MedSurg2 Exam 2 Part 2

The nurse is providing nonpharmacologic interventions for pain relief to a client with a tension headache. Which techniques may the nurse use? Select all that apply. a. Use guided imagery. b. Play soothing music. c. Allow interactions with friends and family members. d. Allow watching TV.

A, B Guided imagery and soothing music can reduce tension and relieve a tension headache. Stimuli should be reduced to help alleviate anxiety and reduce pain.

A patient having an acute stroke with no other significant medical disorders has a blood glucose level of 420 mg/dL. What significance does the hyperglycemia have for this patient? a. The patient has new onset diabetes. b. This is significant for poor neurologic outcomes. c. The patient has developed diabetes insipidus due to the location of the stroke. d. The patient has liver failure.

B Hyperglycemia has been associated with poor neurologic outcomes in acute stroke and should be treated if the blood glucose is above 140 mg/dL (Summers et al., 2009).

If warfarin is contraindicated as a treatment for stroke, which medication is the best option? a. Dipyridamole b. Aspirin c. Clopidogrel d. Ticlodipine

B If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.

After a subarachnoid hemorrhage, the client's laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurse's most appropriate action? a. Administer a bolus of normal saline as prescribed. b. Prepare the client for thrombolytic therapy as prescribed. c. Facilitate testing for hypothalamic dysfunction. d. Prepare to administer 3% NaCl by IV as prescribed.

D The client may be experiencing syndrome of inappropriate antidiuretic hormone (SIADH) or cerebral salt-wasting syndrome. The treatment most often is the use of IV hypertonic 3% saline. A normal saline bolus would exacerbate the problem and there is no indication for tests of hypothalamic function or thrombolytic therapy.

A client recovering from a stroke has severe shoulder pain from subluxation of the shoulder. To prevent further injury and pain, the nurse caring for this client is aware of what principle of care? a. The client should be fitted with a cast because use of a sling should be avoided due to adduction of the affected shoulder. b. Elevation of the arm and hand can lead to further complications associated with edema. c. Passively exercising the affected extremity is avoided in order to minimize pain. d. The client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.

D To prevent shoulder pain, the nurse should never lift a client by the flaccid shoulder or pull on the affected arm or shoulder. The client is taught how to move and exercise the affected arm/shoulder through proper movement and positioning. The client is instructed to interlace the fingers, place the palms together, and push the clasped hands slowly forward to bring the scapulae forward; he or she then raises both hands above the head. This is repeated throughout the day. The use of a properly worn sling when the client is out of bed prevents the paralyzed upper extremity from dangling without support. Range-of-motion exercises are still vitally important in preventing a frozen shoulder and ultimately atrophy of subcutaneous tissues, which can cause more pain. Elevation of the arm and hand is also important in preventing dependent edema of the hand.

A nurse is caring for a client with a cerebral aneurysm. Which nursing interventions would be most useful to the nurse to avoid bleeding in the brain? Select all that apply. a. Report changes in neurologic status as soon as a worsening trend is identified. b. Use a well-lighted room for assessments every 2 hours. c. Follow the healthcare provider's orders to increase fluid volume. d. Maintain the head of the bed at 30 degrees.e. Avoid any activities that cause a Valsalva maneuver.

A, D, E Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in intracranial pressure, and prevent further bleeding. The patient is placed on bed rest in a quiet, nonstressful environment, because activity, pain, and anxiety are thought to elevate the blood pressure, which may increase the risk for bleeding. The head of the bed is elevated 30 degrees to promote venous drainage and decrease intracranial pressure. Any activity that suddenly increases the blood pressure or obstructs venous return is avoided. This includes the Valsalva maneuver, straining, forceful sneezing, pushing oneself up in bed and acute flexion or rotation of the head and neck (which compromises the jugular veins). Stool softeners and mild laxatives are prescribed to prevent constipation, which can cause an increase in intracranial pressure. Dim lighting is helpful for photophobia. Increasing fluid volume does not affect brain bleeding.

A priority in postoperative management of a patient who has had intracranial surgery is what? A) Reducing pain B) Reducing periorbital edema C) Monitoring ICP D) Preserving seizures

ANS: C Ongoing postoperative management is aimed at detecting and reducing cerebral edema, relieving pain and preventing seizures, and monitoring ICP and neurologic status.

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? a. The day before the patient is discharged b. After the patient has passed the acute phase of the stroke c. After the nurse has received the discharge orders d. The day the patient has the stroke

B Although rehabilitation begins on the day the patient has the stroke, the process is intensified during convalescence and requires a coordinated team effort.

A nurse is providing care to a client who has had a stroke. Which symptoms are consistent with right-sided stroke? a. expressive aphasia, defects in the right visual fields, problems with abstract thinking b. impulsive behavior, poor judgment, deficits in left visual fields c. problems with abstract thinking, impairment of short-term memory, poor judgment d. cautious behavior, deficits in left visual fields, misjudgment of distances

B expressive aphasia, defects in the right visual fields, problems with abstract thinkingimpulsive behavior, poor judgment, deficits in left visual fieldsproblems with abstract thinking, impairment of short-term memory, poor judgmentcautious behavior, deficits in left visual fields, misjudgment of distances

The nurse is reviewing the medication administration record of a female client who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke? a. Naproxen 250 PO b.i.d. b. Calcium carbonate 1,000 mg PO b.i.d. c. Aspirin 81 mg PO o.d. d. Lorazepam 1 mg SL b.i.d. PRN

C Research findings suggest that low-dose aspirin may lower the risk of stroke in women who are at risk. Naproxen, lorazepam, and calcium supplements do not have this effect.

Which of the following, if left untreated, can lead to an ischemic stroke? a. Atrial fibrillation b. Cerebral aneurysm c. Arteriovenous malformation (AVM) d. Ruptured cerebral arteries

A Atrial fibrillation is the most frequently diagnosed arrhythmia in the United States. If left untreated, it can lead to an ischemic stroke. Cerebral hemorrhage, arteriovenous malformation, and cerebral hemorrhage can lead to a hemorrhagic stroke. Cerebral aneurysm, arteriovenous malformations, and ruptured cerebral arteries can lead to hemorrhagic stroke.

The nurse is preparing to administer tissue plasminogen activator (t-PA) to a patient who weighs 132 lb. The order reads 0.9 mg/kg t-PA. The nurse understands that 10% of the calculated dose is administered as an IV bolus over 1 minute, and the remaining dose (90%) is administered IV over 1 hour via an infusion pump. How many milligrams IV bolus over 1 minute will the nurse initially administer?

5.4 mg

While completing a health history on a newly diagnosed patient with generalized seizure disorder the nurse would assess for what characteristic associated with the post-ictal state? A) Epileptic cry B) Confusion C) Urinary incontinence D) Body rigidity

ANS: B In the post-ictal state (after the seizure), the patient is often confused and hard to arouse and may sleep for hours. The epileptic cry occurs from the simultaneous contractions of the diaphragm and chest muscles which occur during the seizure. Urinary incontinence and intense rigidity of the entire body are followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction) during the seizure.

During the examination of an unconscious patient, the nurse notices that the patient's pupils are fixed and dilated. What is the clinical significance of the nurse's finding? A) It suggests onset of metabolic problems. B) It indicates paralysis on the right side of the body. C) It indicates paralysis of cranial nerve X. D) It indicates an injury at the midbrain level.

ANS: D Pupils that are fixed and dilated indicate injury at the midbrain level.

You have admitted a patient to the Neurolog Intensive Care Unit with a brainstem herniation. The patient is now exhibiting an altered level of consciousness. The nurse has determined that the patient's mean arterial pressure (MAP) is 60 with an intracranial pressure (ICP) reading of 5 mm Hg. The nurse would be correct in determining the cerebral perfusion pressure (CPP) as which of the following values?A) Normal B) High C) Low D) Compensating

C The cerebral perfusion pressure (CPP) is 55 mm Hg, which is considered low. The normal CPP is 70 to 100 mm Hg. Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. A lower than normal CPP indicates that the cardiac output is insufficient to maintain adequate cerebral perfusion.

A patient has developed diabetes insipidus after having increased ICP following head trauma. When developing a teaching plan for this patient the nurse should include information about which hormone, commonly lacking in patients with diabetes insipidus? A) Antidiuretic hormone (ADH) B) Thyroid-stimulating hormone (TSH) C) Follicle-stimulating hormone (FSH) D) Luteinizing hormone (LH)

A ADH is the hormone lacking in diabetes insipidus. The patient's TSH, FSH, and LH levels won't be affected.

When caring for a patient with a neurologic dysfunction, what complications must the nurse monitor for? (Mark all that apply.) A) Contractures B) Interrupted family processes C) Pressure ulcer D) DVT E) Pneumonia

ANS: A, C, D, E Based on the assessment data, potential complications may include respiratory distress or failure, pneumonia, aspiration, pressure ulcer, deep vein thrombosis (DVT), and contractures. Interrupted family processes is a nursing diagnosis, not a possible complication.

In what position should the nurse place the patient following a craniotomy with a supratentorial approach? A) Position patient flat B) Maintain HOB elevated at 30 to 45 degrees C) Position patient in prone position D) Maintain bed in Trendelenburg position

ANS: B The patient undergoing a craniotomy with a supratentorial (above the tentorium) approach should be placed with the HOB elevated 30 to 45 degrees, with the neck in neutral alignment.

When caring for an unconscious patient what nursing intervention takes highest priority? A) Inserting an indwelling urinary catheter B) Maintaining a patent airway C) Putting a nasogastric (NG) tube in place D) Administering an enema daily

B Maintaining a patent airway always takes top priority. An indwelling urinary catheter and NG tube can be inserted after airway patency has been established. Enemas should be avoided because of the danger of increasing intracranial pressure.

The nursing instructor is discussing increased intracranial pressure (ICP) with the senior nursing students. What would the instructor be correct in telling the students is an early clinical manifestation of ICP? A) Disorientation and restlessness B) Decreased pulse and respirations C) Projectile vomiting D) Loss of corneal reflex

ANS: A Early indicators of ICP include disorientation and restlessness. Later signs include decreased pulse and respirations, projectile vomiting, and loss of brainstem reflexes such as the corneal reflex.

A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to your unit. You would be correct in assessing for what adverse effect of this therapy? A) Bradycardia B) Diarrhea C) Gingivival hyperplasia D) Weight gain

ANS: C Gingivival hyperplasia (swollen and tender gums) can be associated with long-term phenytoin (Dilantin) use. Bradycardia, diarrhea, and weight gain are not associated with dilantin therapy. Adverse effects noted with dilantin therapy are tachycardia, constipation, and weight loss

How does the nurse help the patient and family gain control of their lives? A) By providing educational resources in the community B) By offering referrals to community social clubs C) By introducing the patient to other neurologically impaired people in the community D) By collaborating with other members of the health care team

ANS: D The nurse collaborates with other members of the health care team to provide essential care, offer a variety of solutions to problems, help the patient and family gain control of their lives, and explore the educational and supportive resources available in the community. The nurse does not provide educational resources in the community, provide introductions to others who are neurologically impaired, or refer patients to social clubs

A patient is being admitted to the Neuro ICU following an acute head injury. The patient has cerebral edema. The nurse would expect to administer what priority medications to reduce cerebral edema? A) Hydrochlorothiazide (HydroDIURIL) B) Lasix (Furosemide) C) Mannitol (Osmitrol) D) Spirolactone (Aldactone)

C The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce cerebral edema. This drug acts by reduces the volume of brain and extracellular fluid. Spirolactone, Lasix, and Hydrochorothiazide are used in the treatment of CHF and hypertension.

Your patient is scheduled for intracranial surgery in the morning. You know that it is important that the patient has adequate preparation for surgery to reduce what? A) Postoperative complications B) Length of time under anesthesia C) Establishing expectations that are too high D) Length of time in the hospital

ANS: A Adequate preparation for surgery, with attention to the patient's physical and emotional status, can reduce the risk of anxiety, fear, and postoperative complications. Adequate preparation for surgery does not reduce the length of time under anesthesia or in the hospital and it does not establish expectations that are too high.

You have a patient with an altered level of consciousness. What would be your first action when assessing this patient? A) Assessing the verbal response B) Assessing if the patient follows commands C) Assessing whether the patient will open their eyes D) Assessing response to pain

ANS: A Assessment of the patient with an altered LOC often starts with assessing the verbal response through determining the patient's orientation to time, person, and place. Therefore options B, C, and D are incorrect.

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? a. White female, age 60, with history of excessive alcohol intake b. White male, age 60, with history of uncontrolled hypertension c. Black male, age 60, with history of diabetes d. Black male, age 50, with history of smoking

B 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.

The nurse is caring for a patient on the neurologic unit who is in status epilepticus. What medications does the nurse know may be given to halt the seizure immediately? A) Intravenous phenobarbitol (Luminal) B) Intravenous diazepam (Valium) C) Oral lorazepam (Ativan) D) Oral phenytoin (Dilantin)

ANS: B Status epilepticus (acute prolonged seizure activity) is a series of generalized seizures that occur without full recovery of consciousness between attacks. Medical management of status epilepticus includes intravenous diazepam (Valium) and intravenous lorazepam (Ativan) given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbitol) are given later to maintain a seizure-free state.

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? a. Positioning the client to prevent airway obstruction b. Keeping the client in one position to decrease bleeding c. Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess d. Maintaining the client in a quiet environment

B The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.

A patient with a seizure disorder is presenting having a generalized seizure. An appropriate nursing intervention during the seizure would include what? A) Restrain the patient to prevent injury. B) Open the patient's jaws to insert an oral airway. C) Place patient in high Fowler's position. D) Loosen the patient's restrictive clothing.

ANS: D An appropriate nursing intervention would include loosening any restrictive clothing on the patient. No attempt should be made to restrain the patient during the seizure because muscular contractions are strong and restraint can produce injury. Do not attempt to pry open jaws that are clenched in a spasm to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus.

Which of the following statements reflects nursing management of the patient with expressive aphasia? a. Encourage the patient to repeat sounds of the alphabet. b. Speak clearly and in simple sentences; use gestures or pictures when able. c. Speak slowly and clearly to assist the patient in forming the sounds. d. Frequently reorient the patient to time, place, and situation.

A 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.

A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the emergency department. The physician determines the patient's injury is causing increased intracranial pressure (ICP). The priority nursing evaluations, when assessing level of consciousness in this patient, would be based on what? A) Monro-Kellie hypothesis B) Glasgow Coma Scale C) Cranial nerve function D) Mental status exam

ANS: B Level of consciousness (LOC), a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response. Refer to Chart 63-4. The Monro-Kellie hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components (blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others. Cranial nerve function and the mental status exam would be part of the neurologic examination for this patient, but would not be the priority in evaluating level of consciousness.

When caring for a patient with increased ICP the nurse must monitor for possible secondary complications. One possible complication of increased ICP is SIADH. What nursing interventions would the nurse initiate if the patient developed SIADH? A) Fluid restriction B) Fluid replacement C) Electrolyte replacement D) Electrolyte restriction

ANS: A The nurse also assesses for complications of increased ICP, including diabetes insipidus and SIADH. SIADH requires fluid restriction and monitoring of serum electrolyte levels. You do not "restrict" electrolytes with patients, you monitor them. Diabetes insipidus requires fluid and electrolyte replacement.

What diagnostic test is contraindicated in a patient exhibiting clinical manifestations of increased intracranial pressure? A) CT scan B) Lumbar puncture C) MRI D) Venous Doppler studies

ANS: B A lumbar puncture in a client with increased intracranial pressure (ICP) may cause the brain to herniate from the withdrawal of fluid and change in pressure during the lumbar puncture. Herniation of the brain is a dire and frequently fatal event. A CT scan, MRI, and venous Doppler are considered noninvasive procedures and would not affect the intracranial pressure itself.

A clinic nurse is caring for a patient diagnosed with migraine headaches. When doing patient teaching, the patient questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the patient about alcohol's effects? A) Alcohol causes hormone fluctuation. B) Alcohol causes vasodilation of the blood vessels. C) Alcohol has an excitatory effect on the CNS. D) Alcohol diminishes endorphins in the brain.

ANS: B Alcohol causes vasodilation of the blood vessels. Alcohol has a depressant effect on the central nervous system (CNS). Alcohol does not cause hormone fluctuations, nor does it decrease endorphins (morphine-like substances produced by the body) in the brain.

A client diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the client and family needs to begin as soon as the client is settled on the unit and will continue until the client is discharged. What will family education need to include? a. How to differentiate between hemorrhagic and ischemic stroke b. Risk factors for ischemic stroke c. How to correctly modify the home environment d. Techniques for adjusting the client's medication dosages at home

C For a client with a hemorrhagic stroke, teaching addresses the use of assistive devices or modification of the home environment to help the client live with the disability. This is more important to the client's needs than knowing about risk factors for ischemic stroke. It is not necessary for the family to differentiate between different types of strokes. Medication regimens should never be altered without consultation.

When the nurse observes that the post-craniotomy patient is unresponsive to and unaware of environmental stimuli, the nurse uses which of the following terms to describe the patient in his documentation? A) Unresponsive B) Comatose C) Demonstrating akinetic mutism D) In a persistent vegetative state

ANS: A Coma is a clinical state of unarousable unresponsiveness in which there are no purposeful responses to internal or external stimuli, although nonpurposeful responses to painful stimuli and brainstem reflexes may be present. Persistent vegetative state is a condition in which the patient is described as wakeful but devoid of conscious content, without cognitive or affective mental function. In unresponsiveness, the patient is unresponsive to and unaware of environmental stimuli. Akinetic mutism is a state of unresponsiveness to the environment in which the patient makes no movement or sound but sometimes opens the eyes.

When caring for a patient with a neurologic impairment and his or her family, what are the mutual goals? A) Achieve as high a level of function as possible. B) Enhance the quantity of life. C) Teach the family proper care of the patient. D) Provide community assistance.

ANS: A The goals are to achieve as high a level of function as possible and to enhance the quality of life for the patient with neurologic impairment and his or her family. It is not a goal to enhance the quantity of the patient's life or provide community assistance. The scenario does not indicate that the patient needs to be taken care of by the family.

A nurse is admitting a patient with a severe migraine headache. The patient has a history of myocardial infarction in the past year. What migraine medication would the nurse question for this patient? A) Rizatriptan (Maxalt) B) Naratriptan (Amerge) C) Sumatriptan succinate (Imitrex) D) Zolmitriptan (Zomig)

ANS: C Sumatriptan may cause chest pain and is contraindicated in patients with ischemic heart disease. Adverse effects of sumatriptan succinate include angina, chest pressure, and chest tightness. None of the triptan medications should be taken concurrently with medications containing ergotamine (vascular headache suppressant) due to the potential for a prolonged vasoactive reaction. Maxalt, Amerge, and Zomig are triptans used in routine clinical use for the treatment of migraine headaches.

The nurse is admitting a patient to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this patient's admission orders? (Mark all that apply.) A) Transcranial Doppler flow study B) Cerebral angiography C) MRI D) Cranial radiography E) EMG

ANS: A, B, C Preoperative diagnostic procedures may include a CT scan to demonstrate the lesion and show the degree of surrounding brain edema, the ventricular size, and the displacement. An MRI scan provides information similar to that of a CT scan with improved tissue contrast, resolution, and anatomic definition. Cerebral angiography may be used to study a tumor's blood supply or obtain information about vascular lesions. Transcranial Doppler flow studies are used to evaluate the blood flow within intracranial blood vessels. Regular x-rays of the skull would not be diagnostic for an intracranial mass. An EMG would not be ordered prior to intracranial surgery to remove a mass.

The nurse is caring for a postop craniotomy patient. When writing the plan of care, the patient has a diagnosis of Deficient fluid volume related to fluid restriction related to osmotic diuretic use. What would be an appropriate intervention for this diagnosis? A) Change the patient's position as indicated B) Monitor serum electrolytes C) Maintain NPO status D) Monitor arterial blood gas values

ANS: B The postoperative fluid regimen depends on the type of neurosurgical procedure and is determined on an individual basis. The volume and composition of fluids are adjusted based on daily serum electrolyte values, along with fluid intake and output. Fluids may have to be restricted in patients with cerebral edema. Changing the patient's position, maintaining an NPO status, and monitoring ABG values do not relate to the nursing diagnosis of Risk for imbalanced fluid volume.

The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of Ineffective cerebral tissue perfusion. What would be an expected outcome that the nurse would document for this diagnosis? A) Copes with sensory deprivation. B) Registers normal body temperature. C) Pays attention to grooming. D) Obeys commands with appropriate motor responses.

ANS: D An expected outcome of the diagnosis of Ineffective tissue perfusion in a patient with increased intracranial pressure (ICP) would include obeying commands with appropriate motor responses. Vitals signs and neurologic status are assessed every 15 minutes to every hour. Coping with sensory deprivation would relate to the nursing diagnosis of Disturbed sensory perception. The outcome of Registers normal body temperature relates to the diagnosis of Potential for ineffective thermoregulation. Body image disturbance would have a potential outcome of Pays attention to grooming.

What should the nurse suspect when hourly assessment of urine output on a postcraniotomy patient exhibits a urine output from a catheter of 1500 mL for 2 consecutive hours? A) Cushing's syndrome. B) Syndrome of inappropriate antidiuretic hormone C) Adrenal crisis. D) Diabetes insipidus.

ANS: D Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in patients after brain surgery. Cushing's syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. SIADH is the result of increased secretion of ADH; the patient becomes volume-overloaded, urine output diminishes, and serum sodium concentration becomes dilute. Adrenal crisis is undersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension.

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? a. large-artery thrombotic b. small, penetrating arterythrombotic c. cardio embolic d. cryptogenic

C Ischemic strokes are further divided into five subtypes, according to a mechanism-based classification system: large-artery thrombotic strokes (representing 20% of ischemic strokes); small, penetrating artery thrombotic strokes (25%); cardio embolic strokes (20%); cryptogenic strokes (strokes that cannot be attributed to any specific cause) (30%); and "other" (5%). Large-artery thrombotic strokes are caused by atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion can occur at the site of the atherosclerosis and result in ischemia and infarction (tissue death). Small, penetrating artery thrombotic strokes that affect one or more vessels and cause reduced blood flow are the most common type of ischemic stroke, typically caused by longstanding hypertension, hyperlipidemia, or diabetes. Cardio embolic strokes are associated with cardiac dysrhythmias, such as atrial fibrillation, but can also be associated with valvular heart disease or left ventricular thrombus. The last two classifications of ischemic strokes are cryptogenic strokes, which have no identified cause, and strokes from other causes, such as illicit drug use (cocaine), coagulopathies, migraine, or spontaneous dissection of the carotid or vertebral arteries.

A patient is considered terminal after being involved in a motor vehicle accident in which they received massive trauma to the head. As the patient's ICP increases and condition worsens, the family asks you what indications of approaching death will there be. What would be your best response? A) "There is a change in the pattern of their respirations." B) "Projectile vomiting and hemiplegia usually occur just before death." C) "Posturing may develop as pressure on the brainstem increases." D) "Loss of brainstem reflexes is a sign of approaching death."

ANS: D As ICP increases, the patient's condition worsens, as manifested by the following signs and symptoms: the LOC continues to deteriorate until the patient is comatose. The pulse rate and respiratory rate decrease or become erratic, and the blood pressure and temperature increase. The pulse pressure (the difference between the systolic and the diastolic pressures) widens. The pulse fluctuates rapidly, varying from bradycardia to tachycardia. Altered respiratory patterns develop, including Cheyne-Stokes breathing (rhythmic waxing and waning of rate and depth of respirations alternating with brief periods of apnea) and ataxic breathing (irregular breathing with a random sequence of deep and shallow breaths). Projectile vomiting may occur with increased pressure on the reflex center in the medulla. Hemiplegia or decorticate or decerebrate posturing may develop as pressure on the brainstem increases. Bilateral flaccidity occurs before death. Loss of brainstem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign of approaching death.