Exam 2: Med Surg 3
A patient being treated for a brain tumor is receiving radiation therapy. Which assessment findings indicate that nursing management of this patient is effective?
Albumin 3.5 An albumin level of 3.5 indicates adequate nutritional intake. Nutritional intake should be assessed to ensure nursing management is effective.
An older patient was found unconscious at home and was brought to the hospital. Upon arrival at the emergency department (ED), the patient regained consciousness and spoke with the nurses. During the initial assessment the patient complained of a headache immediately before losing consciousness again. These are all classic manifestations of which head trauma complication?
Epidural hematoma Classic signs of an epidural hematoma include an initial period of unconsciousness at the scene, with a brief lucid interval followed by a decrease in level of consciousness (LOC). Other manifestations may be a headache, nausea and vomiting, or focal findings.
Clincal mnifestation with tumor location: Temporal
Papilledema
The nurse is caring for a patient with a ventricular shunt and notes decreased level of consciousness (LOC), a temperature of 102 °F, and vomiting. Which orders would the nurse anticipate? Select all that apply.
prep for surgery Ceftriaxone 1g IV
The nurse is educating a patient scheduled to travel abroad about prevention of encephalitis. Which information should be included in the teaching plan? Select all that apply.
Avoid swampy areas Use mosquito nets Wear insect repellant clothing
Which signs and symptoms are most characteristic of vascular dementia caused by an acute cerebrovascular event?
Fainting spells Nausea and vomiting Sudden decline in memory
The nurse is administering IV dexamethasone to a patient with a frontal lobe tumor who reports left upper quadrant pain, nausea and vomiting. Upon assessment, the nurse notes coffee ground emesis and tenderness on palpation. Which provider order would the nurse anticipate?
Insert NG tube The nurse would expect to insert a NG tube to decompress the stomach in a patient with active GI bleeding to prevent aspiration.
An older adult patient is found wandering the streets and is brought to the emergency department. The patient cannot recall her name or where she lives and is admitted to the hospital for observation. She periodically has crying fits and calls out for her mother. What are the nurse's best actions?
Look the patient in the eyes. Redirect the patient to another activity.
A nurse is caring for a patient with a family history of stroke. Which priority action should the nurse take to further assess the patient's risk of hemorrhagic stroke?
Monitor the patient's blood pressure Hypertension is a risk factor for hemorrhagic stroke. If the nurse detects high blood pressure, this would be indicative of a further risk of stroke
A 52-year-old patient presents with recurring facial weakness. He says, "I feel fine in the morning, but my face is so weak in the afternoon that I can't even talk." Which drug would the nurse anticipate administering to aid in facial muscle contraction?
Pyridostigmine Pyridostigmine is used to increase muscle strength in patients with myasthenia gravis.
Match the type of subdural hematoma with its progression of symptoms: lteration in mental status progresses as hematoma develops
Subacute
The nurse assesses a 75-year-old patient with Alzheimer's disease. The patient is restlessly pacing around the room and is calling his deceased wife's name. Which actions would the nurse take?
Use the patient's name Touch the patient on the arm
Which surgical procedure should be performed in a patient who has suffered a depressed skull fracture?
Cranioplasty Cranioplasty is performed to repair a cranial defect, such as a depressed skull fracture, resulting from trauma, malformation, or previous surgical procedure.
A patient with a suspected brain tumor asks the nurse why a CT scan has not been ordered. Which statement, made by the nurse, would be the best response?
"An MRI may a better option for diagnosing your tumor." MRI is more appropriate for detecting small tumors. The nurse should clearly explain all procedures and treatments and their rationale.
When educating a patient with right-brain stroke about performing activities of daily living (ADLs), which suggestions would the nurse make?
"Shave both sides of your face." Patients with right-brain stroke often develop one-sided neglect. Reminding them to address the paralyzed side is an important part of patient teaching.
Identify the physiologic events which can lead to increased intracranial pressure and accumulation of CO2. Select all that apply
Brain abscess occipital tumor subdural hematoma bacterial meningitis Blunt force trauma to head
Which patient is most at risk for developing vascular dementia?
65-year-old with history of smoking 2 packs per day and high cholesterolA heavy smoker with high cholesterol is at high risk for vascular dementia. Both smoking and high cholesterol are significant risk factors.
During the assessment of a patient with a head injury from a fall, the patient reports a sudden severe headache, nausea and vomiting. The nurse notes right sided weakness, slurred speech and a right facial droop. For which collaborative care procedure would the nurse expect to prepare the patient?
Burr holes Burr holes are used to remove localized fluid and blood beneath the dura, such as may occur from a hemorrhage.
Match the types of skull fractures with their description. Inward indentation of skull
Depressed
Place the tumor types in order of malignancy from benign to highly malignant.
Acoustic neuroma Oligodendroglioma Glioblastoma multiforme Astrocytoma
Match the type of subdural hematoma with its progression of symptoms: immediate deterioration
Acute
A patient with a history of multi-infarct dementia arrives at the emergency department confused, agitated, and disoriented. Which nursing intervention should the nurse implement first?
Clear the area of sharp objects.The nurse should put the patient's safety first and remove any dangerous materials from the patient's surrounding area.
A patient with a history of a brain aneurysm is in the clinic for a routine examination. The patient wants to know if there are any ways to prevent complications of the aneurysm. Which treatment does the nurse describe to the patient?
Clipping Clipping may prevent a hemorrhagic stroke in a patient with a known brain aneurysm by preventing rebleeding of the aneurysm
Which incidents are the most common causes of head injury?
Falls Car accidents
A patient with hypertension is diagnosed with a hemorrhagic stroke resulting from intracranial hemorrhage. The symptoms began several hours earlier and have been progressively worsening. Which treatment orders would the nurse question for this patient?
Platelet inhibitor Platelet inhibitors are contraindicated for patients with active bleeding, as is suggested by the patient's progressively worsening symptoms. you want beta blockers, antiseizure meds, and calciumc hannel blockers
Which factors are believed to contribute to the development of multiple sclerosis (MS)?
Smoking Genetics Infections Emotional Stress
Compared to neurodegenerative dementia, how does vascular dementia usually present?
abrupt stepwise
When meeting a patient with delirium for the first time, the patient's wife is present and asks the nurse how dementia and delirium are different. How could the nurse respond?
"Dementia develops over time, while delirium is more sudden." This is an appropriate response, because delirium is characterized by a sudden onset.
A patient with no history of seizures presents with multiple episodes of seizure activity and magnetic resonance imaging (MRI) is ordered. When questioned by the patient as to why MRI is being done, what is the best response by the nurse?
"MRI can show structural lesions." MRIs and computed tomography (CT) scans are ordered for patients with no previous diagnosis of seizures to examine the brain for lesions.
A patient arrives at the emergency department with bradypnea, dysphagia, and difficulty communicating. The patient's caregiver indicates the symptoms came on quickly, just in the last hour. The health care provider suspects the patient is suffering from a stroke. Place the actions the nurse would take in the appropriate order when caring for this patient.
1. Administer anticoagulants as needed 2. prepare pt for CT scan 3. admin recombinant tissue plasminogen activator (tPA) 4. take vitals and assess airway
A patient is being discharged after treatment for a hemorrhagic stroke. The patient's caregiver asks the nurse how to care for the patient at home. What is an appropriate response from the nurse? select all that apply
:Be sure to keeps scheduled appointments every week" "assist with ROM activites to prevent atrophy" "Ensure every pt takes antihypertensice meds every day at evening meal" "If you notice any worsening of symptoms, you shoudl contact HCP ASAP"
The nurse is caring for a patient with encephalitis. The patient reports headache, nausea and irritability. The nurse notes temperature 103.2, BP 138/88, HR 97, Respirations 22, SpO2 96%. Which action would the nurse take first?
Administer Phenytoin IV Phenytoin should be administered as a prophylactic for seizure prevention.
Which information can an electroencephalogram (EEG) provide about a patient who is having seizures?
An EEG can show the location of abnormal brain activity. EEGs show the location of abnormal brain activity, thereby facilitating identification of the seizure.
Which physiologic event leads to decreased oxygen and death of the brain cells?
Decreased cerebral blood flow Decreased cerebral blood flow from compression of cerebral blood vessels leads to decreased oxygen and brain tissue death.
Which pathologic process affects the development of relapse in multiple sclerosis (MS)?
Demyelination Demyelination is the destruction of myelin sheaths surrounding neurons and has the greatest effect on relapse in MS.
Clincal mnifestation with tumor location: Frontal
Diplopia
Clincal mnifestation with tumor location: Occipital
Dysphagia
How is epilepsy different from other seizure disorders?
Epilepsy is caused by a chronic underlying condition. Epilepsy is different from other seizure disorders as epileptic seizure activity is caused by a chronic underlying condition. In some patients epilepsy is noted as the underlying cause of the seizures.
Which statement best describes bacterial meningitis?
Inflammation of brain and spinal cord tissue caused by Streptococcus pneumoniae Bacterial meningitis is an acute inflammation of meningeal tissue surrounding brain and spinal cord.
A patient has had a hemorrhagic stroke and was just evaluated for dysphagia by a speech therapist. Which rehabilitation order should the nurse expect?
Initiate oral diet Speech therapists routinely assess gag reflex, swallowing ability, chewing ability, and pocketing and will prescribe appropriate diet and fluid consistency. The nurse may initiate an oral diet if the speech therapist indicates the patient is ready.
A patient is suspected of having a hemorrhagic stroke. Magnetic resonance imaging (MRI) is ordered, but results are inconclusive. For which procedure should the nurse expect to prepare the patient?
Lumbar puncture A lumbar puncture may be done to look for evidence of red blood cells in the cerebrospinal fluid if a subarachnoid hemorrhage is suspected but MRI does not show evidence of hemorrhage.
A nurse is caring for a patient with new onset of delirium. The nurse should collaborate with which members of the patient care team in planning interventions to protect the patient's skin integrity? Select all that apply
Nurses Dietician Physical therapist Healthcare provider
A nurse is caring for a patient with new onset of delirium. When organizing the patient's discharge from the hospital, the nurse should ensure that which type of provider will visit the patient at home?
Physical therapist Priority interventions for a patient with delirium include prevention of skin breakdown and increasing physical activity. The nurse should ensure that a physical therapist will see the patient at home to teach range-of-motion exercises and build lower extremity strength.
A nurse is monitoring a patient with increased intracranial pressure using a ventriculostomy. The patient's ICP monitor indicates that the P2 wave is higher than the other waves. Which provider order would the nurse anticipate?
Prepare for surgery. When P2 wave depicting relative brain volume is higher than the other waves, it indicates a high ICP with compromised intracranial compliance. The nurse would expect to prepare the patient for surgery to assess/reposition the ventriculostomy tube.
A patient is concerned about having a stroke after a close relative died suddenly from a hemorrhagic stroke. What should the nurse recommend the patient discuss with the health care provider?
Scheduling a follow-up evaluation Routine health assessments are a preventative measure to reduce the risk of stroke, especially for patients who are at increased risk, including those receiving anticoagulation therapy and those with a family history of stroke.
Match the types of skull fractures with their description. linear or depressed fracture without fragmentation
Simple
A patient presents with symptoms of Parkinson's disease. Which medical history finding would be most concerning for the nurse?
The patient takes medication daily for schizophrenia. Some antipsychotic medications can cause Parkinson-like symptoms.
A patient is being evaluated for discharge. Which is a determining factor in the discharge planning?
The patient's ability to perform activities of daily living (ADLs) The patient's level of independence in ADLs is a critical factor in discharge planning.
Why would it be important to know a patient's past history of dementia when assessing the patient for delirium?
The symptoms of dementia may cover up delirium. Dementia and delirium may be confused. Dementia is a risk factor for delirium.
A patient with rapidly increasing ICP had an emergency craniotomy to relieve the pressure. Now that the patient is stable, which action should the care team perform?
Transport to CT scan Once the patient is stable, the collaborative care team should complete a CT scan to quickly diagnose the reason for the increased ICP.
What are the primary symptoms used to help diagnose patients with Parkinson's disease?
Tremor, rigidity, bradykinesia
Which factor would assist the nurse in distinguishing between dementia and delirium in a patient?
sleep onset duration
A patient presents with abnormal extension, does not open their eyes to stimulus, and does not give a sound as reaction to pain. The patient exhibiting these signs would be given a score of ----- using the Glasgow Coma Scale.
4
A nurse is caring for a patient with Parkinson's disease in long-term care who coughs when drinking and eating. How should the nurse modify the patient's diet?
perfrom dysphagia screening test, only allow patient to consume thickened liquids remove shredded and ground meats from diet
A 68-year-old male has been diagnosed with delirium. Which signs of delirium should the nurse expect when assessing the patient?
poor appetite inability to sleep inability to answer easy question snapping at people with provocation
A nurse is caring for a patient who recently suffered a traumatic brain injury. The patient complains of severe headache, nausea and vomiting, and is irritable. The nurse notes increased blood pressure and a fixed right pupil. Which action would the nurse take first?
Elevate the head of the bed The patient's symptoms indicate worsening ICP. Elevating the head of the bed helps to facilitate drainage of CSF in a patient with increased ICP.
A patient with bacterial meningitis is found lying supine, complaining of headache and nausea. Which nursing intervention is priority for this patient?
Elevate the head of the bed The patient is experiencing a headache and nausea due to increased intracranial pressure from the meningitis. Elevating the head of the bed will promote cerebrospinal fluid drainage and relieve the patient's headache and nausea.
The daughter of a patient with mixed delirium wants to know how it is different from other types of delirium. What is the nurse's best response?
"Your father may switch between hypoactive symptoms and hyperactive symptoms." With mixed delirium the patient will switch between hypoactive and hyperactive delirium.
A patient with dementia has been acting agitated and has started hitting health care staff who interact with him. Which medication may be helpful for this patient?
Haloperidol Haloperidol, an antipsychotic, is appropriate in very small doses for acute agitation and is used to manage behavioral problems in patients with dementia.
A patient who has suffered an ischemic stroke has been admitted to the hospital and is in stable condition after tPA treatment. Which nursing assessment is a priority for this patient?
Asking the patient simple time and place questions In a stable patient, neurological checks, such as asking the patient simple orientation questions, should be performed.
A nurse is caring for a patient who has recently been diagnosed with encephalitis. When the nurse enters the patient's room, the patient claims that they "fell asleep in bed, but woke up on the floor" and don't remember how they got there. The patient is showing increased confusion. Which nursing action should be implemented immediately for this patient?
Assess the patient for Injuries The patient should be thoroughly assessed for signs of injury, since they have had an unwitnessed fall.
A patient with dementia is being discharged from the hospital. Which points should the nurse include in a discharge plan for the caregiver?
Ensure that windows are locked. Install handrails in the bathroom. Ensure that emergency numbers are on speed-dial. Rearrange the living area so that patient does not need to use stairs.
A patient with increased intracranial pressure is being treated. Which medications can be given simultaneously in order to decrease this patient's increased ICP?
Mannitol Hyoertonic Saline Mannitol can be given in combination with another medication to treat increased ICP in severe cases. Hypertonic saline is given in combination with another medication to decrease ICP in severe cases
A patient is showing symptoms of encephalitis. Which question should the nurse ask the patient?
"Have you recently spent time in wooded or swampy areas?" Encephalitis is often acquired from tick or mosquito bites that may be obtained while hiking.
Which patient complaint would alert the nurse to a hemorrhagic stroke caused by a ruptured aneurysm?
"I don't remember ever having a headache this bad." Sudden onset of a severe headache that is different from a previous headache and typically the "worst headache of one's life" is a patient complaint that would alert the nurse to a hemorrhagic stroke caused by a ruptured aneurysm.
An 85-year-old patient presents with urethral discharge and painful urination as well as confusion. The health care provider ordered a urinalysis. What is the rationale for this test in relation to the confusion?
A urinary tract infection can trigger delirium. A urinary tract infection is often the trigger for delirium in an older adult. An 85-year-old with a UTI may have acute onset of delirium symptoms.
A nurse enters the room of an 87-year-old patient after emergency surgery. The patient becomes combative and starts hitting the nurse during routine care. What should the nurse do first?
Administer haloperidol as ordered Haloperidol is an antipsychotic drug used for agitation and combativeness related to delirium. The nurse should administer the drug as ordered to calm the patient and prevent injury to the patient or staff.
The nurse understands that which abnormalities are responsible for the development of Alzheimer's disease?
Amyloid plaques Neurofibrillary tangles
Which scenario(s) depict a patient with late clinical signs of delirium?
An 86-year-old male hospitalized with pneumonia is agitated and trying to get out of bed, stating he is "crawling with bugs." An 82-year-old female admitted for emergency post-stroke treatment has been in the ICU for five days, seeing and talking to people not visible. An 80-year-old hospitalized man is easily excited about the change to his daily routine, and is yelling and screaming at the hospital staff. SUBMIT
The nurse is caring for a patient who experienced an ischemic stroke and is depressed and having trouble coping. What are priority nursing actions for this patient? select all that apply
Ask pt how they feel about diagnosis ask pt if family would like to join to talk about long-term treatment plan
A patient is experiencing prolonged multiple seizures. Which collaborative care interventions should be prioritized during this critical time?
Assess vital signs maintain patent airway obtain blood chemistries
Which components can affect a patient's increased intracranial pressure?
Blood, Brain tissue hematoma cerebrospinal fluid
Which cancers commonly metastasize to the brain?
Breast and Lung
MAtch the type of subdural hematoma with its progression of symptoms: progressive alteration in LOC with a nonspecific progression
Chronic
A patient with Alzheimer's disease reports concern over his mental status, specifically an inability to recall the names of common objects around the house. Additionally, the patient's spouse indicates that the patient will periodically lose his way within the house they have shared for over 40 years. Which medications would the nurse expect to administer to this patient?
Donepezil Memantine
A nurse is managing a patient who exhibits signs of delirium. Which neurotransmitter imbalances contribute to the development of delirium in this patient?
Dopamine Serotonin
The nurse is taking the history of a patient who has suffered a stroke. The patient has a history of atrial fibrillation and reports that the symptoms came "out of nowhere." The nurse suspects the patient suffered which type of stroke?
Embolic Atrial fibrillation is a risk factor for an embolic stroke. Other heart conditions associated with emboli are myocardial infarction and inflammatory and valvular heart conditions.
A 2-week-old infant has been hospitalized for cellulitis in the cheek and is being discharged after receiving antibiotic treatment. For which reasons would this patient be at increased risk for a seizure?
Facial cellulitis increases the risk for brain infection. Bacteria from facial cellulitis can spread to the brain and lead to encephalitis and possible seizures.
During the assessment of a patient with a brain abscess, the nurse notes elevated blood pressure and altered level of consciousness. Which additional symptoms should the nurse assess for? Select all that apply.
Fever Nausea Headache Drowsiness
A patient is being discharged from the hospital after suffering a stroke that has left the patient immobilized. Which nursing care is a priority to ensure the patient receives appropriate post-hospital care?
Identify appropriate rehabilitation resources At discharge, the nurse should identify community resources for the patient, including appropriate rehabilitation resources for a patient who is immobilized.
Which actions can the nurse take to decrease environmental stimuli for a patient with bacterial meningitis
Turn off TV Turn off overhead lights limit visitors close blinds
The nurse is caring for a patient with headache, blurred vision, nausea, and vomiting after being struck with a baseball bat during a game. The nurse notes elevated blood pressure and confusion. CT reveals a subdural hematoma. Which provider order would the nurse implement first?
Prep patient scalp for burr holes The nurse would anticipate the need to create burr holes to evacuate blood from the subdural hematoma.
A patient with a temporal lobe tumor is having trouble communicating with the nurse. What is the appropriate nursing action?
Provide the patient with a pen and paper Providing a pen and paper allows the patient with aphagia related to a temporal lobe tumor to communicate directly with the nurse. Communication difficulty may also indicate progression of the tumor into the parietal lobe.
A patient with a large tumor in the occipital region asks the nurse about the benefits of surgery. Which information would the nurse include in the response? Select all that apply
Removeal can releive symptoms Surgery can reduce the tumor mass removal of tumor will decrease ICP Coplete surgical removal may not be possible
A 27-year-old patient presents after having had a seizure. The patient's parents accompany him and confirm that there is no family history of seizures on either side. The family asks the nurse how this could have happened. The nurse explains that which other factors may have contributed to the patient's seizure?
Renal Failure Hypoglycemia Alcohol withdrawal
A 35-year-old male patient with a history of epilepsy is in the intensive care unit after having a car accident. Because of injuries sustained during the accident, the patient is sedated for ventilation support. Which signs and symptoms should the nurse continue to assess for in this patient?
Tachycardia Muscle tremors Cerebral Hypoxia increased intracranial pressure (ICP)
A nurse is reviewing the discharge orders for a patient newly diagnosed with myasthenia gravis (MG). Which information should the nurse teach the patient regarding the use of pyridostigmine?
Take meds on a schedule plan meds for peak times during activities taking too much meds can lead to cholinergic crisis
A patient is being evaluated for an ischemic stroke. The patient tells the nurse that the primary health care provider indicated that a narrowing of blood vessels caused the stroke. Which type of stroke does the nurse explain that the patient has?
Thrombotic Formation of a thrombus narrows the blood vessels in the brain and is the cause for a thrombotic stroke.
A patient is diagnosed with a hemorrhagic stroke related to intracerebral hemorrhage. The patient is stable, and the nurse is performing an assessment. Which possible assessment findings would be related to the patient's diagnosis? select all that apply
Use of illicit drugs history of hemophilia history fo hypertension
A patient is being discharged after treatment for a left-brain hemorrhagic stroke. The patient voices concern about being completely dependent of others to feed him. Which patient teaching is necessary for this patient?
Using the left hand to perform tasks The nurse should teach the patient to use the unaffected upper extremity to perform tasks such as eating and shaving.
A charge nurse is meeting with the team members on the unit and is discussing care of a patient with bacterial meningitis. Which information about visitors is most important for the charge nurse relay to the care team?
Visitors should be limited, and will be required to wear appropriate PPE. Visitation should be limited to allow the patient to rest. Patients will be on isolation precautions and visitors and care team members will be required to wear masks, gowns and gloves. Any persons or visitors coming into contact with someone diagnosed with bacterial meningitis may also require prophylactic antibiotics.
A nurse is caring for a female patient with myasthenia gravis. The patient states that she has been angry and depressed and says, "I can't do anything for longer than a few minutes." How should the nurse respond?
"Try to adapt your schedule so you aren't as tired." Patients with myasthenia gravis should adapt their schedule to include ample rest periods and prevent fatigue.
A nurse is caring for a patient with a history of seizures who has been taking antiseizure medication. The patient says, "I haven't had a seizure in almost a year. When can I stop taking the pills?" How should the nurse respond?
"You must be seizure free for at least 2 years." Patients with a history of seizures must be seizure free for 2 to 5 years before medication may be weaned.
While the nurse is preparing Ms. Cohen for discharge, Ms. Cohen states that she takes an additional phenytoin when she begins to note the aura and headache that accompany her seizures. Which response by the nurse would be most appropriate?
"You should only take the medication as prescribed." The nurse should educate Ms. Cohen about the importance of compliance with the medication regimen.
The nurse is giving discharge instructions to a patient with multiple sclerosis (MS). Put the symptoms the patient should monitor for in order, from highest to lowest importance.
1. Difficulty swallowing 2. SOB 3. Vomiting 4. Peripheral Edema 5. Leg Cramps The nurse should base education on the symptoms that are most concerning. Shortness of breath and difficulty swallowing indicate problems with the respiratory system or airway and the patient's ability to obtain nutrition. Peripheral edema indicates a potential circulatory problem. Vomiting increases the risk for fluid and electrolyte imbalance. Leg cramps are uncomfortable but are not an emergency.
The nurse is caring for a patient with a history of epilepsy, and the patient starts having a seizure. Which is the priority collaborative care action for this patient?
Apply bag-valve mask for respirations. Supporting the patient's respirations is the priority action.
A patient is diagnosed with acute onset of ischemic stroke and treated with tissue plasminogen activator (tPA). What is the nurse's primary role during tPA administration?
Assess patient level of consciousness During tPA administration the nurse should closely monitor the patient's vital signs and neurologic status, including level of consciousness, to assess for improvement or deterioration related to treatment.
A patient diagnosed with a transient ischemic attack (TIA) is treated with a carotid endarterectomy (CEA). The patient returns two weeks later having suffered another TIA. Which surgical procedure would the nurse anticipate preparing the patient for?
Extracranial-intracranial (EC-IC) bypass EC-IC bypass is used to reroute blood flow around an obstruction for patients who do not benefit from other forms of therapy.
Which assessments are most important for the nurse to conduct when admitting a patient diagnosed with a brain tumor? Select all that apply
pain level range of motion vision screening patient orientation
A patient is diagnosed with an intracerebral hemorrhagic stroke and asks the nurse, "How could this have happened?" What is the best response from the nurse?
"Blood leaked into your brain tissue." An intracerebral hemorrhagic stroke is caused by a leakage of blood from a vessel or bursting of a blood vessel, which results in bleeding into the brain tissue.
A 78-year-old patient with a broken hip is hospitalized. The patient develops delirium. The patient's children ask whether medication is an option for delirium. How should the nurse respond?
"Drug therapy can be used for patients that may have extreme agitation, but should be used cautiously." This is an appropriate response because drug therapy is reserved for patients with severe agitation and should be used as a last resort.
The nurse is educating a patient about the prevention of vascular dementia. Which statement made by the patient demonstrates understanding of the topic?
"I should eat fresh fruits and vegetables." This would be an appropriate answer. The patient should eat a heart-healthy diet, which includes fresh fruits and vegetables.
A patient is scheduled to undergo a Guglielmi detachable coils procedure. The patient asks the nurse why this procedure is being done. What is the best response from the nurse?
"It can protect against an aneurysm burst by encouraging clot formation." The Guglielmi detachable coils procedure assists with thrombus and scar formation, which keeps the aneurysm from rupturing and causing a subarachnoid hemorrhage.
The nurse is educating a student nurse about risk factors for delirium in younger patients. Which statement made by the student nurse indicates a need for further education?
"The younger female patient would have the higher risk for developing delirium." Females are less likely than males to develop delirium. This statement is incorrect and requires further teaching.
A patient is concerned by recent occurrences of "forgetfulness" that have interfered with both work and social interactions. Which questions should the nurse ask to elicit the most information from the patient?
"Which social activities do you enjoy?" "How are you managing your forgetfulness?" "Are you taking any medications that help you with your forgetfulness?"
A charge nurse is teaching a new nurse about vascular dementia. Which statement about vascular dementia is correct?
"it is a result of brain lesions" "the patient may have a loss of cognitive function" "it is caused by a decrease in blood flow to the brain"
A 71-year-old man presents with new onset seizures. Which information should be included in patient teaching regarding medications?
"use a soft bristle toothbrush from this point forward" "notify the provider if you notice right upper quadrant pain or severe abdominal pain" "take meds daiy until provider gives other instructions" "you will need regular blood draws when you're taking this medication"
Which manifestations would cue the nurse to suspect the onset of delirium in a patient?
Apathetic demeanor Combative behavior Difficulty following directions
The nurse is caring for a patient who has had three seizures in the past 2 days. The patient reports headache, right upper quadrant pain, and irritability. The nurse notes icteric sclera, abdominal distention, and elevated blood pressure. Which additional action would the nurse take next?
Assess liver function. The patient's symptoms indicate liver failure. The nurse would order tests to evaluate the patient's liver function.
During assessment of a patient with head trauma, the nurse notes slurred speech and a right sided facial droop. Which action should the nurse take? Select all that apply
Assess pt airway patency Visualize pt pupillary response Evaluate pat level of consciousness
A patient is being treated for a hemorrhagic stroke. The patient is alert and able to verbalize basic needs and wants. The patient is currently able to use the bathroom with assistance but continues to have facial paralysis. Which patient care goals are most appropriate for this patient before discharge?
Assess the patient for dysphagia. The patient has facial paralysis. Before discharge, the nurse should ensure that the patient is able to maintain adequate nutrition, as malnutrition caused by inability to eat can be a complication of stroke.
When caring for a patient admitted with a temporal lobe tumor, the nurse prepares the patient for which diagnostic procedure?
Biopsy Histology is performed from tissue obtained during surgery or biopsy to definitively diagnose malignancy.
A 25 year old patient is seen in the emergency department with acute onset of mental status and behavioral changes and a diagnosis of new onset delirium has been made. Which laboratory tests would be included in the evaluation of this patient, in order to determine the cause?
Blood Alcohol Level Serum electrolytes thyroid function tests CBC
A patient arrives at the emergency department with symptoms of a stroke. Which diagnostic test should the nurse immediately prepare the patient for to further investigate the cause of the patient's symptoms?
CT to distinguish between ischemic and hemorrhagic stroke, perfromed within 30 min of arrviing at ER
A patient is being seen for a routine checkup. When entering the exam room, the nurse sees the patient seizing on the floor, with arms and legs jerking. List the nursing interventions to implement for this patient in the correct order.
Call for help admin antiseizure meds Ensure patient safety turn pateint onto left side provide assistance with respiration
When caring for patients with dementia, the nurse is aware that which neurodegenerative dementia may be mistaken for both Alzheimer's disease and Parkinson's disease?
Dementia with Lewy bodies Dementia with Lewy bodies presents with symptoms of both Alzheimer's disease and Parkinson's disease. Therefore it is possible for this condition to be mistaken for either of these diseases if a thorough assessment is not performed.
A patient with a parietal lobe tumor who is receiving radiation therapy complains of worsening headaches, nausea, and drowsiness. The nurse suspects increased ICP and anticipates which health care provider order?
Dexamethasone 10 mg IV Dexamethasone is a corticosteroid and is used to treat cerebral edema. Headache, nausea, and drowsiness are symptoms of cerebral edema.
Match the appropriate pharmacological therapy to the dementia symptom it treats.
Difficulty identifying family members Haloperidol Inability to find joy in previously enjoyable activities Donepezil Physical violence or aggression Ciprofloxacin
A patient arrives at the emergency department and indicates that she has had a stroke. Which assessment findings would the nurse expect to see to support the patient's claim?
Dyspnea drooling dysphagia slurred speech
A patient is being treated for an ischemic stroke and asks the nurse if there is any way to prevent complications of a stroke without drug therapy. Which suggestions does the nurse provide? select all that apply
Eat a lot of fiber turn Q 2 hours complication fo stroke is constipation and avoid laying in same spot for long time
A nurse is caring for a patient after resection of a temporal lobe tumor. The patient begins to complain of headache and nausea. Which action should the nurse take?
Elevate head of patient's bed Elevating the head of the bed allows for appropriate drainage of CSF and is helpful for the patient with increased ICP.
A patient arrives in the emergency department with signs of a hemorrhagic stroke. The patient's electronic health record indicates a history of arteriovenous malformation (AVM), and the patient is scheduled for a gamma knife procedure and interventional neuroradiology. What is the purpose of the interventional neuroradiology?
Embolizing the blood vessels Interventional neuroradiology may be done before either a gamma knife procedure or surgical resection to embolize the blood vessels that supply the AVM.
A nurse is caring for a patient with delirium. Which intervention, suggested by the nurse, may help create a calm and safe environment for the patient?
Encouraging family members to stay at the bedside The nurse should create a calm and safe environment by encouraging family members to stay at the bedside. This can help the patient with delirium stay calm as the family members are a familiar face in a strange environment.
How is the onset of neurodegenerative dementia commonly described?
Gradual Neurodegenerative dementia is often described as gradual and progressive, with symptoms developing slowly over time.
A patient is newly diagnosed with dementia after several months of progressive cognitive decline. The patient is prescribed medication to aid in memory and is still able to perform light duty at work. Which intervention is indicated to counteract the decline in cognitive function?
Hanging calendars on the wall Providing calendars or using sticky notes to aid memory is often a successful approach to managing cognitive decline and memory loss. The nurse should give the patient and caregivers this information and assist if necessary.
A 77-year-old female patient with osteoarthritis is admitted to the ICU after an emergency surgery. Which factors would make this patient at risk for developing delirium?
ICU environment Age of the patient Emergency surgery
What is the result of acetylcholine receptor destruction in myasthenia gravis?
Impaired skeletal muscle function Acetylcholine receptor destruction causes progressive skeletal dysfunction and alters motor function.
A patient with suspected myasthenia gravis (MG) is scheduled for an edrophonium test and questions the nurse regarding the procedure. The nurse would explain that the diagnosis will be confirmed if which action is witnessed after the edrophonium injection?
Improves muscle contractility The edrophonium test is the diagnostic evaluation for MG. If muscle contractility improves with administration of the medication, the patient is diagnosed with MG.
A patient with myasthenia gravis is having difficulty swallowing and breathing. Which nursing intervention should be implemented for this patient?
Insert an oral airway. An oral airway will help maintain the patency of the airway.
A nursing home patient who is normally independent in ADLs is refusing to get out of bed. The patient has been diagnosed with hypoactive delirium. Which signs could the attending nurse expect?
Lack of activity Decreased motor activity indicates hypoactive type of delirium.
A patient has been admitted to the hospital and is being treated for complications of a hemorrhagic stroke. The patient develops a fever and dyspnea. What is the priority step in nursing management?
Maintain adequate oxygenation. Maintaining adequate oxygenation is an intervention for the patient presenting with respiratory symptoms such as dyspnea
A patient previously diagnosed with lung cancer now reports headaches, nausea and vomiting, and a new onset of muscle weakness. Which condition does the nurse suspect?
Metastatic tumor Because the patient was previously diagnosed with lung cancer, the nurse would suspect a metastatic brain tumor.
A 28-year-old patient sprained a knee while running and has had pain and swelling that comes and goes for over a month. The patient presents today with paresthesias of the hand and a repeat fall. With which degenerative neurologic problem would this patient be diagnosed?
Myasthenia gravis Intermittent muscle weakness and leg swelling are indicative of myasthenia gravis.
A patient with a 15-year history of multiple sclerosis (MS) presents with chronic pain and inflammation. The patient receives opioid therapy and home treatment to preventing MS triggers. The patient asks the nurse whether there are any other treatment options. The nurse explains that the provider should discuss the benefits and risks of which procedures?
Neurectomy deep brain stimulation intrathecal baclofen pump dorsal column electrical stimulation
Which type of dementia may be caused by a sharp blow to the head during a football game?
Normal pressure hydrocephalus Normal pressure hydrocephalus is caused by obstruction in the flow of cerebrospinal fluid (CSF), leading to a buildup of CSF in the brain. This type of obstruction may be caused by a head injury.
While treating a pediatric patient for an unrelated condition, the nurse notices the child "staring off into space" for a few seconds and showing confusion when asked about the episode. When the nurse asks the patient's mother about this, his mother replies, "Oh, he does that all the time. He's a daydreamer." How should the nurse respond to this information?
Notify the provider. A health care provider may decide to order an electroencephalogram (EEG), which can help identify abnormal electrical brain activity
A nurse is caring for a patient with myasthenia gravis admitted for observation related to hypertension. Which provider order would the nurse question?
Oral Lasix twice daily The nurse would question an order for diuretics for a patient with myasthenia gravis because diuretics such as oral Lasix can cause fluid and electrolyte imbalance and worsen the patient's muscle weakness.
Based on Mr. Cantrell's health history and assessment, the nurse should anticipate which collaborative interventions as part of the plan of care?
Patient education on smoking cessation Treatment with antihypertensive medication Lipid panel to evaluate cholesterol level
A patient is brought into the clinic by a caregiver who indicates that the patient's behavior has changed progressively over the last few months. The patient is more forgetful and has experienced loss of simple cognitive abilities, resulting in an inability to maintain employment. For which diagnostic studies to confirm dementia would the nurse prepare this patient?
Patient history Cognitive function tests Neuroimaging
Which intervention is appropriate for a patient who experiences worsening agitation in the late afternoon or evening?
Play soft music during the evening. Creating a quiet, calm environment is crucial to minimizing agitation, especially that which worsens at night.
The nurse is caring for a patient who presents with an actively bleeding head wound. The patient is obtunded, with one fixed pupil. The pulse is thready and respiratory effort is increased. Which provider orders would the nurse anticipate? select all that appy
Prepare for intubation Administer intravenous (IV) 0.9% saline Patients with head injuries should be treated with 0.9% Normal Saline to help fluid shift from the cerebral space back into the cells, decreasing ICP. Patients with head injuries who are obtunded with pinpoint pupils and increased respiratory effort should be intubated.
Which nursing intervention needs correction regarding the priority of care for a patient with new onset delirium?
Prepare the patient for a CT scan Preparing the patient for a CT scan is only a priority in cases in which a head injury is known or suspected.
Which nursing assessment can indicate the presence of increased intracranial pressure?
Pupillary assessment Pressure on the cranial nerves causes fixed pupils in patients with increased ICP. Brisk pupil constriction is a normal finding and is not expected with increased ICP.
For which reason would a patient with vascular dementia be receiving a short-term regimen of memantine, an N-methyl-d-aspartate (NMDA) receptor antagonist?
Reducing confusion and promoting cognition The treatment for vascular dementia is similar to that for neurodegenerative dementia and includes cholinesterase inhibitors and NMDA receptor antagonists to manage cognitive function and memory.
A patient is brought into the clinic by a caregiver who reports that the patient has been experiencing confusion and progressive loss of memory and has been using poor judgment. On assessment, the patient appears unshaven and unwashed and smells of urine. What documented sign would the nurse recognize as an indicator of late-stage dementia?
Soiled clothing The patient's soiled clothing suggests an inability to care for him/herself and is associated with later stages of dementia.
A patient is in the clinic for a routine examination and is concerned about a family history of hemorrhagic stroke. Which suggestions should the nurse make for the patient to reduce the risk of hemorrhagic stroke?
Start an exercise routine daily. Lack of exercise is a modifiable risk factor for strokes. Patients who exercise daily can help reduce high blood pressure. Hypertension is a risk factor for hemorrhagic stroke, so exercise will reduce the patient's risk of having a hemorrhagic stroke.
A patient at high risk for a hemorrhagic stroke has just had a clipping procedure to treat an aneurysm. The nurse is instructed to administer Nimotop (Nimodipine) to minimize cerebral damage. Which is the priority action of the nurse before administration of the drug?
Take the patient's vital signs. Nimodipine is contraindicated for patients with a low heart rate and hypotension. The nurse should take the patient's pulse and blood pressure before administering the drug. If pulse is ≤60 beats/min or systolic blood pressure is <90 mm Hg, the nurse should withhold the medication and contact the primary health care provider.
What is the rationale for further testing and assessment after the Confusion Assessment Method (CAM) is used?
The CAM is only a screening tool. The Confusion Assessment Method (CAM) is a reliable screening tool for assessing delirium. It identifies the presence of delirium, but not the cause. The cause of the delirium would still be unknown after administering the CAM, which is why it is necessary to perform further testing.
A 72-year-old patient with a urinary tract infection is hospitalized. The nurse observes that the patient appears drowsy and lethargic. Upon checking the patient's chart, the nurse suspects that which drug is responsible for the patient's symptoms?
The antipsychotic A patient with a UTI is at higher risk for developing delirium. Anti-psychotic drugs are sometimes used to treat this delirium and carry the risk of side effects, such as lethargy, drowsiness or mood swings and restlessness.
A 74-year-old man presents to occupational therapy with his caregiver. His caregiver has been concerned because the patient, a former engineer, is having trouble doing simple addition problems. The patient has also been wearing thick jackets, despite the summer heat. What are appropriate nursing goals for this patient?
The caregiver will be referred to a support group. The patient will dress appropriately for the season.
A 27-year-old man presents with a history of epilepsy and has started having occasional labored breathing. The patient is taking a number of antiseizure medications and admits he has been "very depressed." Noting that this patient is at increased risk for sudden, unexplained death in epilepsy (SUDEP), which nonnarcotic therapy recommendations could be given to this patient?
Try biofeedback attend local support group sessions visit the respiratory therapy department
The family of a patient with vascular dementia asks the nurse why some health care providers call the disease multi-infarct dementia. Which information should be included in the nurse's explanation to this family?
Vascular dementia may be caused by multiple strokes. Vascular dementia may be caused by a single stroke (infarct) or multiple strokes and therefore can be called multi-infarct dementia.
A patient with a parietal lobe tumor is disoriented and has left-sided weakness. Which interventions would the nurse implement to ensure patient safety? Select all that apply.
apply non-skid socks provide an around the clock sitter instruct atient to ask for help before getting out of bed
A patient with Parkinson's disease presents for continued care. The patient was initially taking carbidopa-levodopa and was later prescribed bromocriptine after the effectiveness of carbidopa-levodopa appeared to wear off. The patient is not responding to these medication changes and has developed difficulty walking and holding objects. Which collaborative care treatments are options for this patient?
deep brain stimulation ablation of the affected area transplant of fetal neural tissue
Which disease or condition is most commonly mistaken for dementia?
depression Severe depression can often mimic dementia such that the two conditions can be mistaken for one another.
A nurse is caring for a patient with Parkinson's disease. Which points should the nurse teach the patient to aid muscle development and decrease the risk of injury?
elevate toilet seat place nonskid pads under all rugs use assistive deviced when necessary include light weight training in an exercise regimen follow diet with balanced carbs and protein
Which factors place a 92-year-old patient at higher risk for developing delirium?
is over the age of 65 ambulates with assist of a wheeled walker has CHF and DM has prescriptions for antihypertensives and diuretics
A patient is concerned about the risk for ischemic stroke due to a medical history of diabetes and hypertension along with a strong family history of the condition. What advice can the nurse recommend to minimize the risk of stroke?
maintain blood glucose start exercise regimen remain on antihypertensive meds
While treating a patient in status epilepticus, which care actions can the nurse delegate to the unlicensed assistive personnel (UAP)?
obtain vitals, pad bed rails, perform chest compressions
The nurse is educating a patient with a parietal lobe tumor regarding symptoms to report to the health care provider. Which information should be included in the teaching? select all that apply
slurred speech Spatial disorders
A nurse is educating the patient and family about signs of head injury complications that should be reported to the health care provider. Which signs and symptoms should be included in the teaching? Select all that apply.
slurred speech severe Headache difficulty waking up new onset irritability
Which subjective findings are indicative of bacterial meningitis? Select all that apply.
stiff neck severe headache Nausea and vomiting
Which medical diagnoses can be causative factors for vascular dementia?
stroke cerebellar hemorrhage subarachnoid hemorrgage
The nurse recognizes which modifiable risk factors in the patient's history as important etiological factors in developing vascular dementia?
tobacco use hypertension high BG
A patient reports of severe headache, projectile vomiting, blurred and doubled vision, sensitivity to light and a fever of 102.5. Which nursing care actions are appropriate for this patient?
turn off lights to relieve symptoms ensure fluids are given frequently to prevent dehydration perform frequent neuro checks
During the admission assessment of a patient diagnosed with a brain tumor, which questions should the nurse ask to gain pertinent information about the patient's condition? Select all that apply
"Who is the current president of the United States?" "Do you get dizzy when you change positions from sitting to standing?" "What other chronic conditions have you been diagnosed with? "Have you ever been diagnosed with meningitis or encephalitis?"
An older adult has experienced atypical seizures. When taking the patient history, which symptom would the nurse expect the patient to report?
Angry outbursts This is an appropriate response, because patients with atypical seizures experience peculiar behavior and confusion.
A patient is recovering well following a craniectomy. Once the patient has fully recovered, the collaborative care team should expect the patient to undergo which procedure?
Cranioplasty A cranioplasty will be necessary in order to repair the skull and replace the removed bone flap.
A patient who has suffered an epidural hematoma is experiencing increased ICP. What surgical procedure should the collaborative care team perform?
Craniotomy Craniotomy, which involves removing a part of the skull, should be used decrease ICP for a patient with an epidural hematoma.
Why is nutrition an important part of the collaborative care of a patient with increased intracranial pressure?
Malnutrition promotes cerebral edema Malnutrition causes a decrease in albumin related to low protein intake. This increases the fluid shift that causes cerebral edema.
What is the best way for the nurse to assess a patient for delirium who is unable to communicate?
Review medical history Obtain history from family members
A nurse is providing care to a patient following an ischemic stroke. The patient has dysphagia. Which acute care intervention should the nurse include in the patient's care?
Place the patient on aspiration precautions Placing the patient on aspiration precautions is an appropriate intervention to include in the care of a patient with dysphagia.
A patient has experienced progressive memory loss and cognitive dysfunction for 10 years. The patient's caregiver reports the patient is currently experiencing acute agitation and confusion. What is the nurse's priority of care?
Protection from harm A priority of nursing care for the patient with dementia is safety, especially if the patient is agitated and may harm him/herself or others. Patient safety should also be a priority of caregiver education.
A patient presents to the emergency department with loss of consciousness. The patient's caregiver indicates that the patient was fine until an hour ago when the patient complained of a severe headache and loss of control of facial muscles. Which condition does the nurse suspect is causing the patient's symptoms?
Subarachnoid hemorrhage A subarachnoid hemorrhage causing a hemorrhagic stroke often occurs without warning and manifests as a severe headache and facial nerve deficits.
A patient with progressive dementia is hospitalized for treatment of an infected diabetic foot ulcer. What additional care should this patient receive because of the dementia diagnosis?
additional emotional support More frequent monitoring and supervision Frequent reorientation and review of the plan of care
The nurse is caring for a patient who has experienced recurring seizures since the death of her child. Which nursing interventions can be implemented to prevent the patient from having a seizure while in the nurse's care?
ensure adequate sleep, consume a healthy diet each day, help patient engage in stress reduction strategies
A patient has been newly diagnosed with multiple sclerosis (MS). Which points should the nurse include in a teaching plan on nutrition therapy?
minimize caffiene increase roughage increase fluid intake
Which reasons might place an older adult patient admitted to the hospital be at higher risk for delirium?
pain immobility medications sleep deprivation
A patient is being discharged from the hospital after experiencing an ischemic stroke. The nurse is involving the caregivers in the patient teaching. Which statement by the caregiver indicates that further teaching is required?
"If we notice confusion, slurred speech, or facial paralysis, we should immediately administer a low-dose aspirin." Confusion, slurred speech, and facial paralysis are signs of a repeat stroke. The appropriate action is to immediately call 911, not administer aspirin.
The nurse is caring for a patient with a brain abscess. The patient reports a severe headache, nausea and vomiting. Which nursing intervention should be implemented?
Administer IV antiemetic medication Antiemetics decrease the patient's nausea and vomiting, thereby decreasing the patient's ICP. Decreasing the ICP can help relieve the patient's headache, as well.
A college student presents to the health clinic reporting that a roommate was diagnosed with bacterial meningitis two days earlier. Which nursing intervention should be performed first?
Administer cephalosporin Patients who come in contact with persons diagnosed with meningitis should be treated with prophylactic antibiotics like cephalosporin immediately in order to prevent possible infection.
Why is a CT scan the best diagnostic test for evaluating acute head trauma?
Allows for rapid diagnosis and intervention CT scan is best for evaluating acute head trauma because the procedure is quick and can be performed in an acute care setting.
A patient with bacterial meningitis has a temperature of 101.2 °F. Which health care provider orders would the nurse anticipate? select all that apply
Ampicillin IV Maintenance IV fluids Acteaminophen PO PRN
The nurse is caring for a patient with a brain tumor and increased intracranial pressure. The initial vital signs were BP 128/88, HR 106, RR 22, Oxygen saturation 98%. Which follow-up vital signs would indicate worsening ICP?
BP 172/98, HR 64, RR 24, oxygen saturation 99% is characteristic of Cushing's triad, elevated BP and decreased HR, indicating worsening ICP.
A patient is admitted to the hospital following a motor vehicle accident. The patient has an oval shaped bruise behind the right ear in the mastoid region, a very runny nose, and is unable to move the muscles in the right side of his face. Which skull fracture do these clinical manifestations correspond to?
Basilar skull fracture Basilar skull fracture is characterized by Battle's sign, rhinorrhea and facial paralysis, in addition to cerebrospinal fluid (CSF) or brain otorrhea, bulging of tympanic membrane caused by blood or CSF, tinnitus or hearing difficulty, conjugate deviation of gaze and/or vertigo.
A patient is treated for a transient ischemic attack. The nurse and the health care team will suggest which preventive measures to help prevent an embolic stroke in this patient? select all that apply
Take apirin 81 mg/day eat well-balanced diet limit alcohol consumption adopt moderate exercise regimen
Match the types of skull fractures with their description. multiple fractures with bone fragmentation
Communited
Match the types of skull fractures with their description. Depressed fracture with scalp lacerations
Compound
A patient has just presented to the emergency room with facial drooping, slurred speech, and left-sided paralysis. The symptoms began 2 hours ago. Which emergent therapy should the nurse prepare the patient for?
Computerized topography (CT) scan A CT Scan should be performed to rule out a hemorrhagic stroke. Once a hemorrhagic stroke has been ruled out, then a medication regimen can be started.
The nurse is caring for a patient with a brain abscess that is causing a severe increase in ICP. Drug therapy has been ineffective thus far. Which collaborative care order would the nurse anticipate?
Draining of the abscess Draining the abscess or surgical removal of the encapsulation are required if antibiotic therapy is ineffective. Draining of the brain abscess is an appropriate care action for this patient.
The nurse is caring for a patient with encephalitis who was positive for cytomegalovirus. Which immunocompromising condition is this related to?
HIV Cytomegalovirus encephalitis is a common complication in HIV/AIDS patients.
A nurse is assessing a patient following a head trauma. Which assessment findings are consistent with a diagnosis of Cushing's triad? Select all that apply
Heart rate of 52 bpm irregular breahting pattern systolic BP reading of 178 mm Hg Initial BP of 160/45 with later reading of 189/32 mm Hg
Which complication may occur if the brain tumor obstructs the ventricles?
Hydrocephalus If the ventricles are obstructed, the patient may develop hydrocephalus. This can be treated by use of a ventricular shunt.
The medical team reports a score of seven on the Glasgow Coma Scale (GCS) during initial assessment of a patient with a head trauma. What is the next step in the patient's treatment?
Intubation Patients with a GCS score below eight, which indicates severe head injury, require immediate intubation to allow for mechanical ventilation and to protect the airway.
The nurse is caring for a patient with a brain tumor in the temporal region who has developed aphagia. Which action is most important for the nurse to take?
Keep a white board and markers in the patient's room at all times. Tumors in the temporal region affect the patient's speech and may cause aphagia. The nurse should develop a means of communication, such as use of a white board.
The nurse is caring for a patient who reports headache, fever, and neck stiffness. Which diagnostic test should the nurse prepare the patient for?
Lumbar Puncture Headache, fever, and nuchal rigidity are symptoms of meningitis. Following the initiation of antibiotic therapy, lumbar puncture is performed to collect culture specimens for diagnosis and confirmation of the disease.
A patient who recently traveled abroad reports headache, fatigue, and fever. Which diagnostic test results would the nurse expect?
Lumbar puncture reveals clear CSF, with glucose and white blood cells (WBCs) Patients who have recently traveled to areas with West Nile Virus and who report fatigue, headache and fever, should be screened for encephalitis. A possible normal lumbar puncture with clear CSF, with glucose and WBCs would be expected.
Which diagnostic studies would be performed in order to determine whether internal bleeding is present in a patient with increased intracranial pressure? Select all that apply.
MRI Infrascanner
A nurse is assisting the provider during a neurological assessment on an unconscious adult patient with increased intracranial pressure. When holding the eyelids open and moving the patient's head to the right side, the eyes move to the right side. How would the nurse report this finding?
Normal oculocephalic reflex Oculocephalic reflex, or the dolls eye reflex, is tested by turning the patient's head briskly to the left or right while holding the eyelids open. A normal response is movement of the eyes across the midline in the direction opposite that of the turning.
Which bacteria are the primary infective organisms leading to brain abscess?
Staph aureus
The nurse is caring for a patient with increased ICP after a motor vehicle collision. Which physical assessment findings would be a late sign of herniation into the brainstem?
Sustained periods of apnea Apnea is a late sign of herniation into the brain stem. If compression of the brain stem is unrelieved, the patient will suffer respiratory arrest.
Collaborative care of brain tumors should be focused on which factors? Select all that apply.
preventing/managing increased ICP ID the tumor type and location Remove and decrease the tumor mass
A patient is day #3 following an ischemic stroke and the nurse notes an increase in both blood pressure and body temperature. The patient is also nauseous and appears agitated. Which nursing actions are needed to prevent further brain injury in this patient? select all that apply
sit pt up maintain alignment between head and neck of pt admin acetaminophen
A patient is being treated for an ischemic stroke thought to result in damage to the right brain. The nurse understands that which statements by the patient would support this diagnosis?
"im having difficulty telling how far away things are" "i think this is just an allergic reaction" "Ever since these symptoms started, Ive had a hard time concentrating on one thing"
A patient who has experienced a stroke asks the nurse what causes the symptoms being experienced. What is the best response by the nurse?
"Neuronal death." When blood flow to the brain is interrupted, neurologic metabolism stops and the cells of the brain die, neuronal death, resulting in the signs and symptoms of a stroke.
In the acute phase after head injury, how can the nurse determine the progression of the patient's injury?
Ask questions to determine cognition Frequent neurological checks are completed to assess the progression of the patient's injury, to monitor for worsening neurological function and recognize decompensation early.
A nurse is caring for a patient with increased ICP due to a subdural hematoma. Upon assessment, the nurse notes one pupil is 3mm and the other is 7mm. Which action should the nurse take next?
Assess the cranial nerves for abnormalities. The nurse would complete a full neurological exam including assessment of the cranial nerves.
The nurse is caring for a patient who sustained major head trauma after a motor vehicle collision. The patient's lab values reveal a BUN of 47, creatinine of 3.1, hemoglobin of 6.8 and potassium level of 6.1. Which provider order would the nurse question?
Give Mannitol IV Mannitol is an osmotic diuretic given to decrease ICP; however, it is contraindicated in patients with renal failure. The patients elevated BUN and creatinine indicate the presence of acute renal failure. The nurse would question this order.
During assessment of a patient with a basilar skull fracture resulting in intracranial pressure (ICP), the nurse notes a cluster breathing pattern. The patient is otherwise stable with a BP of 115/76, HR of 88 and an abdominal exam that shows no distension and soft bowel sounds throughout. Which action should the nurse take?
Reposition the patient by elevating the head of bed. Repositioning the patient and elevating the head of the bed will facilitate drainage of cerebral spinal fluid (CSF). This will help decrease ICP and facilitate a more normal, life sustaining breathing pattern.
A patient sustained a head injury two days ago. The patient asks the nurse if a hot bath could be provided. How should the nurse respond?
"You should take a lukewarm bath." Hot baths should be avoided for patients recovering from head injuries because the hot water causes changes in blood pressure which may affect the blood flow to the brain, causing lightheadedness or dizziness.
