12). What is the most distinctive sign or symptom of this syndrome?
Confabulation Confabulation (i.e., recitation of imaginary experiences to fill in gaps in memory) is probably the most distinctive feature of the disease.
The nurse is caring for a 31-year-old trauma victim admitted to the neurologic intensive care unit. While doing the initial assessment, the nurse finds that the client is flexing the arms, wrists, and fingers. There is adduction of the upper extremities with internal rotation and plantar flexion of the lower extremities. How would the nurse describe this in the notes?
Decorticate posturing Decorticate (flexion) posturing is characterized by flexion of the arms, wrists, and fingers, with adduction of the upper extremities, internal rotation, and plantar flexion of the lower extremities.
A nurse caring for a client with a head injury is concerned that respirations are 30 breaths per minute. Which physiologic factor will affect cerebral blood flow? · Decreased hydrogen ion concentration · Decreased serum sodium level · Decreased carbon dioxide level · Increased oxygen saturation
Decreased carbon dioxide level p 424 Cerebral blood flow is largely dependent on PaCO2. Hyperventilation causes decreased PaCO2 which subsequently leads to arterial vasoconstriction thus lowering cerebral blood flow (CBF), cerebral blood volume, and ICP.
The health care provider is concerned that a client may be at risk for problems with cerebral blood flow. The most important data to assess would be:' · Decreased level of oxygen · Decreased level of carbon dioxide · Decreased level of PCO2 · Decreased hydrogen ions
Decreased level of oxygen Regulation of blood flow to the brain is controlled largely by autoregulatory or local mechanisms that respond to the metabolic needs of the brain. Metabolic factors affecting cerebral blood flow include an increase in carbon dioxide and hydrogen ion concentrations; cerebral blood flow is affected by decreased O2 levels and increased hydrogen ions, carbon dioxide, and PCO2 levels.
The CT scan report identified that a client with a skull fracture has developed a hematoma that resulted from a torn artery. The report would be interpreted as: · Chronic subdural hematoma · Intracranial hematoma · Epidural hematoma · Subdural hematoma
Epidural hematoma
Excessive activity of the excitatory neurotransmitters and their receptor-mediated effects is the cause of which type of brain injury? · Excitotoxic · Hypoxic · Ischemic · Increased intercranial volume and pressure
Excitotoxic Excitotoxicity is a final common pathway for neuronal cell injury and death. It is associated with excessive activity of excitatory amino acid neurotransmitters. Glutamate - binds NMDA receptor opens to Ca & Na
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? · Flaccid motor response · Normal flexion · Confused conversation · Spontaneous eye opening
Flaccid motor response 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 who is diagnosed with seizures describes feeling confused after experiencing a seizure. The family members report that the client has been smacking his lips prior to having a seizure. The client most likely experienced which type of seizure?
Focal Focal seizures with impairment of consciousness sometimes referred to as psychomotor seizures are often accompanied by automatisms or repetitive nonpurposeful activities such as lip smacking, grimacing, patting, or rubbing clothing. Confusion during the postictal period (after a seizure) is common.
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 but is oriented to person and place but not time. What type of seizure did this client most likely experience?
Focal seizure with impairment to consciousness Focal seizures with impairment of consciousness, sometimes referred to as psychomotor seizures, are often accompanied by automatisms or repetitive nonpurposeful activities such as lip smacking, grimacing, patting, or rubbing clothing. Confusion during the postictal period (after a seizure) is common.
he chart of a client admitted because of seizures notes that the seizure activity began simultaneously in both cerebral hemispheres. The nurse should interpret this to mean that the client experienced: · unknown type of seizure. · focal seizure with impairment of consciousness. · focal seizure without impairment of consciousness. · generalized seizure.
Generalized seizure When seizure activity begins simultaneously in both cerebral hemispheres, it is considered a generalized seizure.
The nurse is planning an inservice on hypoxia versus ischemia in brain-injured clients. The nurse should include which of the following? · Ischemia denotes a deprivation of oxygen with maintained perfusion. · Hypoxia denotes an interruption in blood flow. · Hypoxia produces a generalized depressive effect on the brain. · Ischemia does not interfere with delivery of glucose.
Hypoxia produces a generalized depressive effect on the brain. Hypoxia denotes a deprivation of oxygen with maintained blood flow (perfusion), whereas ischemia is a situation of greatly reduced or interrupted blood flow. Hypoxia produces a generalized depressant effect on the brain. Ischemia interferes with delivery of oxygen and glucose as well as the removal of metabolic wastes.
A family brings a client to the emergency department with increasing lethargy and disorientation. They think the client had a seizure on the drive over to the hospital. The client has been sick with a "cold virus" for the last few days. On admission, the clients' temperature is 102°F. Which other clinical manifestations may lead to the diagnosis of encephalitis?
Impaired neck flexion resulting from muscle spasm Like meningitis, encephalitis is characterized by fever, headache, and nuchal rigidity (impaired neck flexion resulting from muscle spasm), but more often clients also experience neurologic disturbances, such as lethargy, disorientation, seizures, focal paralysis, delirium, and coma
A family is sitting with a patient in the intensive care unit who sustained significant head injuries in a motorcycle accident. They are questioning the nurse about why the patient's eyes open but do not stay open for long. The nurse explains that the patient is probably in which of the following states?
In a stuporous state due to a reticular activated system (RAS) injury Injury to the RAS would be suspected due to the change in the level of consciousness. The RAS and functional cerebral hemispheres are necessary for arousal and wakefulness; damage to either will negatively affect a person's level of consciousness.
A client has developed global ischemia of the brain. The nurse determines this is: · inadequate to meet the metabolic needs of entire brain. · inadequate perfusion of the nondominant side of the brain. · inadequate perfusion of the right side of the brain. · inadequate perfusion to the dominant side of the brain.
Inadequate to meet the metabolic needs of the entire brain Global ischemia occurs when blood flow is inadequate to meet the metabolic needs of the entire brain. The result is a spectrum of neurologic disorders reflecting diffuse brain dysfunction. Unconsciousness occurs within seconds of severe global ischemia, resulting either from complete cessation or from marked decrease in blood flow.
Which pathophysiologic process occurs in cases of bacterial meningitis? · Trauma introduces skin-borne pathogens to the cerebrospinal fluid. · Inflammation allows pathogens to cross into the cerebrospinal fluid. · Infection in the cerebrospinal fluid causes spinal cord compression and neurologic deficits. · Infection in the cerebrospinal fluid causes vasoconstriction and cerebral hypoxia.
Inflammation allows pathogens to cross into the cerebrospinal fluid.
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 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.
Which one of the following is the most common primary intracranial tumor in adults?
Neurogliomas or neoplasms of astrocytic origin Neurogliomas or neoplasms of astrocytic origin are the most common type of primary brain tumor in adults.
Hypoxic injury will result in which of the following effects on the brain?
Neuronal cell injury and death Neuronal cell injury and death is directly caused by hypoxic injury. The others are specific to several other brain injury types.
The nurse is preparing a client for oculovestibular reflex assessment (cold caloric test). The nurse explains that the test is used to elicit which of the following?
Nystagmus
A nurse at a long term care facility provides care for an 85 year-old man who has had recent transient ischemic attacks (TIAs). Which of the following statements best identifies future complications associated with TIAs? TIA's:
Resolve rapidly but may place the client at an increased risk for stroke. TIAs can be considered a warning sign for future strokes. They are not hemorrhagic in nature and their effects are not normally cumulative. They may require treatment medically or surgically.
A client has started having uncontrolled seizures that are not responding to usual medications. Nursing working with the client must pay special attention to which of the following priority aspects of this clients care? Assessment of: · ECG for arrhythmias · Urine output and continence · Respiratory status and oxygen saturation · Ability to grasp hands and squeeze on command
Respiratory status and oxygen saturation Tonic-clonic status epilepticus is a medical emergency and, if not promptly treated, may lead to respiratory failure and death. Treatment consists of appropriate life support measures. Airway/breathing is always the priority in this emergency situation.
The nurse is assessing a client and notes the client is now displaying decerebrate posturing. The position would be documented as: · 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. · 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. · 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 Decerebrate (extensor) posturing results from increased muscle excitability. It is characterized by 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.
The emergency department nurse is caring for a patient who fell and had a head injury. Which of the following assessments would be noted during the early stage of intracranial pressure increase?
Stable vital signs The vital signs remain unchanged in the early stage of increased intracranial pressure.
The nurse taking a report on a client coming into the emergency room plans care for a client with brain dysfunction based on which of the following symptoms?
Stupor The most frequent sign of brain dysfunction is an altered level of consciousness such as stupor.
What term is used to describe a level of consciousness that sees a client responding only to vigorous and repeated stimuli and has minimal or no spontaneous movement? · Lethargy · Stupor · Obtundation · Coma
Stupor Stupor is unresponsive except to vigorous and repeated stimuli; responds appropriately to painful stimuli; lies quietly with minimal spontaneous movement; may have incomprehensible sounds and/or eye opening. Obtundation responds to painful stimuli; follows simple commands; appears very drowsy Lethargy Oriented to time, place, and person; very slow in mental processes, motor activity, and speech; responds to pain appropriately
The nurse is explaining how vasogenic brain edema occurs to a client's family. The most appropriate information for the nurse to provide would be: · Normal physiologic circumstances result in decreased adsorption of CSF. · There is an increase in the production of cerebrospinal fluid volume. · The blood-brain barrier is disrupted, allowing fluid to escape into the extracellular fluid. · 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. 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.
A patient 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 of the following purposes?
Thrombolysis Synthetic tissue plasminogen activators work with the body's natural tissue plasminogen activators to convert plasminogen to plasmin, which breaks down clots to allow for the reestablishment of blood flow. There are two causes of strokes: hemorrhagic and thrombotic, with thrombotic strokes occurring much more frequently. Thrombolytics play a large role in increased outcomes seen with thrombotic strokes.
The most common cause of ischemic stroke is:
Thrombosis. Ischemic stroke includes those caused by large artery thrombosis (20%), small artery thrombosis (25%), cardiogenic embolism (20%) and cryptogenic (undetermined cause)(30%), making thrombosis the most common cause (45%).
A client who is being seen in the outpatient clinic reports a single episode of unilateral arm and leg weakness and blurred vision that lasted approximately 45 minutes. The client is most likely experiencing:
Transient ischemic attack (TIA) Transient ischemic attacks are brief episodes of neurologic function resulting in focal cerebral ischemia not associated with infarction that usually resolve in 24 hours. The causes of transient ischemic attack are the same as they are for stroke. Embolic stroke usually has a sudden onset with immediate maximum deficit.
A patient in the intensive care unit who has a brain tumor has experienced a sharp decline. The care team suspects that water and protein have crossed the blood-brain barrier and been transferred from the vascular space into the client's interstitial space. Which of the following diagnoses best captures this pathophysiology?
Vasogenic edema Vasogenic edema occurs with conditions that impair the function of the blood-brain barrier and allow transfer of water and protein from the vascular into the interstitial space. It occurs in conditions such as tumors, prolonged ischemia, hemorrhage, brain injury, and infectious processes.
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: · myoclonic activity. · aura. · automatisms. · hallucination.
automatisms. The nurse reports that the client exhibited automatisms, defined as repetitive nonpurposeful activities such as lip smacking, grimacing, patting and/or rubbing clothing. Seizures with Impairment of Consciousness or Awareness often arise from the temporal lobe. The seizure begins in a localized area but may progress rapidly to involve both hemispheres. These are sometimes referred to as psychomotor
The nurse is caring for a client with head trauma. The client is flexing the arms, wrists, and fingers. There is adduction of the upper extremities with internal rotation and plantar flexion of the lower extremities. How would the nurse describe this in the notes? · diencephalon posturing · decerebrate posturing · extensor posturing · decorticate posturing
decorticate posturing Decorticate (flexion) posturing is characterized by flexion of the arms, wrists, and fingers, with adduction of the upper extremities, internal rotation, and plantar flexion of the lower extremities.
The nurse is educating parents of a child with arteriovenous malformation. The nurse determines that the parents need additional education when the parents state: · "It may divert blood away from other parts of the brain." · "The vessels of the malformations may become weak and bleed." · "The vessels of the malformation may enlarge to form a lesion." · "It is a rare complication of concussions."
· "It is a rare complication of concussions." it is a congenital defect
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? · Minor residual deficits · Atherosclerotic lesions in cerebral vessels · Diffuse cerebral electrical malfunctions · Aneurysm leakage
· Atherosclerotic lesions in cerebral vessels
Manifestations of brain tumors are focal disturbances in brain function and increased ICP. What causes the focal disturbances manifested by brain tumors? · Brain edema and disturbances in blood flow · Tumor infiltration and increased blood pressure · Tumor infiltration and decreased ICP · Brain compression and decreased ICP
· Brain edema and disturbances in blood flow
An older adult male client has been brought to the emergency department after experiencing stroke-like symptoms a few hours ago, and has been subsequently diagnosed with an ischemic stroke. The care team is eager to restore cerebral perfusion despite the likely death of the brain cells directly affected by the stroke. What is the rationale for the care team's emphasis on restoring circulation? · Cells of the penumbra may be saved from hypoxic damage if blood flow is promptly restored. · Necrosis will continue unabated throughout the brain unless blood flow is restored. · Failure to restore blood flow creates a severe risk for future transient ischemic attacks. · Unless blood flow is restored, the client faces the risk of progressing to hemorrhagic stroke
· Cells of the penumbra may be saved from hypoxic damage if blood flow is promptly restored.
A client's emergency room report includes the presence of a contrecoup injury. The nurse plans care for a client with which of the following? · Closed head injury opposite the area of impact · Infection resulting from exposed brain tissue · Open spinal cord injury with complete severing of neurons Closed head injury in the area of impact
· Closed head injury opposite the area of impact
A client presented to the emergency department with a sudden onset of unilateral weakness and gait disturbances. The client has undergone rapid assessment and diagnostic testing and the nurse has just received an order for STAT administration of tissue-type plasminogen activator (tPA). What conclusion can the nurse draw from this medication order? · The client likely has a recent history of transient ischemic attacks. · Diagnostic testing has ruled out the presence of a hemorrhagic stroke. · The client's stroke-related deficits have been determined to be permanent. · Medication reconciliation has shown that the client takes antiplatelet aggregators.
· Diagnostic testing has ruled out the presence of a hemorrhagic stroke.
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 · Head trauma · Acquired immune suppression · Polyvinyl chloride exposure
· High dose irradiation exposure · Acquired immune suppression 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. high dose radiation (gliomas, meningiomas, nerve sheath) immunosupression = cns lymphoma
Which sign would be considered a late indicator of increased intracranial pressure? · Narrow pulse pressure · Right-sided heart failure · High mean arterial pressure · Tachycardia
· High mean arterial pressure Cushing reflex due to ischemia of vasomotor center, Inc. MAP to Inc. CPP 1. hypertension 2 bradycardia 3. widened pulse pressure (pp = systolic - diastolic)
While lecturing to a group of physiology students, the instructor asks, "What metabolic factors cause vasodilation of cerebral vessels, thereby increasing cerebral blood flow to the brain?" The best student response would be: · Decreased serum sodium level · Increased oxygen saturation · Increased carbon dioxide level · Decreased hydrogen ion concentration
· Increased carbon dioxide level provides a potent stimulus for vasodilation—doubling PCO2 in the blood doubles cerebral blood flow. Inc. Carbon dioxide = vasodilation Inc Hydrogen ion = vasodilation to wash away acidic Dec. Oxygen concentration = vasodilation
Following a head injury, a client is diagnosed with intracranial epidural hematoma. During the initial assessment, the client suddenly becomes unconscious. What additional clinical manifestations correlate with this diagnosis? · Ipsilateral hemiparesis · Diffuse venous bleeding from the nose · Ipsilateral pupil dilation · Increased head circumference with hydrocephalus
· Ipsilateral pupil dilation due to tear in artery (middle meningeal) rapid expansion, compression brain; Brief unconscious, lucid, then unconscious pupil dilation hemiparesis due to uncal herniation
The nurse assessing a client with a traumatic brain injury assesses for changes in which neurologic component? Select all that apply. · Level of consciousness · Metabolic function · Motor function · Sensory function · Cognition
· Level of consciousness · Motor function · Sensory function · Cognition
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? · Muscular dystrophy · Pseudohypertrophy · Muscle atrophy · Involuntary movements
· Muscle atrophy Passive range-of-motion exercises help to maintain joint function and prevent edema, shoulder subluxation, and muscle atrophy and may help to reestablish motor patterns.
A child has developed a benign brain tumor in the cerebellum and the floor of the third ventricle. The proper documentation for this type of tumor includes which terminology? · Oligodendrogliomas · Fibrillary astrocytomas · Ependymomas · Pilocytic astrocytomas
· Pilocytic astrocytomas Oligodendrogliomas midlife, hemorrhagic Fibrillary astocytomas: midlife, Inc. ICP Ependymomas: children, hydrocephalus; 12% adults
A client's recent computed tomography (CT) scan has revealed the presence of hydrocephalus. Which treatment measure is most likely to resolve this health problem? · Aggressive diuresis · Administration of hypertonic intravenous solution · Lumbar puncture · Placement of a shunt
· Placement of a shunt
As a client explains to the nurse what occurred prior to the onset of seizure activity, the client describes perceiving a feeling or warning that the seizure would occur. The nurse documents the perceived warning as which of the following? · Clonic · Atonic · Prodrome · Ictal
· Prodrome ictal = middle of seizure clonic= sustained rhythmical jerking atonic = lacking muscular tone.
An adult client has been admitted to a rehabilitation center after hospital treatment for an ischemic stroke. Which aspect of the client's history would be considered to have contributed to his stroke? · The man takes iron supplements for the treatment of chronic anemia. · The client is an Asian male. · The client takes corticosteroids for the treatment of rheumatoid arthritis. · The client's blood pressure has historically been in the range of 150/90 to 160/100 mm Hg.
· The client's blood pressure has historically been in the range of 150/90 to 160/100 mm Hg.
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? · Thrombogenesis · Hemostasis · Thrombolysis · Hemolysis
· 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? · Deficits in the autonomic control of blood pressure · Weakness in the muscular wall of an artery · Impaired synthesis of clotting factors · Increased levels of cerebrospinal fluid
· Weakness in the muscular wall of an artery
The spouse of a client admitted to the hospital after a motor vehicle accident reports to the nurse that the client has become very drowsy. The nurse should: · contact the physician. · instruct the spouse not to let the client fall asleep until the physician has assessed the client. · assess the client for additional signs/symptoms of increased intracranial pressure. · prepare the client for EEG testing.
· assess the client for additional signs/symptoms of increased intracranial pressure.
The parents of an infant born with hydrocephalus are concerned about the size of the baby's head. The doctors are telling them that the infant needs the surgical placement of a shunt. The nurse caring for the infant in the neonatal intensive care unit explains that placement of a shunt will: · increase intracranial pressure. · reverse any neurologic deficits that are present. · not affect the size of the infant's head. · decrease the likelihood of further neurological deficits.
· decrease the likelihood of further neurological deficits.
An 85-year-old patient with a medical history of diabetes, thrombocytopenia, and hypertension is on the cardiac step-down unit following the development of atrial defibrillation with a heart rate of 120-140. The atrial fibrillation was successfully cardioverted to a normal sinus rhythm and the patient was preparing to be discharged from the hospital when suddenly the patient developed right-sided hemiplegia and dysphasia. The nurse understands that this patient has many modifiable risk factors for stroke including which of the following? Select all that apply.
• Atrial fibrillation • Diabetes • Hypertension
A client may be at risk for the development of hypoxia. Select the conditions that would place a client at risk. Select all that apply.
• Carbon monoxide poisoning • Increased oxygenation by the lungs • Severe anemia Hypoxia usually is seen in conditions such as exposure to reduced atmospheric pressure, carbon monoxide poisoning, severe anemia, and failure of the lungs to oxygenate the blood.
When trying to explain the difference between vasogenic versus cytotoxic cerebral edema, the physiology instructor mentions that cytotoxic edema displays which of the following functions in the brain? Select all that apply.
• Causes ischemia to build up lactic acid due to anaerobic metabolism • Allows cells to increase volume to the point of rupture, damaging neighboring cells
Hydrocephalus is caused by which of the following? Select all that apply.
• Decreased absorption of cerebral spinal fluid • Obstruction of cerebral spinal fluid Hydrocephalus is defined as an abnormal increase in cerebral spinal fluid volume. The two causes include decreased absorption and obstruction of cerebral spinal fluid.
The nurse contacts the physician regarding a client's early signs of diminishing level of consciousness based on which of the following? Select all that apply.
• Disorientation • Blunted responsiveness • Inattention
An older adult is being evaluated for dementia. Which of the following assessments do not indicate normal aging? Select all that apply.
• Is easily agitated when routines are not followed • Is unable to explain the meaning of a proverb • Needs cues to perform hygiene activities Normal aging often includes slower processing of short term memory, and intact long-term memory with recognition cues for recall. Dementia may inhibit cognitive function so the client is unable to perform normal activities such as bathing and dressing. They become agitated, experience difficulty in higher order thinking and problem solving, and may see things that are not there.
The nurse reading the results of a lumbar puncture cerebral spinal fluid analysis anticipates that the client's meningitis will be self-limiting in nature because of which of the following findings? Select all that apply.
• Lymphocytes • Moderately increased protein Viral meningitis, which presents with lymphocytes, moderately increased protein and normal glucose levels in the cerebral spinal fluid upon lumbar puncture, is self-limiting in nature.
Huntington disease is a genetic disorder that does not usually manifest itself until the client is in his or her 40s or 50s. What are the most common early psychological changes that occur with Huntington disease? (Select all that apply.)
• Moodiness • Impulsive behavior • Personality changes Depression and personality changes are the most common early psychological manifestations. Memory loss is often accompanied by impulsive behavior, moodiness, antisocial behavior, and a tendency toward emotional outbursts.
Following a car accident of a male teenage that did not have their seatbelt on; he arrived in the emergency department with a traumatic brain injury. He has severe cerebral edema following emergent craniotomy. Throughout the night, the nurse has been monitoring and reporting changes in his assessment. Which of the following assessments corresponds to a supratentorial herniation that has progressed to include midbrain involvement? Select all that apply.
• Pupils fixed at ~ 5 mm in diameter. • Respiration rate of 40 breaths/min. • Decerebrate posturing following painful stimulation of the sternum. With midbrain involvement, pupils are fixed and midsize (5 mm in diameter), and reflex adduction of the eyes is impaired; pain elicits decerebrate posturing; and respirations change from Cheyne-Stokes to neurogenic hyperventilation.