Med Surg- Neurologic Function- Prep U
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." Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies - Page 2043
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
A client with a brain tumor is experiencing changes in cognition that require the nurse to reorient the client frequently. When performing this task, which devices would be appropriate for the nurse to use? Select all that apply.
Calendar Picture of the client's family Clock Client's clothing Clients with changes in cognition caused by their lesions require frequent reorientation and the use of orienting devices (e.g., personal possessions, photographs, lists, and a clock). Words would not be as helpful as items that are familiar to the client. Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018
Which are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply.
Intracranial hemorrhage Major abdominal surgery within 10 days Intracranial hemorrhage, neoplasm, aneurysm, and major surgical procedures within 14 days are contraindications to t-PA. Clinical diagnosis of ischemic stroke, being 18 years of age or older, and a systolic BP less than or equal to 185 mm Hg are eligibility criteria. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 2015
A client is having a tonic-clonic seizure. What should the nurse do first?
Take measures to prevent 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
A client with a neurologic deficit is feeling frustrated because it is very difficult to pronounce words since having a stroke. The client is struggling with:
dysarthria Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies - Page 2011
A client with epilepsy is having a seizure. During the active seizure phase, the nurse should:
place the client on his side, remove dangerous objects, and protect his head.
Corticosteroids are used in the management of brain tumors to
reduce cerebral edema. Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2017, Chapter 70: pg 2096
A client with a neurologic impairment reports having problems with constipation. Which foods might the nurse recommend?
vegetables
The nurse is discharging home a client who had a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image?
Depression Depression is a common and serious problem in the client who has had a stroke. It can result from a profound disruption in his or her life and changes in total function, leaving the client with a loss of independence. The nurse needs to encourage the client to verbalize feelings to assess the effect of the stroke on self-esteem. Confusion, uncertainty, and disassociation are not the most common client response to a change in body image, although each can occur in some clients. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 2011
A nurse is preparing a client for a computed tomography (CT) scan that requires infusion of radiopaque dye. Which question is the most important for the nurse to ask?
"Are you allergic to seafood or iodine?" Seafood and the radiopaque dye used in CT contain iodine. To prevent an allergic reaction to the radiopaque dye, the nurse should ask the client about allergies to seafood or iodine before the CT scan. Because fasting is unnecessary before a CT scan, the nurse doesn't need to obtain information about the client's last food and fluid intake. The client's last dose of medication and current weight also are irrelevant. Chapter 65: Assessment of Neurologic Function - Page 1966
A client who just experienced a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus?
Cardiac and respiratory status Acute care begins with managing ABCs. Clients may have difficulty keeping an open and clear airway secondary to decreased LOC. Neurologic assessment with close monitoring for signs of increased neurologic deficit and seizure activity occurs next. Fluid and electrolyte balance must be controlled carefully with the goal of adequate hydration to promote perfusion and decrease further brain activity. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 2026
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
Change in level of consciousness
Which of the following statements reflects nursing management of the patient with expressive aphasia?
Encourage the patient to repeat sounds of the alphabet Nursing management of the patient with expressive aphasia includes encouraging the patient to repeat sounds of the alphabet. Nursing management of the patient with global aphasia includes speaking clearly and in simple sentences and using gestures or pictures when able. Nursing management of the patient with receptive aphasia includes speaking slowing and clearly to assist the patient in forming the sounds. Nursing management of the patient with cognitive deficits, such as memory loss, includes frequently reorienting the patient to time, place, and situation. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 2011
The nurse determines which nursing intervention would best assist the client with a brain tumor who may be at increased risk for aspiration?
Evaluation of gag reflex and ability to swallow Evaluation of the gag reflex and ability to swallow to prevent the risk of aspiration is an important nursing intervention. Monitoring vital signs, assistance with self-care, and frequent reorientation are important, but are not the most important intervention. Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders - Page 2097
A nurse is assisting with the assessment of a client with suspected brain abscess. Which of the following findings would be consistent with such an abscess in the frontal lobe of the brain? Select all that apply.
Expressive aphasia Hemiparesis Seizures Signs and symptoms of a frontal lobe abscess include hemiparesis, expressive aphasia, seizures, and frontal headache. Vision changes are associated with a temporal lobe abscess. Nystagmus is a sign of a cerebellar abscess. Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies - Page 2068
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
During a client's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help clients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply.
LOC at time of admission National Institutes of Health Stroke Scale (NIHSS) score Age It is helpful for clinicians to be knowledgeable about the relative importance of predictors of stroke outcome (age, NIHSS score, and LOC at time of admission) to provide stroke survivors and their families with realistic goals. Race and gender are not significant predictors of stroke outcome. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 2019
The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer?
Mannitol
A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best priority nursing action to be taken?
Perform a vision field assessment The nurse should perform a vision field assessment to evaluate the client for hemianopia. This finding could indicate damage to the visual area of the brain as a result of evolving CVA. Repositioning the tray and assisting with feeding would not be the best nursing action until new finding has been evaluated. Hemianopia can be associated with a CVA but, when presenting as a new finding, should be evaluated and reported immediately. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 2011
A 69-year-old client is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The health care provider suspects bacterial meningitis and admits the client to the ICU. What interventions should the nurse perform? Select all that apply.
Perform frequent neurologic assessments Monitor pain levels and administer analgesics Administer antipyretics as prescribed Clients with meningitis require antipyretics and analgesia to treat fever and pain. As well, their neurologic status must be monitored closely. Transfusions are not anticipated. Infection control precautions are implemented, but positive pressure isolation is not necessary because the client is not immunocompromised. Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies - Page 2068
As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply.
Recent intracranial pathology Symptom onset greater than 3 hours prior to admission Current anticoagulation therapy Some of the absolute contraindications for thrombolytic therapy include symptom onset greater than 3 hours before admission, a client who is anticoagulated (with an INR above 1.7), or a client who has recently had any type of intracranial pathology (e.g., previous stroke, head injury, trauma). Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 2015
After having a stroke, a patient has cognitive deficits. What are the cognitive deficits the nurse recognizes the patient has as a result of the stroke? Select all that apply.
Short- and long-term memory loss Decreased attention span Poor abstract reasoning Cognitive deficits associated with stroke include short- and long-term memory loss, decreased attention span, and poor abstract reasoning. Expressive aphasia is a verbal deficit, not a cognitive deficit. Paresthesias are sensory deficits, not cognitive deficits. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 2012
The nurse is caring for a client diagnosed with an ischemic stroke and knows that effective positioning of the client is important. Which of the following should be integrated into the client's plan of care?
The client should be placed in a prone position for 15 to 30 minutes several times a day. If possible, the clients placed in a prone position for 15 to 30 minutes several times a day. A small pillow or a support is placed under the pelvis, extending from the level of the umbilicus to the upper third of the thigh. This helps to promote hyperextension of the hip joints, which is essential for normal gait, and helps prevent knee and hip flexion contractures. The hip joints should not be maintained in flexion and the Trendelenburg position is not indicated. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 2020
The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members with the client who has an aneurysm?
The stimulation can increase intracranial pressure (ICP) or trigger a seizure
A client reports light-headedness, speech disturbance, and left-sided weakness lasting for several hours. The neurologist diagnosed a transient ischemic attack, which caused the client great concern. What would the nurse include during client education?
When symptoms cease, the client will return to presymptomatic state. Impaired blood circulation can be caused by arteriosclerosis, cardiac disease, or diabetes. A TIA is a sudden, brief episode of neurologic impairment. Symptoms may disappear within 1 hour; some continue for as long as 1 day. One third of people who experience a TIA subsequently develop a stroke. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 2011
A physician orders aspirin, 325 mg P.O. daily for a client who has experienced a transient ischemic attack (TIA). The nurse should teach the client that the physician has ordered this medication to:
reduce the chance of blood clot formation
The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke?
Facial droop
The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four clients who might be at risk for a stroke. Which client is likely at the highest risk for a hemorrhagic stroke?
White male, age 60, with history of uncontrolled hypertension Uncontrolled hypertension is the primary cause of a hemorrhagic stroke. Control of hypertension, especially in individuals over 55 years of age, clearly reduces the risk for hemorrhagic stroke. Additional risk factors are increased age, male gender, and excessive alcohol intake. Another high-risk group includes Black people, where the incidence of first stroke is almost twice that as in White people. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 2025