Neuro
A client begins to exhibit signs and symptoms of a stroke at a community health fair. Emergency care for the client includes:
going to the nearest stroke center.
A nurse at a long term care facility provides care for an 85 year-old man who has had recent transient ischemic attacks (TIAs). Which of the following statements best identifies future complications associated with TIAs? TIA's:
Resolve rapidly but may place the client at an increased risk for stroke. TIAs can be considered a warning sign for future strokes. They are not hemorrhagic in nature and their effects are not normally cumulative. They may require treatment medically or surgically.
A 26 year-old female is resting after a one-minute episode during which she lost consciousness while her muscles contracted and extremities extended. This was followed by rhythmic contraction and relaxation of her extremities. On regaining consciousness, she found herself to have been incontinent of urine. What has the woman most likely experienced?
A tonic-clonic seizure. A tonic-clonic seizure often begins with tonic contraction of the muscles with extension of the extremities and immediate loss of consciousness. Incontinence of bladder and bowel is common. Cyanosis may occur from contraction of airway and respiratory muscles. The tonic phase is followed by the clonic phase, which involves rhythmic bilateral contraction and relaxation of the extremities.
A nurse is teaching a client newly diagnosed with a seizure disorder about medications. The most important information for the nurse to provide would be:
Antiepileptic medications should never be discontinued abruptly. Consistency in taking seizure medications is essential to obtaining and maintaining therapeutic blood levels of the medication. Abrupt withdrawal can cause seizure recurrence. Monitoring and assessment of drug levels are important.
A client has started having uncontrolled seizures that are not responding to usual medications. Nursing working with the client must pay special attention to which of the following priority aspects of this clients care? Assessment of:
Respiratory status and oxygen saturation Tonic-clonic status epilepticus is a medical emergency and, if not promptly treated, may lead to respiratory failure and death. Treatment consists of appropriate life support measures. Airway/breathing is always the priority in this emergency situation.
Excessive activity of the excitatory neurotransmitters and their receptor-mediated effects is the cause of which type of brain injury?
Excitotoxic Excitotoxicity is a final common pathway for neuronal cell injury and death. It is associated with excessive activity of excitatory amino acid neurotransmitters.
The nurse assessing for the doll's head response (doll's eye response) in an unconscious client documents which of the following as an abnormal response?
Eyes turn right when head is turned right
The chart of a client admitted because of seizures notes that the seizure activity began simultaneously in both cerebral hemispheres. The nurse should interpret this to mean that the client experienced which of the following?
Generalized seizure When seizure activity begins simultaneously in both cerebral hemispheres, it is considered a generalized seizure.
A parent brought her 8-year-old child to the emergent care center to be examined following a fall off a playground set, resulting in a head injury. On discharge, the nurse explains to the parent that some symptoms may continue, including the inability to remember what happened before the fall. Which of the following terms best describes the diagnosis?
Retrograde amnesia The loss of memory following a concussion can be part of the postconcussion syndrome. The term for loss of memory before the accident is retrograde amnesia.
The nurse is assessing a client and notes the client is now displaying decerebrate posturing. The position would be documented as:
Rigidity of the arms with palms of the hands turned away from the body and with stiffly extended legs and plantar flexion of the feet Decerebrate (extensor) posturing results from increased muscle excitability. It is characterized by rigidity of the arms with palms of the hands turned away from the body and with stiffly extended legs and plantar flexion of the feet.
Which of the following clients' signs and symptoms would allow a clinician to be most justified in ruling out stroke as a cause? An adult:
Has had a gradual onset of weakness, headache and visual disturbances over the last two days. A cardinal trait of the manifestations of stroke is that the onset is sudden, and a gradual onset of symptoms over two days would suggest an alternative etiology.
Which one of the following is the most common primary intracranial tumor in adults?
Neurogliomas or neoplasms of astrocytic origin Neurogliomas or neoplasms of astrocytic origin are the most common type of primary brain tumor in adults.
Hypoxic injury will result in which of the following effects on the brain?
Neuronal cell injury and death Neuronal cell injury and death is directly caused by hypoxic injury. The others are specific to several other brain injury types.
The nurse is preparing a client for oculovestibular reflex assessment (cold caloric test). The nurse explains that the test is used to elicit which of the following?
Nystagmus
A patient admitted to the emergency department with a change in mental status and a history of AIDS and primary central nervous system (CNS) lymphoma becomes extremely combative with the medical personnel. A family member is very upset with the patient's behavior. The nurse explains that these behaviors are most likely caused by which of the following?
Recurrence of primary CNS lymphoma
The emergency department nurse is caring for a patient who fell and had a head injury. Which of the following assessments would be noted during the early stage of intracranial pressure increase?
Stable vital signs The vital signs remain unchanged in the early stage of increased intracranial pressure.
The MRA scan of a client with a suspected stroke reports ruptured berry aneurysm. The nurse plans care for a client with which of the following?
Subarachnoid hemorrhage The rupture of a berry aneurysm leads to a subarachnoid hemorrhage.
The most common cause of an ischemic stroke is which of the following?
Thrombosis Thrombi are the most common cause of ischemic strokes, usually occurring in atherosclerotic blood vessels.
Based on assessment parameters for motor response on the Glasgow Coma Scale, to which client should the nurse assign a score of 5?
Localizes pain
A patient with memory loss is concerned about the possibility that it may be inherited. Which of the following disorders is an inherited dementia?
Huntington's disease Huntington's disease is an inherited disorder with chorea and dementia.
The spouse of a patient diagnosed with Alzheimer's disease asks the nurse why the patient often neglects to take a shower. The spouse states that the patient was always diligent with hygiene in the past; however, over the past few months that has not been the case. Which of the following is the nurse's best response?
"You should remind the patient to shower." The patient should be reminded to shower because most likely he or she has difficulty remembering to do so. In the moderate stage of Alzheimer's disease, which can last for several years, it is not unusual for hygiene to be neglected because the person may just not remember if he or she did or did not shower.
A nurse on a neurology unit is assessing a female brain-injured client. The client is unresponsive to speech, and her pupils are dilated and do not react to light. She is breathing regularly but her respiratory rate is 45 breaths per minute. In response to a noxious stimulus, her arms and legs extend rigidly. What is her level of impairment?
Coma
A client who is diagnosed with seizures describes feeling confused after experiencing a seizure. The family members report that the client has been smacking his lips prior to having a seizure. The client most likely experienced which type of seizure?
Focal Focal seizures with impairment of consciousness sometimes referred to as psychomotor seizures are often accompanied by automatisms or repetitive nonpurposeful activities such as lip smacking, grimacing, patting, or rubbing clothing. Confusion during the postictal period (after a seizure) is common.
A client with a history of a seizure disorder has been observed suddenly and repetitively patting his knee. After stopping this repetitive action, the client appears confused but is oriented to person and place but not time. What type of seizure did this client most likely experience?
Focal seizure with impairment to consciousness Focal seizures with impairment of consciousness, sometimes referred to as psychomotor seizures, are often accompanied by automatisms or repetitive nonpurposeful activities such as lip smacking, grimacing, patting, or rubbing clothing. Confusion during the postictal period (after a seizure) is common.
A patient is having difficulty with sleeping and has also been experiencing marital difficulties over the past couple of months. The patient tells the nurse at the physician's office that all this started after he had a car accident earlier that year. Which of the following would be the most important question for the nurse to ask?
"Did you sustain any injuries in the accident?" Postconcussion syndrome can interfere with daily living and also with relationships and can continue for months. The syndrome can include amnesia, insomnia, headache, difficulty concentrating, and irritability. In this situation, it would be very important to determine if the patient sustained a head injury to rule out postconcussion syndrome.
A patient discharged from the hospital 5 days ago following a stroke has come to the emergency department with facial droop that progressed with hemiplegia and aphasia. The patient's spouse is extremely upset because the physician stated that the patient cannot receive thrombolytic medications to reestablish cerebral circulation and the spouse asks the nurse why. Which of the following is the nurse's most accurate response?
"Thrombolytics may cause cerebral hemorrhage." A previous stroke, occurring within 3 months of the administration of thrombolytics, significantly increases the risk of intracranial hemorrhage.
The regulation of cerebral blood flow is accomplished through both autoregulation and local regulation. This allows for the brain to meet its metabolic needs. What is the low parameter for arterial blood pressure before cerebral blood flow becomes severely compromised?
60 mm Hg If blood pressure falls below 60 mm Hg, cerebral blood flow becomes severely compromised, and if it rises above the upper limit of autoregulation, blood flow increases rapidly and overstretches the cerebral vessels.
What medication teaching should be done for a woman of childbearing age with a seizure disorder?
Antiseizure drugs increase the risk for congenital abnormalities. For women with epilepsy who become pregnant, antiseizure drugs increase the risk for congenital abnormalities and other perinatal complications.
The nurse working in an emergency room is caring for a client who is exhibiting signs and symptoms of a stroke. What does the nurse anticipate that the physician's orders will include?
CT scan The nurse should anticipate that the client will be ordered a CT scan to rule out hemorrhagic stroke that would preclude the administration of tissue plasminogen activator (tPA).
Intracranial aneurysms that rupture cause subarachnoid hemorrhage in the client. How is the diagnosis of intracranial aneurysms and subarachnoid hemorrhage made?
CT scan The diagnosis of subarachnoid hemorrhage and intracranial aneurysms is made by clinical presentation, CT scan, and angiography.
The nurse is working in the emergency room. One client's presenting symptoms include the worst headache ever, nuchal rigidity and nausea. Another client's presenting symptoms include fever, stiff back, and positive Kernig's sign. Which client should the nurse assess first?
Client with the worst headache, nuchal rigidity and nausea The nurse should assess the client with presenting symptoms of worst headache ever, nuichal rigidity and nausea because these are presenting signs of aneurysmal subarachnoid hemorrhage from a ruptured cerebral aneurysm. The client with the presenting symptoms of fever, stiff back, and positive Kernig's sign is experiencing symptoms of meningitis. Ruptured cerebral aneurysm is a medical emergency with a higher priority than meningitis.
An emergency room nurse receives a report that a client's Glasgow Coma Scale (GCS) is 3. The nurse prepares to care for a client with which of the following?
Flaccid motor response A score of 3 on the Glasgow Coma Scale indicates the lowest possible score in each of the three scoring categories (eye opening, motor response, and verbal response) and includes flaccid or no motor response, no verbal response and the inability to open the eyes.
The nurse is planning an inservice on hypoxia versus ischemia in brain-injured clients. The nurse should include which of the following?
Hypoxia produces a generalized depressive effect on the brain. Hypoxia denotes a deprivation of oxygen with maintained blood flow (perfusion), whereas ischemia is a situation of greatly reduced or interrupted blood flow. Hypoxia produces a generalized depressant effect on the brain. Ischemia interferes with delivery of oxygen and glucose as well as the removal of metabolic wastes.
The nurse taking a report on a client coming into the emergency room plans care for a client with brain dysfunction based on which of the following symptoms?
Stupor The most frequent sign of brain dysfunction is an altered level of consciousness such as stupor.
The most common cause of ischemic stroke is:
Thrombosis. Ischemic stroke includes those caused by large artery thrombosis (20%), small artery thrombosis (25%), cardiogenic embolism (20%) and cryptogenic (undetermined cause)(30%), making thrombosis the most common cause (45%).
The nurse contacts the physician regarding a client's early signs of diminishing level of consciousness based on which of the following? Select all that apply.
• Disorientation • Blunted responsiveness • Inattention
The nurse is conducting a staff inservice on increased intracranial pressure. The nurse determines that the participants are understanding the information when they identify that blood pressure increases in increased intracranial pressure because of which of the following?
An attempt to increase cerebral perfusion Blood pressure increases in increased intracranial pressure due to the body's attempt to increase tissue perfusion. When the pressure in the cranial cavity approaches or exceeds the mean arterial pressure, tissue perfusion becomes inadequate.
An 80-year-old patient with a history of heavy alcohol use is being seen by his provider for drowsiness, confusion, and headache. His family states that he fell and hit his head "several weeks ago." Which type of hematoma does the provider suspect?
Chronic subdural
Generalized convulsive status epilepticus is a medical emergency caused by a tonic-clonic seizure that does not spontaneously end, or recurs in succession without recovery. What is the first-line drug of choice to treat status epilepticus?
Intravenous lorazepam
What term is used to describe a level of consciousness that sees a client responding only to vigorous and repeated stimuli and has minimal or no spontaneous movement?
Stupor Stupor is unresponsive except to vigorous and repeated stimuli; responds appropriately to painful stimuli; lies quietly with minimal spontaneous movement; may have incomprehensible sounds and/or eye opening.
A patient suffering a thrombotic stroke is brought into the emergency department by ambulance and the health care team is preparing to administer a synthetic tissue plasminogen activator for which of the following purposes?
Thrombolysis Synthetic tissue plasminogen activators work with the body's natural tissue plasminogen activators to convert plasminogen to plasmin, which breaks down clots to allow for the reestablishment of blood flow. There are two causes of strokes: hemorrhagic and thrombotic, with thrombotic strokes occurring much more frequently. Thrombolytics play a large role in increased outcomes seen with thrombotic strokes.
A patient in the intensive care unit who has a brain tumor has experienced a sharp decline. The care team suspects that water and protein have crossed the blood-brain barrier and been transferred from the vascular space into the client's interstitial space. Which of the following diagnoses best captures this pathophysiology?
Vasogenic edema Vasogenic edema occurs with conditions that impair the function of the blood-brain barrier and allow transfer of water and protein from the vascular into the interstitial space. It occurs in conditions such as tumors, prolonged ischemia, hemorrhage, brain injury, and infectious processes.
A client may be at risk for the development of hypoxia. Select the conditions that would place a client at risk. Select all that apply.
• Carbon monoxide poisoning • Increased oxygenation by the lungs • Severe anemia Hypoxia usually is seen in conditions such as exposure to reduced atmospheric pressure, carbon monoxide poisoning, severe anemia, and failure of the lungs to oxygenate the blood.
When trying to explain the difference between vasogenic versus cytotoxic cerebral edema, the physiology instructor mentions that cytotoxic edema displays which of the following functions in the brain? Select all that apply.
• Causes ischemia to build up lactic acid due to anaerobic metabolism • Allows cells to increase volume to the point of rupture, damaging neighboring cells
The nurse assessing a patient with a traumatic brain injury assesses for changes in which of the following? Select all that apply.
• Sensory function • Motor function • Cognition • Level of consciousness Brain injuries can cause changes in level of consiousness and alterations in cognition, motor, and sensory function; therefore, the nurse assessing a patient with a traumatic brain injury should assess for changes in these areas.
The CT scan report identified that a client with a skull fracture has developed a hematoma that resulted from a torn artery. The report would be interpreted as:
Epidural hematoma
According to the Glasgow Coma Scale, opening one's eyes to only painful stimuli would receive which score?
2 Only opening eyes to painful stimulation is scored as a 2. Spontaneously opening eyes is scored as a 4; opening eyes to speech is scored as a 3; no opening is scored as a 1.
A nurse is monitoring the intracranial pressure (ICP) of a client. The nurse would consider the client to have a normal reading when the results identify:
0 to 15 mm Hg The cranial cavity contains blood, CSF, and brain tissue. Each of these three volumes contributes to ICP, which is normally maintained within a range of 0 to 15 mm Hg when measured in the lateral ventricles.
The parent of an infant who developed hydrocephalus while in utero is very concerned that the child will have significant intellectual dysfunction. The best response to the parent would be which of the following?
"Because the skull sutures are not fused there may be no brain damage." When hydrocephalus develops in utero, before the cranial sutures have fused, the head can swell and decrease intracranial pressure, thereby decreasing the amount of brain tissue that is compressed.
The family of an older adult reports increasing inability to perform basic activities of daily living. After evaluation, the client is diagnosed with Alzheimer's disease. What intervention will be implemented to slow cognitive decline?
Acetylcholinesterase inhibitors
A client is brought to the emergency department and is diagnosed with an ischemic stroke confirmed by CT scan. The most important treatment for this client would be to:
Administer IV tissue-type plasmin activator (tPA)
The nurse is caring for a client admitted to the emergency room with suspected meningitis. The nurse prepares to perform which nursing intervention upon physician orders, while diagnostic testing is being completed?
Administration of antibiotics The nurse should prepare to administer antibiotics as ordered by the physician while the diagnostic tests are being completed. Delay in initiation of antimicrobial therapy, most frequently due to medical imaging prior to lumbar puncture or transfer to another medical facility, can result in poor client outcomes.
Global and focal brain injuries manifest differently. What is almost always a manifestation of a global brain injury?
Altered level of consciousness
For seizure disorders that do not respond to anticonvulsant medications, the option for surgical treatment exists. What is removed in the most common surgery for seizure disorders?
Amygdala The most common surgery consists of removal of the amygdala and an anterior part of the hippocampus and entorhinal cortex, as well as a small part of the temporal pole, leaving the lateral temporal neocortex intact. Only a portion of the hippocampus and entorhinal cortex, and temporal pole are removed.
The nurse is caring for a client with a brain tumor when the client begins to vomit. Which intervention should the nurse do first?
Assess for other signs/symptoms of increased intracranial pressure. The tumor may be causing increased intracranial pressure. Vomiting, with or without nausea, is a common symptom of increased intracranial pressure and/or brain stem compression. The nurse's first action is to assess for other signs/symptoms of increased intracranial pressure. Once the assessment is completed, the nurse should contact the physician if indicated by the findings.
The nurse caring for a client with a newly diagnosed intracranial tumor anticipates that the neoplasm will be which of the following?
Astrocytic neoplasms Collectively, astrocytic neoplasms are the most common type of primary brain tumor in adults; therefore the nurse anticipates that this is the cause of the client's intracranial tumor.
The nurse caring for a client with an aneurysmal subarachnoid hemorrhage understands that the most common cause of this condition is which of the following?
Berry aneurysm Aneurysmal subarachnoid hemorrhage is a type of hemorrhagic stroke caused by the rupture of a cerebral aneurysm and resultant bleeding into the subarachnoid space. Most of these aneurysms are small saccular aneurysms, called berry aneurysms.
Following a collision while mountain biking, the diagnostic work up of a 22 year-old male has indicated the presence of an acute subdural hematoma. Which of the following pathophysiological processes most likely underlies his diagnosis?
Blood has accumulated between the man's dura and subarachnoid space. A subdural hematoma develops in the area between the dura and the arachnoid space while epidural hematomas exist between the skull and dura.
A teenager has been in a car accident and experienced acceleration-deceleration head injury. Initially, the client was stable but then started to develop neurological signs/symptoms. The nurse caring for this client should be assessing for which type of possible complication?
Brain contusions and hematomas
A teenager has been in a car accident and experienced acceleration-deceleration head injury. Initially, the client was stable but then started to develop neurological signs/symptoms. The nurse caring for this client should be assessing for which type of possible complication?
Brain contusions and hematomas Contusions (focal brain injury) cause permanent damage to brain tissue. The bruised, necrotic tissue is phagocytized by macrophages, and scar tissue formed by astrocyte proliferation persists as a crater. The direct contusion of the brain at the site of external force is referred to as a acceleration injury, whereas the opposite side of the brain receives the deceleration injury from rebound against the inner skull surfaces. As the brain strikes the rough surface of the cranial vault, brain tissue, blood vessels, nerve tracts, and other structures are bruised and torn, resulting in contusions and hematomas.
A client has sustained a severe, diffuse brain injury that resulted in seriously compromised brain function. The client is at greatest risk for:
Brain death Severe brain injury that results in seriously compromised brain function can result in brain death.
Manifestations of brain tumors are focal disturbances in brain function and increased ICP. What causes the focal disturbances manifested by brain tumors?
Brain edema and disturbances in blood flow Intracranial tumors give rise to focal disturbances in brain function and increased ICP. Focal disturbances occur because of brain compression, tumor infiltration, disturbances in blood flow, and brain edema.
When the suspected diagnosis is bacterial meningitis, what assessment techniques can assist in determining if meningeal irritation is present?
Brudzinski sign and Kernig sign Two assessment techniques can help determine whether meningeal irritation is present. Kernig sign is resistance to extension of the knee while the person is lying with the hip flexed at a right angle. Brudzinski sign is elicited when flexion of the neck induces flexion of the hip and knee.
A soccer player has been diagnosed with a brain contusion after being injured in a game. The best explanation of the injury by the nurse would be:
Bruising on the surface of the brain occurred. Contusions represent bruising on the surface of the brain, and lacerations are a tearing of brain tissue.
The nurse is conducting a community education program on concussions. The nurse evaluates that the participants are understanding the education when they state that which of the following offers the brain protection from external forces?
Cerebral spinal fluid The brain is protected from external forces by the rigid confines of the skull and the cushioning afforded by the cerebrospinal fluid.
A client has suffered a stroke that has affected his speech. The physician has identified the client as having expressive aphasia. Later in the day, the family asks the nurse to explain what this means. The most accurate response would be aphasia that is:
Characterized by an inability to easily communicate spontaneously or translate thoughts or ideas into meaningful speech or writing Expressive or nonfluent aphasia is characterized by an inability to easily communicate spontaneously or translate thoughts or ideas into meaningful speech or writing.
Which of the following clients is at least risk for rapid bleeding?
Client with a subdural hematoma A subdural hematoma develops in the area between the dura and arachnoid space and is usually the result of a tear in small bridging veins that connect the surface of the cortex to dural sinuses. This is a slow source of bleeding, thus the client with a subdural hematoma is less likely to develop a rapid bleed than a client with an epidural hematoma, red stroke, and/or subarachnoid hemorrhage.
Which type of seizure begins in a localized area of the brain but may progress rapidly to involve both hemispheres?
Complex partial Complex partial type seizures begin in a localized area of the brain but may progress rapidly to involve both hemispheres.
A patient who is diagnosed with seizures describes feeling a strange sensation before losing consciousness. The family members report that the patient has been smacking their lips prior to having a seizure. Which type of seizure disorder presents with these symptoms?
Complex partial or focal seizure with impairment of consciousness
Wernicke-Korsakoff syndrome is a dementia that is associated with chronic alcoholism. It is caused by a deficiency in thiamine (vitamin B12). What is the most distinctive sign or symptom of this syndrome?
Confabulation Confabulation (i.e., recitation of imaginary experiences to fill in gaps in memory) is probably the most distinctive feature of the disease.
The nurse is caring for a 31-year-old trauma victim admitted to the neurologic intensive care unit. While doing the initial assessment, the nurse finds that the client is flexing the arms, wrists, and fingers. There is adduction of the upper extremities with internal rotation and plantar flexion of the lower extremities. How would the nurse describe this in the notes?
Decorticate posturing Decorticate (flexion) posturing is characterized by flexion of the arms, wrists, and fingers, with adduction of the upper extremities, internal rotation, and plantar flexion of the lower extremities.
A patient suffering global cerebral ischemia a week after a suicide attempt by hanging is in the intensive care unit receiving treatment. The parent asks the nurse why it is necessary to keep the patient paralyzed with medications and on the ventilator. The most appropriate response would be that these therapies do which of the following?
Decrease metabolic needs and increase oxygenation The general goal of treatment with global cerebral ischemia is to decrease metabolic needs and increase oxygenation to the injured cerebral tissue. Artificial ventilation provides appropriate oxygenation; keeping the patient paralyzed decreases the body's metabolic needs.
The health care provider is concerned that a client may be at risk for problems with cerebral blood flow. The most important data to assess would be:
Decreased level of oxygen Regulation of blood flow to the brain is controlled largely by autoregulatory or local mechanisms that respond to the metabolic needs of the brain. Metabolic factors affecting cerebral blood flow include an increase in carbon dioxide and hydrogen ion concentrations; cerebral blood flow is affected by decreased O2 levels and increased hydrogen ions, carbon dioxide, and PCO2 levels.
A patient with Alzheimer's disease (AD) is forgetful and has started to lose interest in social activities. Which of the following treatment routines would be beneficial for the patient?
Donepezil (Aricept) The cholinesterase inhibitor donepezil (Aricept) has been effective in slowing cognitive decline in early stages of AD.
A child is being seen in the emergency department (ED) after ingesting crayons with lead in them. He is disoriented and having seizures. The provider suspects he has which of the following?
Encephalitis Less frequent causes of encephalitis include ingesting toxic substances such as lead. People experience neurologic disturbances such as lethergy, disorientation, seizures, focal paralysis, delirium and coma.
A family brings a client to the emergency department with increasing lethargy and disorientation. They think the client had a seizure on the drive over to the hospital. The client has been sick with a "cold virus" for the last few days. On admission, the clients' temperature is 102°F. Which other clinical manifestations may lead to the diagnosis of encephalitis?
Impaired neck flexion resulting from muscle spasm Like meningitis, encephalitis is characterized by fever, headache, and nuchal rigidity (impaired neck flexion resulting from muscle spasm), but more often clients also experience neurologic disturbances, such as lethargy, disorientation, seizures, focal paralysis, delirium, and coma
A family is sitting with a patient in the intensive care unit who sustained significant head injuries in a motorcycle accident. They are questioning the nurse about why the patient's eyes open but do not stay open for long. The nurse explains that the patient is probably in which of the following states?
In a stuporous state due to a reticular activated system (RAS) injury Injury to the RAS would be suspected due to the change in the level of consciousness. The RAS and functional cerebral hemispheres are necessary for arousal and wakefulness; damage to either will negatively affect a person's level of consciousness.
A client has developed global ischemia of the brain. The nurse determines this is:
Inadequate to meet the metabolic needs of the entire brain Global ischemia occurs when blood flow is inadequate to meet the metabolic needs of the entire brain. The result is a spectrum of neurologic disorders reflecting diffuse brain dysfunction.
The emergency room doctor suspects a client may have bacterial meningitis. The most important diagnostic test to perform would be:
Lumbar puncture The diagnosis of bacterial meningitis is confirmed with abnormal CSF findings. Lumbar puncture findings, which are necessary for accurate diagnosis, include a cloudy and purulent CSF under increased pressure.
The nurse is explaining how vasogenic brain edema occurs to a client's family. The most appropriate information for the nurse to provide would be:
The blood-brain barrier is disrupted, allowing fluid to escape into the extracellular fluid. Vasogenic brain edema occurs with conditions that impair the function of the blood-brain barrier and allow the transfer of water and protein from the vascular space into the interstitial space.
A client who is being seen in the outpatient clinic reports a single episode of unilateral arm and leg weakness and blurred vision that lasted approximately 45 minutes. The client is most likely experiencing:
Transient ischemic attack (TIA) Transient ischemic attacks are brief episodes of neurologic function resulting in focal cerebral ischemia not associated with infarction that usually resolve in 24 hours. The causes of transient ischemic attack are the same as they are for stroke. Embolic stroke usually has a sudden onset with immediate maximum deficit.
Global or diffuse brain injury is manifested by changes in the level of consciousness.
True Global brain injury nearly always results in altered levels of consciousness, ranging from inattention to stupor or coma.
The nurse is caring for a client experiencing a seizure. During the seizure the nurse notes that the client repetitively rubs his/her clothing. When contacting the client's physician, the nurse notes that the client exhibited:
automatisms. The nurse reports that the client exhibited automatisms, defined as repetitive nonpurposeful activities such as lip smacking, grimacing, patting and/or rubbing clothing.
The nurse observes a new nurse performing the test for Kernig's sign on a client. The new nurse performs the test by providing resistance to flexion of the knees while the client is lying with the hip flexed at a right angle. The nurse should explain to the new nurse that:
resistance should be provided with the knee in a flexed position. The test for Kernig's sign for meningeal irritation is performed by providing resistance to flexion of the knees while the client is lying with the hip flexed at a right angle.
An 85-year-old patient with a medical history of diabetes, thrombocytopenia, and hypertension is on the cardiac step-down unit following the development of atrial defibrillation with a heart rate of 120-140. The atrial fibrillation was successfully cardioverted to a normal sinus rhythm and the patient was preparing to be discharged from the hospital when suddenly the patient developed right-sided hemiplegia and dysphasia. The nurse understands that this patient has many modifiable risk factors for stroke including which of the following? Select all that apply.
• Atrial fibrillation • Diabetes • Hypertension
Hydrocephalus is caused by which of the following? Select all that apply.
• Decreased absorption of cerebral spinal fluid • Obstruction of cerebral spinal fluid Hydrocephalus is defined as an abnormal increase in cerebral spinal fluid volume. The two causes include decreased absorption and obstruction of cerebral spinal fluid.
There are several types of brain injuries that can occur. What are the primary (or direct) brain injuries? (Select all that apply.)
• Focal lesions of laceration • Contusion • Diffuse axonal • Hemorrhage
An older adult is being evaluated for dementia. Which of the following assessments do not indicate normal aging? Select all that apply.
• Is easily agitated when routines are not followed • Is unable to explain the meaning of a proverb • Needs cues to perform hygiene activities Normal aging often includes slower processing of short term memory, and intact long-term memory with recognition cues for recall. Dementia may inhibit cognitive function so the client is unable to perform normal activities such as bathing and dressing. They become agitated, experience difficulty in higher order thinking and problem solving, and may see things that are not there.
Which symptoms would support the diagnosis of a stroke involving the posterior cerebral artery? Select all that apply.
• Loss of central vision • Repeating of verbal responses Posterior cerebral artery stroke would produce visual defects and the repeat of verbal and motor responses.
The nurse reading the results of a lumbar puncture cerebral spinal fluid analysis anticipates that the client's meningitis will be self-limiting in nature because of which of the following findings? Select all that apply.
• Lymphocytes • Moderately increased protein Viral meningitis, which presents with lymphocytes, moderately increased protein and normal glucose levels in the cerebral spinal fluid upon lumbar puncture, is self-limiting in nature.
Huntington disease is a genetic disorder that does not usually manifest itself until the client is in his or her 40s or 50s. What are the most common early psychological changes that occur with Huntington disease? (Select all that apply.)
• Moodiness • Impulsive behavior • Personality changes Depression and personality changes are the most common early psychological manifestations. Memory loss is often accompanied by impulsive behavior, moodiness, antisocial behavior, and a tendency toward emotional outbursts.
Following a car accident of a male teenage that did not have their seatbelt on; he arrived in the emergency department with a traumatic brain injury. He has severe cerebral edema following emergent craniotomy. Throughout the night, the nurse has been monitoring and reporting changes in his assessment. Which of the following assessments corresponds to a supratentorial herniation that has progressed to include midbrain involvement? Select all that apply.
• Pupils fixed at ~ 5 mm in diameter. • Respiration rate of 40 breaths/min. • Decerebrate posturing following painful stimulation of the sternum. With midbrain involvement, pupils are fixed and midsize (5 mm in diameter), and reflex adduction of the eyes is impaired; pain elicits decerebrate posturing; and respirations change from Cheyne-Stokes to neurogenic hyperventilation.
The nurse is caring for a client who has received tissue plasminogen activator (tPA). The nurse's plan of care should include education relating to which of the following? Select all that apply.
• Warfarin (Coumadin) therapy • Reduction of risk factors • Signs and symptoms of occurrence
