Ch. 16 Disorders of Brain Function
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, by definition, resolve rapidly, but they constitute an increased risk for stroke.
The 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:
generalized seizure.
The parent of an infant who developed hydrocephalus while in utero is very concerned that the child will have significant intellectual dysfunction. The best response to the parent would be:
"Because the skull sutures are not fused there may be no brain damage."
The family of a male client documented to be in a vegetative state excitedly reports to the nurse that the client has just opened his eyes for the first time. The best response by the nurse is:
"I will come and assess the client."
Much like brain death, there are criteria for the diagnosis of a persistent vegetative state which has lasted for more than 1 month. What are criteria for the diagnosis of persistent vegetative state? Select all that apply.
- Bowel and bladder incontinence - Lack of language comprehension - Variable preserved cranial nerve reflexes
The nurse assessing a client with a traumatic brain injury assesses for changes in which neurologic component? Select all that apply.
- Cognition - Level of consciousness - Motor function - Sensory function
According to the Glasgow Coma Scale, opening one's eyes to only painful stimuli would receive which score?
2
The nurse is caring for a client admitted to the emergency room with suspected meningitis. The nurse prepares to perform which nursing intervention upon physician orders, while diagnostic testing is being completed?
Administration of antibiotics
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.
An 85-year-old client with a history of diabetes, thrombocytopenia, and hypertension develops atrial fibrillation with an irregular heart rate of 120-140 beats/min. After successful cardioversion to normal sinus rhythm, the client is preparing to be discharged when he suddenly develops right-sided hemiplegia and dysphasia. Which modifiable risk factors for stroke does this client have? Select all that apply.
Atrial fibrillation Diabetes Hypertension
A teenager has been in a car accident and experienced an acceleration-deceleration head injury. Initially, the client was stable but then started to develop neurological signs/symptoms. The nurse caring for this client should be assessing for which type of possible complication?
Brain contusions and hematomas
When the suspected diagnosis is bacterial meningitis, what assessment techniques can assist in determining if meningeal irritation is present?
Brudzinski sign and Kernig sign
The nurse working in an emergency room is caring for a client who is exhibiting signs and symptoms of a stroke. What does the nurse anticipate that the physician's orders will include?
CT scan
The nurse is conducting a community education program on concussions. The nurse evaluates that the participants understand the education when they state that which of these offers the brain protection from external forces?
Cerebrospinal fluid
An 80-year-old client 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
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
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
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?
Diagnostic testing has ruled out the presence of a hemorrhagic stroke.
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?
Encephalitis
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
The nurse is planning an inservice on hypoxia versus ischemia in brain-injured clients. The nurse should include which of the following?
Hypoxia produces a generalized depressive effect on the brain
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
The nurse is caring for an older adult client with hemiplegia following a stroke. While planning the client's care, the nurse knows the client is at risk for developing which condition?
Muscle atrophy
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:
administer IV tissue plasminogen activator (tPA).
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?
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?
Prodrome
The MRA scan of a client with a suspected stroke reports ruptured berry aneurysm. The nurse plans care for a client with:
Subarachnoid hemorrhage
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.
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 client's blood pressure has historically been in the range of 150/90 to 160/100 mm Hg.
The most common cause of an ischemic stroke is which of the following?
Thrombosis: Thrombi are the most common cause of ischemic strokes, usually occurring in atherosclerotic blood vessels.
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)
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:
assess the client for additional signs/symptoms of increased intracranial pressure.
The nurse is caring for a client experiencing a seizure. During the seizure the nurse notes that the client repetitively rubs his/her clothing. When contacting the client's physician, the nurse notes that the client exhibited:
automatisms
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 that:
bruising on the surface of the brain occurred.
Severe head trauma from a coup-contrecoup injury may result in which type of brain injury?
cerebral hematoma
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:
characterized by an inability to communicate spontaneously with ease or translate thoughts or ideas into meaningful speech or writing.
A client suffering global cerebral ischemia a week after a suicide attempt by hanging is in the intensive care unit receiving treatment. The parent asks the nurse why it is necessary to keep the client paralyzed with medications and on the ventilator. The most appropriate response would be that these therapies:
decrease metabolic needs and increase oxygenation.
A client has developed global ischemia of the brain. The nurse determines this is:
inadequate to meet the metabolic needs of the entire brain.
The nurse is assessing a client and notes the client is now displaying decerebrate posturing. The position would be documented as:
rigidity of the arms with palms of the hands turned away from the body and with stiffly extended legs and plantar flexion of the feet.
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
(T/F) Global or diffuse brain injury is manifested by changes in the level of consciousness.
True
When trying to explain the difference between vasogenic versus cytotoxic cerebral edema, the physiology instructor mentions that cytotoxic edema displays which 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
The nurse is completing a Glasgow Coma Scale assessment on a client with a traumatic brain injury. Which of the following should the nurse include in the assessment? Select all that apply.
- Eye opening response - Verbal utterances - Motor response
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/min. In response to a noxious stimulus, the client's arms and legs extend rigidly. What is the client's level of impairment?
Coma: Coma is marked by the client not responding appropriately to stimuli and being in a sleeplike state with eyes closed. The client is not conscious so would not meet the criteria for delirium, which is an acutely confused state. Because this client still exhibits a pain response (the extended arms and legs indicate decerebrate posturing), the client does not meet the criteria for brain death or a vegetative state. Unresponsive pupils do not confirm brain death.
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 client's temperature is 102°F (38.9°C). Which other clinical manifestations may lead to the diagnosis of encephalitis?
Impaired neck flexion resulting from muscle spasm
The nurse reading a client's lumbar puncture results notifies the physician of findings consistent with meningitis when which sign/symptom is noted?
Large number of polymorphonuclear neutrophils
A client has been diagnosed with a cerebral aneurysm and placed under close observation before treatment commences. Which pathophysiologic condition has contributed to this client's diagnosis?
Weakness in the muscular wall of an artery
A client suffering a thrombotic stroke is brought into the emergency department by ambulance and the health care team is preparing to administer a synthetic tissue plasminogen activator for which purpose?
Thrombolysis
A client 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 client's spouse is extremely upset because the physician stated that the client cannot receive thrombolytic medications to reestablish cerebral circulation and the spouse asks the nurse why. What is the nurse's most accurate response?
"Thrombolytics may cause cerebral hemorrhage."
Global and focal brain injuries manifest differently. What is almost always a manifestation of a global brain injury?
Altered level of consciousness (In contrast to focal injury, which causes focal neurologic deficits without altered consciousness, global injury nearly always results in altered levels of consciousness ranging from inattention to stupor or coma)
The nurse observes that the upper extremities of a client with a brain injury are abducted while the lower extremities are internally rotated. The nurse communicates which terminology during hand-off reporting?
Decorticate posturing
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:
Epidural hematoma (An epidural hematoma is one that develops between the inner side of the skull and the dura, usually resulting from a tear in an artery, most often the middle meningeal, usually in association with a head injury in which the skull is fractured)
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
A nurse is preparing for a course in cardiopulmonary resuscitation (CPR) and realizes that ventricular fibrillation quickly disrupts blood flow to the brain that causes which result in a matter of seconds?
Global ischemia
A high school student sustained a concussion during a football game. The school nurse will educate the family about postconcussion syndrome and ask them to watch for and report which manifestations of its presence?
Headaches and poor concentration
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: Motor response on the Glasgow Coma Scale is scored as follows: obeys commands 6; localizes pain 5; normal flexion 4; decorticate posture 3; decerebrate posture 2; flaccid 1. Therefore, the nurse should score the client with localized pain as a 5 for the motor response portion of the Glasgow Coma Scale.
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:
decrease the likelihood of further neurological deficits.
