Intracranial regulation and palliative care
What safety actions does the nurse need to take for a patient on oxygen therapy who is undergoing magnetic resonance imaging (MRI)?
Ensure that no patient care equipment containing metal enters the room where the MRI is located.
The patient tells the doctor that he and his family have accepted the terminal diagnosis of pancreatic cancer. The patient further explains that he is interested in being comfortable and that he no longer wishes to fight the cancer. This approach to end-of-life care is known as which of the following?
Palliative care
A patient is suspected of having had a stroke. Which of the following is the initial diagnostic test for a stroke?
Noncontrast CT scan
The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate?
the head of the bed elevated 15 to 20 degrees
A nurse is assisting with a community screening for people at high risk for stroke. To which of the following clients would the nurse pay most attention?
A 60-year-old African-American man
Which of the following is a contraindication for the administration of tissue plasminogen activator (t-PA)?
Intracranial hemorrhage
The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke?
Weakness on one side of the body and difficulty with speech
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?
pupil size and pupillary response
While providing care to a terminally ill client, the client's niece asks the nurse about the client's condition and prognosis. Which of the following would be most appropriate?
Ask the client's consent before sharing any information with the niece.
Which of the following is the most common side effect of tissue plasminogen activator (tPA)?
Bleeding
Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply.
Eye opening Verbal response Motor response
A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take?
Face the client and establish eye contact.
During unplanned, spontaneous moments, dying patients usually discuss fears or concerns that nurses should not ignore or rush. What is the nurse's best response in such situations?
The nurse can communicate interest and a willingness to listen by sitting down, leaning forward in the patient's direction, and making direct eye contact.
While talking with a client who has been diagnosed with a terminal illness, the client asks, " Am I dying?" Which response from the nurse would be appropriate? Select all that apply.
"This must be very difficult for you." "Tell me more about what's on your mind."
A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment?
Brain CT scan or MRI
Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)?
coughing
For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication?
using a "picture board" for the client to point to pictures
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."
Thrombolytic therapy for the treatment of an ischemic stroke should be initiated within how many hours of the onset of symptoms to obtain the best functional outcome?
3 hours
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 a patent airway.
A nurse is providing hospice care in Portland, Oregon,to client with terminal liver cancer. The client confides to the nurse, "I'm in agony all the time. I want this to be over now—please help me." Which of the following interventions is the best for the nurse to implement? Select all that apply.
Control the client's pain with prescribed medication. Encourage the client to explain his wishes. Advise the client's physician of the client's condition.
The nurse has created a plan of care for a patient who is at risk for increased ICP. The patient's care plan should specify monitoring for what early sign of increased ICP?
Disorientation and restlessness
A patient with neurological disorder has difficulty swallowing. The nurse should take special care of the patient's diet because of a potential risk of imbalanced nutrition in the patient. Which of the following measures may be taken by the nurse to ensure that the patient's diet allows for easy swallowing?
Help the patient sit upright when eating and feed slowly
Which of the following is a modifiable risk factor for transient ischemic attacks and ischemic strokes?
History of smoking.
Which of the following are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply.
Intracranial hemorrhage Major abdominal surgery within 10 days
A nurse is reviewing the trend of a patient's scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the patient's status?
Level of consciousness
The nurse is caring for a patient diagnosed with a hemorrhagic stroke. The nurse recognizes that which of the following interventions is most important?
Maintaining a patent airway
A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority?
Maintenance of a patent airway
The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of "ineffective cerebral tissue perfusion." What would be an expected outcome that the nurse would document for this diagnosis?
Obeys commands with appropriate motor responses.
A nurse is caring for a client with a terminal illness. The client asks the nurse to help him end his own life to alleviate his suffering and that of his family. When responding to the client, the nurse integrates knowledge of which of the following?
Participating in assisted suicide violates the Code of Ethics for Nurses.
A client has learned of a terminal illness and impending death. The client asks the nurse to explain the concepts and care that are provided under the definition of palliative care. Which of the following would the nurse include in the explanation for this client? Select all that apply.
Provides pain relief Integrates spirituality Enhances quality of life Offers a team approach to care
Your client has been informed that he has terminal COPD. He and his family have not yet agreed on his final arrangements and are discussing his options. How can you best intervene as his nurse in his final decisions?
Respect the client's autonomy and right to determine how to spend the rest of his life.
After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question?
Performing a lumbar puncture
Which of the following nursing actions by the nurse demonstrates an effective method to assess the patient and the patient's family's ability to cope with end-of-life interventions?
Remaining silent, allowing the patient and family to respond after asking a question related to end-of-life care
A client with Alzheimer's disease has a nursing diagnosis of Risk for injury related to memory loss, wandering, and disorientation. To prevent injury, which nursing intervention should appear in this client's care plan?
Remove potential hazards from the client's environment.
A client with Alzheimer's disease says, "I'm so afraid. Where am I? Where is my family?" How should the nurse respond?
"You are in the hospital and you're safe here. Your family will return at 10 o'clock, which is 1 hour from now."
When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes?
30-degree head elevation
You are the nurse caring for an elderly patient who is confused and agitated. When the patients' family comes to visit the patient you ask them how long the patient has been confused. The family states that the patient has been confused for a long time and the confusion is getting worse. The patient is subsequently diagnosed with dementia. What is the most common cause of dementia in an elderly patient?
Alzheimer's disease.
A terminally ill patient has feelings of rage toward the nurse. According to Elisabeth Kübler-Ross, the patient is in which stage of dying?
Anger
An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following reasons?
She is taking coumadin.
