Exam 2 semester 4

A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement?

"TIA is a warning sign. Let's talk about lowering your risks."

The nurse is talking with the mother of a client who is diagnosed with a traumatic brain injury. The mother states that she has never seen the client lash out when frustrated or throw things across the room. Which instruction, made by the nurse, is most correct?

"The client may be experiencing a change in affect due to the brain injury."

A nurse is helping a client understand the cause of ischemic stroke. Which statements might be included in this discussion? Select all that apply. Check all that apply:

"The type of stroke you had occurs in 80% of the people who have a stroke." "Your stroke occurred because a blood clot got lodged in an artery that carries blood to your brain."

A neurologic nurse is reviewing seizures with a group of staff nurses. How should this nurse best describe the cause of a seizure?

A dysrhythmia in the nerve cells in one section of the brain

A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first?

Ask the client if he has trouble breathing.

A client in the emergency department has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the client has which type of skull fracture?

Basilar

A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client?

Bradycardia and hypertension

The nurse is caring for a client with a brain tumor. What drug would the nurse expect to be prescribed to reduce the edema surrounding the tumor?

Dexamethasone

A client with increased intracranial pressure is receiving mannitol via intravenous infusion. Which assessment finding is most important in determining the effectiveness of this treatment?

Level of consciousness is improving

A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care?

Monitoring is needed as rapid neurologic deterioration may occur.

A client is admitted to the neurologic ICU with a spinal cord injury. When assessing the client the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect?

Spinal shock

A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for?

Suicidal ideations

A client newly diagnosed with multiple sclerosis (MS) asks about a cure for her disease process. The nurse gives which of the following information?

There is no cure for MS.

A nurse is monitoring a client with Guillain-Barré syndrome. The nurse should assess the client for which responses? Select all that apply.

respiratory distress difficulty swallowing

The nurse knows that symptoms associated with a TIA, usually a precursor of a future stroke, usually subside in what period of time?

1 hour

A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first?

Altered level of consciousness

The nurse is reviewing the medication administration record of a female client who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke?

Aspirin 81 mg PO o.d

An unresponsive patient is brought to the ED by a family member. The family states, "We don't know what happened." Which of the following is the priority nursing intervention?

Assess for patent airway

A nurse is caring for client diagnosed with Huntington disease. The client's plan of care includes interventions to address the client's potential for injury. Which would be included as a cause for this risk?

Choreiform movements

A client is experiencing severe pain related to increased ICP. Which analgesic would be ordered for this client to help alleviate pain?

Codeine

The nurse is caring for a client who has been admitted with a head injury and continually assesses for signs of increasing intracranial pressure (ICP). The earliest sign of increasing ICP is

Decreased LOC

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration?

Decreased level of consciousness

When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal?

Elevate head of bed 30 degrees

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure?

Generalized

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is:

Hypertension

A client is being assessed for a possible transient ischemic attack (TIA). Which of the following assessment findings suggests to the nurse that the client is experiencing a TIA?

Impaired muscle coordination

A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?

Inform the primary care physician immediately

EMS that they are transporting a 17-year-old male who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what?

MVA

A client the nurse is caring for experiences a seizure. What would be a priority nursing action?

Protect the client from injury

A client has just been diagnosed with Parkinson disease and the nurse is planning the client's subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the client's family?

Risk for injury

A client with meningitis has a history of seizures. Which activity should the nurse do while the client is actively seizing?

Turn the client to the side during a seizure and do not restrain movements

Which of the following assessment findings would indicate an increasing intracranial pressure (ICP) in a client with head trauma? Select all that apply. Check all that apply:

Widening pulse pressure Bradycardia Irregular respirations

A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect?

autonomic dysreflexia

Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere?

left sided weakness

For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to:

promote carbon dioxide elimination

A patient diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following?

tPA

Medical management of a client with a cerebral aneurysm does not include:

thrombolytic therapy

A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?

Ineffective breathing pattern

The nurse is completing an assessment on a client with a history of migraines. The nurse would identify which of the following factors as a possible trigger for a migraine headache? Select all that apply. Check all that apply:

Red wine Menstruation Flashing lights

A nurse is completing discharge teaching for the client who has left-sided hemiparesis following a stroke. When investigating the client's home environment, the nurse should focus on which nursing diagnosis?

Risk for injury

A nurse is providing care to a client with a brain tumor. The client has experienced seizures as a result of the tumor. Which area would be a priority for this client?

Safety

A 13 year old was brought to the ED after being hit in the head by a baseball and is subsequently diagnosed with a concussion. What assessment finding would rule out discharging the client?

The client's speech is slightly slurred

A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the client's current health status is most likely to have precipitated this event?

The client's urinary catheter became occluded.

A nurse is providing education to a community group about ischemic strokes. One group member asks if there are ways to reduce the risk for stroke. Which of the following is a risk factor that can be modified?

hypertension

While snowboarding, a client fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be?

Concussion

The nurse is caring for a client with an inoperable brain tumor. What is a major threat to this client?

Increased intracranial pressure

Which are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply. Check all that apply:

Major abdominal surgery within 10 days Intracranial hemorrhage

Which signs and symptoms would the nurse expect to see in a client who has had a large cerebral hemorrhage?

breathing is noisy and labored, cheek on the side of the CVA blows out on exhalation, eyes deviate toward the affected side of the brain

This sign is generally found in what type of skull fracture?

Basilar skull fracture

The nurse is caring for a client who continues to have increasingly high intracranial pressure. Which complication is expected unless intracranial pressure is resolved?

Herniation through the foramen magnum