Med Surge 2 Neuro PrepU Unit 16 Neurologic Function Ch.65-70
A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound?
Irrigates the wound to remove debris
A nurse is discussing a lumbar puncture with a nursing student who observed the procedure. The student noticed that the cerebrospinal fluid was blood tinged and asks what that means. The correct reply is which of the following?
"It can mean a traumatic puncture or a subarachnoid bleed." CSF should be clear and colorless. Pink or bloody may indicate a subarachnoid bleed or local trauma from the puncture.
The diagnosis of multiple sclerosis is based on which test?
MRI
The nurse is discussing spinal cord injury (SCI) at a health fair at a local high school. The nurse relays that the most common cause of SCI is
MVC
The nurse explains to the client with projectile vomiting and severe headache that a medication is being prescribed to reduced edema surrounding the brain and lessen these symptoms. What medication is the nurse preparing to administer?
Mannitol
A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?
Mannitol. Used to decrease swelling in the brain cells
During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates:
cranial nerves IX and X.
When the nurse observes that the client has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the client's posture as
decerebrate
A gymnast sustained a head injury after falling off the balance beam at practice. The client was taken to surgery to repair an epidural hematoma. In postoperative assessments, the nurse measures the client's temperature every 15 minutes. This measurement is important to:
decrease the potential for brain damage.
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
The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction?
"I can apply powder under the liner to help with sweating."
The nurse is preparing a client for a neurological examination by the physician and explains tests the physician will be doing, including the Romberg test. The client asks the purpose of this particular test. The correct reply by the nurse is which of the following?
"It is a test for balance."
The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of?
Basilar skull fracture. A fracture of the base of the skull is referred to as a basilar skull fracture. Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone
A 45-year-old client presents to the ED reporting trouble speaking and numbness of the right arm and leg. The nurse suspects an ischemic stroke. Which insult or abnormality can cause an ischemic stroke?
Cocaine use
A client with Parkinson's disease has been receiving levodopa as treatment for the past 7 years. The client comes to the facility for an evaluation and the nurse observes facial grimacing, head bobbing, and smacking movements. The nurse interprets these findings as which of the following?
Dyskinesia
The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury?
It results from initial damage to the brain from the traumatic event. The secondary injury results from inadequate delivery of nutrients and oxygen to the cells, usually due to cerebral edema and increased intracranial pressure.
A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?
Keeping the client in one position to decrease bleeding
What nursing intervention will best assist the client with chorea?
Monitor the client on bed rest because chorea is a rapid, jerky, involuntary, purposeless movement of the extremities that interferes with walking, sitting, and activities of daily living.
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.
Nursing assessment findings reveal joint swelling and tenderness and a butterfly rash on the face. The nurse suspects which of the following?
Systemic lupus erythematous
Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?
T6
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?
Take daily weights.
A client has a 12-year history of cluster headaches. After the client describes the characteristics of the head pain, the nurse begins to discuss its potential causes. What would the nurse indicate that the origin of the headaches is:
Unknown
A nurse is performing a neurologic assessment on the client and notes a positive Romberg test. This test for balance is related to which of the following cranial nerves?
VIII (acoustic nerve). Has to do with hearing, air and bone conduction, and balance
A client suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure?
Vasodilation which can be caused by hypotension and hypoxia
A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms?
Vasopressin
A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. The expected treatment would consist of which of the following?
Vasopressin therapy
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
A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order:
electromyography (EMG).
In planning care for a patient with an extrapyramidal disorder, the nurse recognizes that a major difference between Parkinson's disease and Huntington's disease is the development of ________ in clients with advanced Huntington's disease.
hallucinations and delusions
The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention?
Administer corticosteroids as ordered. Cranial arteritis is caused by inflammation, which can lead to visual impairment or rupture of the vessel. Administering the corticosteroid as ordered can decrease the chance of losing vision or vessel rupture.
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?
Administer stool softeners.
A patient with Parkinson's disease asks the nurse what can be done to prevent problems with bowel elimination. What would be an intervention that would assist this patient with a regular stool pattern?
Adopt a diet with moderate fiber intake.
A nurse is teaching a community group about modifiable and nonmodifiable risk factors for ischemic strokes. Which of the following is a risk factor that cannot be modified?
Advanced age
The nurse reviews the physician's emergency department progress notes for the client who sustained a head injury and sees that the physician observed the Battle sign. The nurse knows that the physician observed which clinical manifestation?
An area of bruising over the mastoid bone
The nurse is assessing a client who was brought to the emergency department due to a severe headache with sudden onset, lowered level of consciousness and slurred, non-sensical speech. The client completed chemotherapy and radiation treatment for a glioma-type brain tumor 6 months ago. The client has been taking low molecular weight heparin since completing treatment. The nurse should be prepared to provide care for which possible problem?
Intracerebral hemorrhage. Clients receiving anticoagulant agents, such as low molecular weight heparin, must be closely monitored because of the risk of central nervous system hemorrhage
Which of the following is accurate regarding a hemorrhagic stroke?
Main presenting symptom is an "exploding headache."
The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important?
Maintaining a patent airway. Immediate complications of a hemorrhagic stroke include cerebral hypoxia, decreased cerebral blood flow, and extension of the area of injury. Providing adequate oxygenation of blood to the brain minimizes cerebral hypoxia. Brain function depends on delivery of oxygen to the tissues.
The nurse is planning care for a client with Guillain-Barre syndrome. The priority client outcome would be which of the following?
Maintains effective respirations and airway clearance
A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate?
Notify the physician of a possible cerebrospinal fluid leak.
A patient is diagnosed with amyotrophic lateral sclerosis, also known as ALS or Lou Gehrig's disease. The nurse understands that the symptoms of the disease will begin in what way?
Weakness starting in the muscles supplied by the cranial nerves
A patient suspected of having Guillain-Barré syndrome has had a lumbar puncture for cerebrospinal fluid (CSF) evaluation. When reviewing the laboratory results, what does the nurse find that is diagnostic for this disease?
Elevated protein levels in the CSF
A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements?
"A secondary headache is associated with an organic cause, such as a brain tumor."
Normal ICP
0-15 mmHg
Cerebral edema peaks at which time point after intracranial surgery?
24hrs
Which term refers to the inability to recognize objects through a particular sensory system?
Agnosia
A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapherisis and explains this in which of the following statements?
Antibodies are removed from the plasma.
BE FAST
Balance Eyes Face Arms Speech Time Signs of stroke
Thrombus
Clot
Which is a contraindication for the administration of tissue plasminogen activator (t-PA)?
Intracranial hemorrhage
A nurse helps a patient recently diagnosed with a pituitary adenoma understand that:
Most tumors produce too much of one or more hormones.
The most common cause of cholinergic crisis includes which of the following?
Overmedication
A client who is suspected of having a spinal cord tumor is reporting pain. Upon further assessment, the nurse would anticipate that the client would report that the pain increases when in which position?
Prone
A client has a 12-year history of migraine headaches and is frustrated over how these headaches impact lifestyle. The nurse discusses the potential triggers of the client's migraines. Which is not a potential trigger to migraines?
Seasonal changes
Which condition occurs when blood collects between the dura mater and arachnoid membrane?
Subdural hematoma
Trigeminal nerve treatment
Tegritol
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 (TPA) is which of the following?
3hrs
A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time?
4:00 p.m. Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset.
Which Glasgow Coma Scale score is indicative of a severe head injury?
7. A score between 3 and 8 is generally accepted as indicating a severe head injury.
Embolism
Thrombus when traveling
The nurse has been educating a client newly diagnosed with MS. Which statement by the client indicates an understanding of the education?
"I will stretch daily as directed by the physical therapist."
The daughter of a patient with Huntington's disease asks the nurse what the risk is of her inheriting the disease. What is the best response by the nurse?
"If one parent has the disorder, there is a 50% chance that you will inherit the disease."
A client with post-polio syndrome displays fatigue and decreased muscle strength. How should the nurse best respond to the client?
"Intravenous immunoglobulin infusion may help you."
Normal cerebral perfusion pressure (CPP)
70-100 mmHg
A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client?
A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self"
A nurse knows that a patient exhibiting seizurelike movements localized to one side of the body most likely has what type of tumor?
A motor cortex tumor
Which is a late sign of increased intracranial pressure (ICP)?
Altered respiratory patterns. This may indicated pressure or damage to the brain stem
A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate?
Alternatively patch one eye every 2 hours.
Which disease includes loss of motor neurons in the anterior horns of the spinal cord and motor nuclei of the lower brain stem?
Amyotrophic lateral sclerosis
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?
An absence seizure
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?
A thrombus formation at the site of the endarterectomy
A client with quadriplegia is in spinal shock. What finding should the nurse expect?
Absence of reflexes along with flaccid extremities
A client has a neurological defect and will be transferred to a nursing home because family members are unable to care for the client at home. While receiving a bed bath, the client yells at the nurse, "You don't know what you are doing!" What is the best reaction by the nurse?
Accept the patient's behavior and do not take it personally.
In myasthenia gravis (MG), there is a decrease in the number of receptor sites of which neurotransmitter?
Acetylcholine
Which of the following neurotransmitters are deficient in myasthenia gravis?
Acetylcholine
A client is suspected to have bacterial meningitis. What is the priority nursing intervention?
Administer prescribed antibiotics.
Which nursing intervention is appropriate for a client with double vision in the right eye due to MS?
Apply an eye patch to the right eye.
Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?
Apraxia
A client diagnosed with a stroke is ordered to receive warfarin. Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is
Aspirin
Which nursing intervention is the priority for a client in myasthenic crisis?
Assessing respiratory effort
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
Which drug should be available to counteract the effect of edrophonium chloride?
Atropine
Which phase of a migraine headache usually lasts less than an hour?
Aura
You are a neurotrauma 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?
Autonomic dysreflexia
A client is scheduled for an EEG. The client inquires about any diet-related prerequisites before the EEG. Which diet-related advice should the nurse provide to the client?
Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours before the test
Which positions is used to help reduce intracranial pressure (ICP)?
Avoiding flexion of the neck with use of a cervical collar
A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease?
Edrophonium (Tensilon)
Which of the following is the most common side effect of tissue plasminogen activator (tPA)?
Bleeding
When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?
Body temperature
Which signs are manifestations of the Cushing triad?
Bradycardia Hypertension Bradypnea
A patient who has suffered a stroke is unable to maintain respiration and is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breathe?
Brain Stem.
At which of the following spinal cord injury levels does the patient have full head and neck control?
C5
A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation?
Cardio embolic
A 76-year-old client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain?
Carotid endarterectomy
A nurse is assisting with a neurological examination of a client who reports a headache in the occipital area and shows signs of ataxia and nystagmus. Which of the following conditions is the most likely reason for the client's problems?
Cerebellar abscess
A patient recently noted difficulty maintaining his balance and controlling fine movements. The nurse explains that the provider will order diagnostic studies for the part of his brain known as the:
Cerebellum
In which location are most brain angiomas located?
Cerebellum
The nurse is caring for a client who has been hospitalized for investigation of a sudden change in gait due to loss of balance and coordination. A magnetic resonance imaging scan reveals the client has a brain tumor. On or close to which brain structure is the tumor most likely situated?
Cerebellum. It is the brain structure responsible for balance, coordination and fine muscle control. The tumor is most likely located on or near this brain structure
Which of the following diagnostic studies provides visualization of cerebral blood vessels?
Cerebral angiography
A nurse is preparing a client for a lumbar puncture. The client has heard about post-lumbar puncture headaches and asks what causes them. The nurse tells the client that these headches are caused by which of the following?
Cerebral spinal fluid leakage at the puncture site
The nurse is caring for a client who underwent surgery to remove a spinal cord tumor. When conducting the postoperative assessment, the nurse notes the presence of a bulge at the surgical site. The nurse suspects the client is experiencing what complication from the surgery?
Cerebrospinal fluid leakage
Causes of acquired seizures include
Cerebrovascular disease Metabolic and toxic conditions Brain tumor Drug and alcohol withdrawal
A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis?
Chewing
Decordicate Posturing
Client is stiff with bent arms and clenched fists and legs straight out
A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?
Elevate the head of the bed to promote venous drainage of blood and CSF
The initial sign of increasing intracranial pressure (ICP) includes
Decreased LOC and focal motor deficits
A patient has a deficiency of the neurotransmitter serotonin. The nurse is aware that this deficiency can lead to:
Depression. Serotonin helps control mood and sleep.
The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?
Diplopia and ptosis
The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began?
Drooping eyelids
After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client?
Elevating the head of the bed to 30 degrees. Because the client's gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the client's risk of aspiration.
A client has undergone a lumbar puncture as part of a neurological assessment. The client is put under the care of a nurse after the procedure. Which important postprocedure nursing intervention should be performed to ensure the client's maximum comfort?
Encourage the client to drink liberal amounts of fluids. This will help to restore the volume of CSF that was extracted.
Which statement reflects nursing management of the client with expressive aphasia?
Encourage the client to repeat sounds of the alphabet
Which nursing interventions might need to be considered in a care plan for a client with advanced multiple sclerosis? Select all that apply.
Ensure access to a language board when communicating with the client. Establish a voiding time schedule. Encourage the client to walk with feet wide apart.
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?
Fever and change in urine clarity
Aneurysm rebleeding occurs most frequently during which time frame after the initial hemorrhage?
First 2 weeks
A nurse is caring for a client with deteriorating neurologic status. The nurse is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate?
Flaccidity
After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position?
Flat, except for logrolling as needed
A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action?
Form words that are understandable or comprehend spoken words
Which anatomic part supplies cerebrospinal fluid to the subarachnoid space and down the spinal cord on the dorsal surface?
Fourth ventricle
Which lobe of the brain is responsible for concentration and abstract thought?
Frontal
A patient sustained a head injury during a fall and has changes in personality and affect. What part of the brain does the nurse recognize has been affected in this injury?
Frontal Lobe
A client with Guillain-Barre syndrome cannot swallow and has a paralytic ileus; the nurse is administering parenteral nutrition intraveneously. The nurse is careful to assess which of the following related to intake of nutrients?
Gag reflex and bowel sounds
What is the most common type of brain neoplasm?
Glioma
concussion has symptoms of transient confusion, no loss of consciousness, and duration of mental status abnormalities on examination that resolve in less than 15 minutes.
Grade 1 concussion
concussion has symptoms of transient confusion and no loss of consciousness, but the concussion symptoms or mental status abnormalities on examination last more than 15 minutes.
Grade 2 concussion
While riding a bicycle in a race, a patient fell into a ditch and sustained a head injury. Another cyclist found the patient lying unconscious in the ditch and called 911. What type of concussion does the patient most likely have?
Grade 3 concussion
Modifiable Risk Factors for Cerebrovascular Disorders
HTN (PRIMARY risk factor), cardiovascular disease, high cholesterol, high hematocrit, obesity, diabetes, oral contraceptives, smoking/drug/alcohol use
The nurse is performing an initial assessment on a client admitted with a possible brain abscess. Which of the following would the nurse most likely find?
Headache that is worse in the morning
The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe?
Headache, fever, and nuchal rigidity
A patient has recently been diagnosed with an acoustic neuroma. The nurse helps the patient understand that:
Hearing loss usually occurs.
A client is experiencing muscle weakness and an ataxic gait. The client has a diagnosis of multiple sclerosis (MS). Based on these symptoms, the nurse formulates "Impaired physical mobility" as one of the nursing diagnoses applicable to the client. What nursing intervention should be most appropriate to address the nursing diagnosis?
Help the client perform range-of-motion (ROM) exercises every 8 hours.
A health care provider asks a nurse to assess a patient being evaluated for aseptic meningitis for a positive Brudzinski sign. Which of the following actions should the nurse take?
Help the patient flex his neck and observe for flexion of the hips and knees.
Which of the following symptoms are indicative of a rapidly expanding acute subdural hematoma? Select all that apply.
Hemiparesis Decreased reactivity of the pupils Bradycardia Coma
Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?
Herniation
Which is the most common cause of acute encephalitis in the United States?
Herpes simplex virus
The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient?
High in protein and low in carbohydrate (ketogenic)
Which disturbance results in loss of half of the visual field?
Homonymous hemianopsia
The nursing instructor gives their students an assignment of making a plan of care for a client with Huntington's disease. What would be important for the students to include in the teaching portion of the care plan?
How to facilitate tasks such as using both hands to hold a drinking glass
Which disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive, involuntary dancelike movements and dementia?
Huntington disease
Which of the following areas of the brain are responsible for temperature regulation?
Hypothalamus
A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for:
Hypoxia
A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin?
Immediately
A comatose client is being cared for by a critical care nurse who documents that the client responds only to very painful stimuli by fragmentary, delayed reflex withdrawal. The nurse knows that reflexes in the body are centered where?
In the spinal cord
A nurse assesses a patient who has been diagnosed with having a pituitary adenoma that is pressing on the third ventricle. The nurse looks for the associated sign/symptom. What is that sign/symptom?
Increased intracranial pressure
The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?
Increased pulse rate, adventitious breath sounds
A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?
Increased urine output. The therapeutic effect of mannitol is diuresis
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?
Ineffective airway clearance related to altered LOC
A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client?
Ineffective airway clearance related to brain injury
A client has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the client was reporting neck stiffness earlier in the day. What action should the nurse do first?
Initiate isolation precautions because the signs and symptoms are consistent with bacterial meningitis. The nurse should protect self, other health care workers, and other clients against the spread of the bacteria
What is the only known risk factor for brain tumors?
Ionizing radiation
The nurse is caring for a client with a traumatic brain injury who has developed increased intracranial pressure resulting in syndrome of inappropriate antidiuretic hormone (SIADH). While assessing this client, the nurse expects which of the following findings?
Oliguria and serum hyponatremia. With SIADH, the client becomes volume overloaded, urine output diminishes, and serum sodium concentration becomes dilute
A patient is diagnosed with an aggressive, primary malignant brain tumor. The nurse is aware that the glioma:
Originated within the brain tissue.
Which of the following is a late symptom of spinal cord compression?
Paralysis
Which lobe of the brain is responsible for spatial relationships?
Parietal. Essential to a person's awareness of body position in space, size and shape
When providing teaching to a client who reports tension headaches, which of the following instructions would be most beneficial to prevent onset of symptoms?
Perform stretching exercises and frequent position change because tension headaches are often associated with prolonged tensed muscles
Which of the following drugs may be used after a seizure to maintain a seizure-free state?
Phenobarbital
A client in a long-term nursing facility has severe dysphagia. Which of the following would best assist this client in preventing further complications?
Placement of a feeding tube
A client with a T4-level spinal cord injury (SCI) is experiencing autonomic dysreflexia; his blood pressure is 230/110. The nurse cannot locate the cause and administers antihypertensive medication as ordered. The nurse empties the client's bladder and the symptoms abate. Now, what must the nurse watch for?
Rebound hypotension
A patient diagnosed with MS 2 years ago has been admitted to the hospital with another relapse. The previous relapse was followed by a complete recovery with the exception of occasional vertigo. What type of MS does the nurse recognize this patient most likely has?
Relapsing-remitting (RR)
A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions?
Renal
The nurse is performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome. On which of the following areas will the nurse focus most heavily?
Respiratory
A patient with amyotrophic lateral sclerosis (ALS) asks if the nurse has heard of a drug that will prolong the patient's life. The nurse knows that there is a medication that may prolong the life by 3 to 6 months. To which medication is the patient referring?
Riluzole
The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?" The nurse should respond by describing the action of the:
SNS
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:
Severe headache and early change in level of consciousness
A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?
Shivering
After a seizure, the nurse should place the patient in which of the following positions to prevent complications?
Side-lying, to facilitate drainage of oral secretions, suctioning is performed if needed to maintain a patent airway
The home health nurse is caring for a client with Parkinson's disease. The nurse understands that the purpose of adding selegiline with carbidopa-levodopa to the medication regime should result in which purpose?
Slows the progression of the disease
The nurse is participating in a health fair for stroke prevention. Which will the nurse say is a modifiable risk factor for ischemic stroke?
Smoking
Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?
Spasticity
Which is indicative of a right hemisphere stroke?
Spatial-perceptual deficits
A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside?
Suction machine with catheters
A client with spinal trauma tells the nurse she cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?
Suction the airway.
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 patient has been diagnosed with a brain tumor, a glioblastoma multiforme. The nurse met with the family after the diagnosis to help them understand that:
Surgery can improve survival time but the results are not guaranteed.
A client has a spinal cord injury. The home health nurse is making an initial visit to the client at home and plans on reinforcing teaching on autonomic dysreflexia. What symptom would the nurse stress to the client and his family?
Sweating
The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern?
Temperature increase from 98.0°F to 99.6°F.Fever in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection.
Which cerebral lobe contains the auditory receptive areas?
Temporal
Which of the following tests confirms the diagnosis of myasthenia gravis (MG)?
Tensilon test
The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client best indicates that the client is assuming independence?
The client grasps the affected arm at the wrist and raises it.
Which statement describes the pathophysiology of post-polio syndrome?
The exact cause is unknown, but aging or muscle overuse is suspected.
The nurse is performing a neurological assessment of a client who has sustained damage to the frontal cortex. Which of the following deficits will the nurse look for during assessment?
The inability to tell how a mouse and a cat are alike. Damage to the frontal cortex will display a deficit in intellectual functioning.
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?
The muscles will become fatigued and the patient will not be able to chew food or swallow pills.
A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects in the body systems, the nurse anticipates that the liver will:
convert glycogen to glucose for immediate use.
A nurse is caring for a client with a history of severe migraines. The client has a medical history that includes asthma, gastroesophageal reflux disease, and three pregnancies. Which medication does the nurse anticipate the physician will order for the client's migraines?
Verapamil (Calan), a calcium channel blocker is commonly used to treat migraines (as well as metoprolol)
A nurse is assessing a client diagnosed with multiple sclerosis (MS). Which symptom does the nurse expect to find?
Vision changes
The nurse is seeing the mother of a client who states, "I'm so relieved because my son's doctor told me his brain tumor is benign." The nurse knows what is true about benign brain tumors?
They can affect vital functioning.
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?
Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes. Immediate improvement in muscle strength after administration of this agent represents a positive test and usually confirms the diagnosis.
How Strokes Occur
Thrombus formed due to arteriosclerosis travels up from neck arteries into brain and causes obstruction which leads to ischemia of a region of brain.
A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client
Vomits
A client with hypertension comes to the outpatient department for a routine checkup. Because hypertension is a risk factor for cerebral hemorrhage, the nurse questions the client closely about warning signs and symptoms of hemorrhage. Which complaint is a possible indicator of cerebral hemorrhage in this client?
Tinnitus
The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?
Traction with weights and pulleys
Which diagnostic test may be performed to evaluate blood flow within intracranial blood vessels?
Transcranial Doppler
A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?
Transient ischemic attack. A TIA is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour
A client is diagnosed with meningococcal meningitis. The 22-year-old client shares an apartment with one other person. What would the nurse expect as appropriate care for the client's roommate?
Treatment with antimicrobial prophylaxis as soon as possible, ideally within 24hrs after exposure
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?
Trigeminal neuralgia
A client has just returned from surgery after undergoing a lumbar laminectomy. Which of the following would be most important to do when positioning the client in bed?
Using a logrolling motion to change positions
When completing a neurologic examination on a client, which question is most essential to evaluate the accuracy of the data?
When, if any, was your last narcotic use?
Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?
Widened pulse pressure. Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure (Cushing reflex).
A client is scheduled for standard EEG testing to evaluate a possible seizure disorder. Which nursing intervention should the nurse perform before the procedure?
Withhold anticonvulsant medications for 24 to 48 hours before the exam
myasthenia gravis
a chronic autoimmune disease that affects the neuromuscular junction and produces serious weakness of voluntary muscles
A nurse is assessing pain in a client who has a spinal cord injury. The client states that even a light touch to the legs will illicit severe pain. The client is describing which type of pain?
allodynia
A nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm?
cerebral angiography which detects distortion of the cerebral arteries and veins.
A client is being treated for a lumbar spinal injury that occurred 5 days ago and is currently experiencing the symptoms of spinal shock. Characteristic for this condition, the client is unable to move the lower extremities, is being closely monitored for hypotension and bradycardia, and has impaired temperature control. Which would not be an expected outcome of care?
client maintains mechanical ventilation with minimal mucus accumulation
A Glasgow Coma Scale (GCS) score of 7 or less is generally interpreted as
coma
A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. What is the origin of the client's symptoms?
impaired cerebral circulation
A nurse is working on a surgical floor. The nurse must logroll a client following a:
laminectomy must be logrolled to keep the spinal column straight when turning.
To meet the sensory needs of a client with viral meningitis, the nurse should:
minimize exposure to bright lights and noise because photo-phobia and hypersensitivity to environmental stimuli are the common clinical manifestations of meningeal irritation and infection
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:
raccoon's eyes and Battle sign.
The nurse has completed evaluating the client's cranial nerves. The nurse documents impairment of the right cervical nerves (CN IX and CN X). Based on these findings, the nurse should instruct the client to
refrain from eating or drinking for now.
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:
rest in an air-conditioned room.
Which are characteristics of autonomic dysreflexia?
severe hypertension, slow heart rate, pounding headache, sweating
A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether:
she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.
A client is treated for increased intracranial pressure (ICP). It is important for the client to avoid hypothermia because
shivering in hypothermia can increase ICP.
The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the
supine position with the head slightly elevated.
A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in
thought content.
When communicating with a client who has sensory (receptive) aphasia, the nurse should:
use short, simple sentences.
To evaluate a client's cerebellar function, a nurse should ask:
"Do you have any problems with balance?"
A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse?
"Emotional lability is common after a stroke, and it usually improves with time."
A patient arrives to have an MRI done in the outpatient department. What information provided by the patient warrants further assessment to prevent complications related to the MRI?
"I am trying to quit smoking and have a patch on." medications patches that have a metal backing and metallic lead wires can cause burns if not removed in an MRI
Frontal Lobe
Concentration, abstract thought, information storage, memory, and motor function
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?
Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue.
The nurse reviews the patient's drug regimen for treatment of a brain tumor. She explains to the patient why one of the following drugs would not be prescribed, even though it might have therapeutic benefits. Which drug would not be prescribed for this patient?
Coumadin. anticoagulants are not prescribed due to the risk for CNS hemorrhage.
Which condition is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain?
Creutzfeldt-Jakob disease
A nurse practitioner is presenting health information about strokes at a clinic. She mentions that there are five categories of strokes based on their origin. Which of the following is the category that has the highest incidence of strokes (30%)?
Cryptogenic (strokes that cannot be attributed to any specific cause)
The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has?
Ischemic
A male client who has undergone a cervical discectomy is being discharged with a cervical collar. Which of the following would be most appropriate to include the client's discharge plan?
Keeping the head in a neutral position
Which of the following antiseizure medication has been found to be effective for post-stroke pain?
Lamotrigine (Lamictal)
A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?
Lateral recumbent, with chin resting on flexed knees to maximize the space between the vertebrae. The needle is inserted between L4 and L5
A 53-year-old man presents to the emergency department with a chief complaint of inability to form words, and numbness and weakness of the right arm and leg. Where would you locate the site of injury?
Left frontoparietal region
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?
Limited attention span and forgetfulness
A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem?
Lioresal (Baclofen)
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?
Maintain a diet for the client that is high in protein, vitamins, and calories.
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?
Monitoring the patency of an indwelling urinary catheter. A full bladder can precipitate autonomic dysreflexia
A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator?
More than 200 mL/h
Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord?
Multiple sclerosis
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?
Muscle weakness and hyporeflexia of the lower extremities
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 computed tomogram. This should be performed within 25 minutes or less from the time the patient presents to the emergency department (ED) to determine if the event is ischemic or hemorrhagic
Which statement indicates appropriate nursing intervention for a client with post-polio syndrome?
Provide care aimed at slowing the loss of strength and maintaining overall well-being.
Which is a component of the nursing management of the client with variant Creutzfeldt-Jakob disease (vCJD)?
Providing palliative care
Most common thrombus path
from internal carotid artery to middle cerebral artery to regions of brain OR from vertebral artery to basilar artery to regions of brain
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?
"Have you experienced any viral infections in the last month?"
The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring?
Increased ICP
A nurse is assisting with the clinical examination for determination of brain death for a client, related to potential organ donation. All 50 states in the United States recognize uniform criteria for brain death. The nurse is aware that the three cardinal signs of brain death are:
coma, absence of brain stem reflexes, and apnea.
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:
famotidine (Pepcid). This is to help prevent GI bleeding
A client with spinal cord compression from a tumor must undergo diagnostic testing. Which of the following is the most likely procedure for this client?
Magnetic resonance imaging
Which set of symptoms characterize Korsakoff syndrome?
Psychosis, disorientation, delirium, insomnia, and hallucinations
The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop?
Damage to the optic nerve
A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP?
Decerebrate posturing and loss of corneal reflex
The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?
Maintain cerebral perfusion pressure from 50 to 70 mm Hg. Other measures include elevating the head of the bed as prescribed, maintaining the client's head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation.
Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition?
Raise the head of the bed and place the patient in a sitting position. This will help to lower blood pressure
Bone density testing will be completed for the client with post-polio syndrome. The nurse teaches the client bone density testing is used to identify what potential complication?
Low bone mass and osteoporosis
A nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely?
Positive Brudzinski's sign. When the client's neck is flexed, flexion of the knees and hips is produced.
A health care provider needs help in identifying the precise location of a brain tumor. To measure brain activity, as well as to determine structure, the nurse expects the health care provider to order which of the following tests?
Positron-emission tomography (PET)
The nurse is assessing the client's mental status . Which question will the nurse include in the assessment?
"Who is the president of the United States?"
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?
"You must avoid coughing, sneezing, and blowing your nose." This will avoid disturbing the surgical graft used to close the wound. The HOB must be elevated
A client who has just been diagnosed with mixed muscular dystrophy asks the nurse about the usual course of this disease. How should the nurse respond?
"You may experience progressive deterioration in all voluntary muscles."
A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following?
"The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid."
The nurse is providing health education to a client recently diagnosed with a brain tumor. During the appointment, the client states, "I'm really worried that I will have a seizure while I am at work or with my kids. Should I be concerned about this?" How should the nurse respond?
"There is a risk for seizures in people who have this diagnosis. What have you already discussed with your primary health care provider regarding management of seizures?"
The nurse educator is providing orientation to a new group of staff nurses on an oncology unit. Part of the orientation is to help nurses understand the differences between various types of brain tumors. The nurse educator correctly identifies that glioma tumors are classified based on the fact that they originate where in the brain?
Within the brain tissue
A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is:
190 mm Hg/120 mm Hg. If systolic >185 and diastolic >110 it is contraindicated
A patient is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the patient has?
Dysfunction of the vagus nerve
Which condition occurs when blood collects between the brain or cerebral tissue with displacement of surrounding structures?
Intracerebral hemorrhage
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?
Administer atropine to control the side effects of edrophonium, which include bradycardia, sweating, and cramping.
