Med Surg Neuro Prep U
Hemiplegia, seizures, and decreased level of consciousness (LOC)
A client undergoes cerebral angiography for evaluation after an intracranial computed tomography scan revealed a subarachnoid hemorrhage. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?
raccoon's eyes and Battle sign.
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:
Risk for injury
A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?
Elevate the head of the bed.
A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?
diminished responsiveness.
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:
Heparin sodium
A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?
Frontal
A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?
45
At what rate (in drops per minute) should a nurse start an I.V. infusion if the order is for 1 g of vancomycin (Vancocin) to be given in 180 ml of dextrose 5% in water over 60 minutes? The tubing delivers 15 drops/ml. Enter the correct number ONLY.
For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?
Because hypoxemia can create or worsen a neurologic deficit of the spinal cord
Facial (VII)
Bell's palsy is a disorder of which cranial nerve?
Decreased glucose Increased protein Increased white blood cells
Cerebrospinal fluid (CSF) studies would indicate which of the following in a patient suspected of having meningitis? Select all that apply.
Administer atropine to control the side effects of edrophonium.
During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?
Provide factual information and emotional support.
Family members of a client with traumatic brain injury are extremely distressed about their loved one. How can the nurse best assist the family to cope during this acute phase?
Seizure was 1 minute in duration including tonic-clonic activity.
Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event?
controlling seizures and increased intracranial pressure.
Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at
Acetylcholine
Myasthenia gravis occurs when antibodies attack which receptor sites?
The dynamic equilibrium of cranial contents
The Monro-Kellie hypothesis refers to which of the following statements?
Left visual field deficit
What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?
Ischemic
You are caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke do you know this client has?
"The client is unaware of his left side. You should approach him on the right side."
A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family?
Alternatively patch one eye every 2 hours.
A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?
You must avoid coughing, sneezing, and blowing your nose."
A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?
"Treatment aims at keeping you independent as long as possible."
A client with Parkinson's disease asks the nurse what their treatment is supposed to do since the disease is progressive. What would be the nurse's best response?
Pituitary carcinoma
After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer?
Three hours
An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following?
To dehydrate the brain and reduce cerebral edema
An osmotic diuretic, such as mannitol, is given to the patient with increased intracranial pressure (IICP) for which of the following therapeutic effects?
Immediately
Stephen Oswald, a 68-year-old retired salesman, was brought by squad into the acute care facility where you practice nursing. His wife accompanies him and relates how Stephen reported a severe headache and then was unable to talk or move his right arm and leg. After diagnostics are completed and Mr. Oswald is admitted to the hospital, when would you expect basic rehabilitation to begin?
An area of bruising over the mastoid bone
The ED nurse is receiving a patient-handoff report at the beginning of the nursing shift. The departing nurse notes a patient with a head injury has Battle's sign. The nurse will expect which of the following clinical manifestation?
Remove throw rugs and electrical cords from home environment.
The geriatric advanced practice nurse (APN) is doing client teaching with a client who has had a cerebrovascular accident (CVA) and the client's family. One concern the APN addresses is a potential for falls related to the CVA and resulting muscle weakness. What would be most important for the APN to include in teaching of the client and family related to this concern?
Headache and nuchal rigidity
The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe?
Positive Kernig's sign
The nurse is assessing a newly admitted client with a diagnosis of meningitis. On assessment, the nurse expects to find which of the following?
Hypertension Diaphoresis Nasal congestion
The nurse is assigned to care for patients with SCI on a rehabilitation unit. Which of the following does the nurse recognize are clinical manifestations of autonomic dysreflexia? Select all that apply.
The client has cerebral spinal fluid (CSF) leaking from the ear.
The nurse received report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?
It results from inadequate delivery of nutrients and oxygen to the cells.
The nurse working on a neurological unit is mentoring a nursing student who asks about a client who has sustained primary and secondary brain injuries. The nurse correctly tells the student which of the following, related to the secondary injury?
"There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive."
The parents of a patient intubated due to the progression of Guillain-Barré syndrome ask if their child will die. What is the best response by the nurse?
Mosquito
The primary North American vector transmitting arthropod-borne virus encephalitis is which of the following?
An absence seizure
The school nurse notes a 6-year-old running across the playground with friends. The child stops in mid-stride, freezing for a few seconds. Then the child resumes their progress across the playground. The school nurse suspects what in this child?
Lethargy and stupor
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?
Encouraging the client to bathe with care
When caring for a client with trigeminal neuralgia, which intervention has the highest priority?
Osteoporosis
When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women?
7
Which Glasgow Coma Scale score is indicative of a severe head injury?
Spasticity
Which of the following terms refers to muscular hypertonicity with increased resistance to stretch?
Subdural
Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura?
Decorticate
Which of the following types of posturing is exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?
Place food on the affected side of mouth
Which of the following would not be a recommended intervention for a patient with dysphagia?
Positive Brudzinski sign
Which well-recognized sign of meningitis is exhibited when the patient's neck is flexed and flexion of the knees and hips is produced?
Facial pain in the areas of the fifth cranial nerve
While performing an initial nursing assessment on a client admitted with suspected tic douloureux (trigeminal neuralgia), for which of the following would the nurse expect to observe?
6.3 mg
A 154-pound woman has been prescribed tPA (0.9 mg/kg) for an ischemic stroke. The nurse knows to give how many mg initially?
Fever and change in urine clarity
A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury?
Severe TBI.
A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as:
Vision changes
A nurse is assessing a client diagnosed with multiple sclerosis (MS). Which symptom does the nurse expect to find?
Administer stool softeners.
A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?
Monro-Kellie
A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following?
"There is a strong familial tendency."
A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following?
Initiate isolation precautions.
A patient has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the patient was complaining of neck stiffness earlier in the day. What action should the nurse do first?
Form words that are understandable or comprehend the spoken word
A patient has been diagnosed as having global aphasia. The nurse recognizes that the patient will be unable to do which of the following actions?
Severe headache
A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke?
Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.
A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient?
A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture?
Basilar
Facial
Bell's palsy is a paralysis of which of the following cranial nerves?
From the left side of the client
From which direction should a nurse approach a client who is blind in the right eye?
Every 15 minutes
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)?
Maintaining a patent airway
The nurse is caring for a patient diagnosed with a hemorrhagic stroke. The nurse recognizes that which of the following interventions is most important?
"I can apply powder under the liner to help with sweating."
The nurse is caring for a patient following an SCI who has a halo device in place. The patient is preparing for discharge. Which of the following statements made by the patient indicates the need for further instruction?
Maintenance of a patent airway
The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient?
Establishing eye contact
The nurse is caring for a patient with aphasia. Which of the following strategies will the nurse use to facilitate communication with the patient?
Placing food on the affected side of mouth
The nurse is caring for a patient with dysphagia. Which of the following interventions would be contraindicated while caring for this patient?
Motor vehicle crashes
The nurse is conducting a health fair on spinal cord injury (SCI) at a local high school. The nurse relays that which of the following is the most common cause of SCI?
Muscle weakness and hyporeflexia of the lower extremities
The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis?
Making nursing assessments Setting priorities for nursing interventions Anticipating needs and complications Initiating rehabilitation
The nurse is planning the care of a patient with a TBI in the neurosurgical ICU. In developing the plan of care, what interventions should be a priority? (Select all that apply.)
Tachycardia
Which of the following is not a manifestation of Cushing's Triad?
Agnosia
Which of the following terms refer to the failure to recognize familiar objects perceived by the senses?
Prevent complications, which may interfere with recovering function.
Within the acute care facility where you practice nursing, you have cared for hundreds of clients who have suffered neurologic deficits from various causes, including cerebrovascular accident and closed head injury. While caring for these clients, what was an important nursing goal that motivated you to offer the best care possible?
Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue.
A 24-year-old female rock climber is brought to the Emergency Department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond?
Trigeminal neuralgia
A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder?
Acute
A 65-year-old client was hit in the head with a ball and was knocked unconscious. Upon her arrival at the emergency department and subsequent diagnostic tests, it was determined that she suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would you expect her subdural hematoma to be classified?
Bruit
A 73-year-old client is visiting the neurologist. The client reports light-headedness, speech disturbance, and left-sided weakness that have lasted for several hours. In the examination, an abnormal sound is auscultated in an artery leading to the brain. What is the term for the auscultated discovery?
Suicidal ideations
A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for?
Limited attention span and forgetfulness
A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment?
Take daily weights.
A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus?
A small amount of yellow drainage at the left pin insertion site
A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician?
Compliance with the prescribed medication regimen
A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode?
Left-sided cerebrovascular accident (CVA)
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings?
Neurovascular system
A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment?
70
A client is receiving intravenous (IV) dobutamine (Dobutrex) to help provide adequate perfusion to the brain. The order is for dobutamine 50 mg in 500 mL D5W at 2 mcg/kg/min. The client weighs 58 kg. At how many mL per hour will the nurse administer this medication? Enter the correct number ONLY.
carefully move the client to a flat surface and turn him on his side.
A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:
Paresthesia
A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?
"The paralysis caused by this disease is temporary."
A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?
Anticoagulant therapy
A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the medical treatment to include which of the following?
0.5
A client with a spinal cord injury is to receive Lovenox (enoxaparin) 50 mg subcutaneously twice a day. The medication is supplied in vials containing 80 mg per 0.8 mL. How many mL will constitute the correct dose? Enter the correct number ONLY.
0.5
A client with hypercholesterolemia is receiving Lipitor (atorvastatin) to prevent high cholesterol and stroke. The order is for Lipitor 40 mg PO daily. The medication is supplied in 80 mg tabs. How many tabs will the nurse administer to the client? Enter the correct number ONLY.
Absence of reflexes along with flaccid extremities
A client with quadriplegia is in spinal shock. What finding should the nurse expect?
Maintain a diet for the client that is high in protein, vitamins, and calories.
A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. Which of the following will the nurse most encourage the caregiver to do?
Spouse
A discharge nurse in a rehabilitation facility is coordinating the discharge of Mr. Rigby, 47-year-old tetraplegic, married man with two children in high school. The client is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of Mr. Rigby's care team?
Because shivering in hypothermia can increase ICP
A female client is being treated for increased intracranial pressure (ICP). Why should the nurse ensure that the client does not develop hypothermia? Choose the correct option.
Shivering
A female patient is receiving hypothermic treatment for uncontrolled fevers related to increased intracranial pressure (ICP). Which of the following assessment finding requires immediate intervention?
3
A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?
3
A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?
Ask the client if he has trouble breathing.
A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first?
"Following a stroke, emotional lability is common, and it usually improves with time."
A nurse is instructing the wife of a patient who suffered a stroke about the use of eating devices her husband will be using. During the teaching, the wife starts to cry and states "One minute my husband is laughing, and the next he's crying; I just don't understand what's wrong with him." The nurse's best response is which of the following?
Monitoring is needed as rapid neurologic deterioration may occur.
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?
rest in an air-conditioned room.
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to:
Thrombolytic therapy has a time window of only 3 hours.
A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following?
Decerebrate
A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like the person in part B of the accompanying image. Which posturing is the patient exhibiting?
Maintenance of 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?
Ineffective airway clearance related to altered LOC
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 nursing diagnoses would be the first priority for the plan of care?
Dysarthria
A patient diagnosed with a stroke is having difficulty forming words during communication. This would be appropriately documented as which of the following?
Nuchal rigidity Positive Kernig's sign Positive Brudzinski's sign Photophobia
A patient diagnosed with meningitis would be expected to exhibit which of the following clinical manifestations? Select all that apply.
A thrombus formation at the site of the endarterectomy
A patient had a carotid endarterectomy yesterday and when the nurse arrived in the room to perform an assessment, the patient states, "All of a sudden, I am having trouble moving my right side." What concern should the nurse have about this complaint?
vomits.
A patient has been diagnosed with a concussion. He is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the patient to contact the physician or return to the ED if the patient
Within 24 hours after exposure
A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient?
Basilar
A patient in the emergency room has bruising over the mastoid bone and rhinorrhea. These are indicative of which type of skull fracture?
Parkinson's disease
A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, Cogentin, and Eldepryl. The nurse knows that most likely, the client has a diagnosis of ________.
Noncontrast computed tomogram
A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for?
Noncontrast CT scan
A patient is suspected of having had a stroke. Which of the following is the initial diagnostic test for a stroke?
Cerebral aneurysm
A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom?
An intracerebral hematoma
A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?
It allows for stabilization of the cervical spine along with early ambulation.
A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device?
Look for signs of increased intracranial pressure
A patient with a concussion is discharged after the assessment. Which of the following instructions should the nurse give the patient's family?
Renal
A patient with herpes simplex virus (HSV) encephalitis is receiving acyclovir (Zovirax). To ensure early intervention, the nurse monitors laboratory values and urine output for which of the following adverse reactions?
The muscles will become fatigued and the patient will not be able to chew food or swallow pills.
A patient with myasthenia gravis is in the hospital for treatment of pneumonia. The patient informs the nurse that it is very important to take pyridostigmine bromide (Mestinon) on time. The nurse gets busy and does not administer the medication until after breakfast. What outcome will the patient have related to this late dose?
Side-lying, to facilitate drainage of oral secretions
After a seizure, the nurse should place the patient in which of the following positions to prevent complications?
"Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation."
During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer?
Systemic lupus erythematous
Nursing assessment findings reveal joint swelling and tenderness and a butterfly rash on the face. The nurse suspects which of the following?
Preventing further neurologic damage
Stephen Oswald, a 68-year-old retired salesman, was brought by squad into the acute care facility where you practice nursing. His wife accompanies him and relates how Stephen reported a severe headache, shortly after he was unable to talk or move his right arm and leg. His wife indicates Mr. Oswald has hypertension. What should be your focus of management during this phase?
Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.
The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur?
Aspiration of a brain abscess
The nurse is aware that burr holes may be used in neurosurgical procedures. Which of the following is a reason why a neurosurgeon may choose to create a burr hole in a patient?
Drugs administered may cause a wide variety of adverse effects.
The nurse is caring for a client hospitalized after a motor vehicle accident. The client has a comorbidity of Parkinson's disease. Why should the nurse closely monitor the condition and the drug regimen of a client with Parkinson's disease?
Increased pulse rate, adventitious breath sounds
The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?
80
The nurse is caring for a patient diagnosed with an acute subdural hematoma following a craniotomy. The nurse is preparing to administer an IV dose of dexamethasone (Decadron). The medication is available in a 20-mL IV bag and ordered to be infused over 15 minutes. At what rate (mL/hr) will the nurse set the infusion pump?
Burr holes
The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for?
"I was brushing my teeth."
The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain?
IICP is 12 mm Hg.
The nurse is caring for a patient with a ventriculostomy. Which assessment finding documented demonstrates effectiveness of the ventriculostomy?
Edema to the head with bruising of the mastoid process
The nurse is evaluating the transmission of a report from a paramedic unit to the emergency room. The medic reports that a client is unconscious with edema of the head and face and Battle's sign. What clinical picture would the nurse anticipate?
Conception is not impaired; the birth process is determined with the physician.
The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful?
Facial distortion and pain
The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis?
Provide thickened commercial beverages and fortified cooked cereals.
The nurse is providing diet-related advice to a male patient following a cerebrovascular accident (CVA). The patient wants to minimize the volume of food and yet meet all nutritional elements. Which of the following suggestions should the nurse give to the patient about controlling the volume of food intake?
"Have you experienced any viral infections in the last month?"
The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following?
An absence seizure
The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child?
famotidine (Pepcid).
Three hours after injuring the spinal cord at the C6 level, a client receives high doses of methylprednisolone sodium succinate (Solu-Medrol) to suppress breakdown of the neurologic tissue membrane at the injury site. To help prevent adverse effects of this drug, the nurse expects the physician to order:
Minimize exposure to bright lights and noise.
To meet the sensory needs of a client with viral meningitis, which of the following should the nurse do?
Increased intracranial pressure (ICP)
When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?
30-degree head elevation
When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes?
Homonymous hemianopsia
Which disturbance results in loss of half of the visual field?
Atropine
Which drug should be available to counteract the effect of Tensilon?
Intracranial hemorrhage Major abdominal surgery within 10 days
Which of the following are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply.
Subdural hematoma
Which of the following conditions occurs when there is bleeding between the dura mater and arachnoid membrane?
Main presenting symptom is an "exploding headache."
Which of the following is accurate regarding a hemorrhagic stroke?
Change in level of consciousness (LOC)
Which of the following is the earliest sign of increasing ICP?
Noncontrast computed tomography (CT)
Which of the following is the initial diagnostic in suspected stroke?
Noncontrast CT scan
Which of the following is the initial diagnostic test for a stroke?
Controlling seizures and increased ICP
Which of the following is the primary medical management of arthropod-borne virus (arboviral) encephalitis?
Mosquitoes
Which of the following is the primary vector of arthropod-borne virus encephalitis in North America?
Assessing respiratory effort
Which of the following is the priority nursing intervention for a patient in myasthenic crisis?
Supine position with head slightly elevated
Which of the following positions should be utilized after supratentorial intracranial surgery?
Enemas
Which of the following should be avoided in patients with increased ICP?
Homonymous hemianopsia
Which of the following terms refers to blindness in the right or left halves of the visual fields of both eyes?
Severe headache and early change in level of consciousness
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:
Autonomic dysreflexia
You are a neuro trauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?
Increased ICP
You are caring for a client with an inoperable brain tumor. What is a major threat to this client?
