chpt 16 patho
A 26 year-old female is resting after a 1-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
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
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
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?
Ischemic stroke
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
The MRA scan of a client with a suspected stroke reports ruptured berry aneurysm. The nurse plans care for a client with:
Subarachnoid hemorrhage
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)
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 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
As the nurse is performing a physical assessment of a client, the client begins to have seizure activity including loss of consciousness and limb jerking. The nurse's priority is to:
protect the client from injury
The most common cause of ischemic stroke is
thrombosis
Global and focal brain injuries manifest differently. What is almost always a manifestation of a global brain injury?
Altered level of consciousness
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
The nursing assistant reports to the registered nurse that a client with a brain tumor has a blood pressure of 180/100 mm Hg and a pulse of 50 bpm. Which action is the correct nursing intervention?
Report to physician the client's signs of increased intracranial pressure
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
