Neuro- Stroke, Seizures, ICP

The nurse enters the room as the client is beginning to have a tonic-clonic seizure. What action should the nurse implement first? 1. Note the first thing the client does in the seizure. 2. Assess the size of the client's pupils. 3. Determine if the client is incontinent of urine or stool. 4. Provide the client with privacy during the seizure.

1. Noticing the first thing the client does during a seizure provides information and clues as to the location of the seizure in the brain. It is important to document whether the beginning of the seizure was observed.

During a neurologic assessment the nurse asks a patient to close the eyes and asks the patient to identify a paper clip placed in the hand. What is the nurse assessing? 1) Stereognosis 2) Hyperesthesia 3) Graphesthesia 4) Two-point discrimination

1. Stereognosis or the ability to identify an object by its shape by simply holding the object.

. The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate? 1. The head of the bed elevated 30 to 45 degrees. 2. Trendelenburg's position. 3. Left Sims position. 4. The head elevated on two pillows.

1. The client's ICP is elevated, and the client should be positioned to avoid extreme neck flexion or extension. The head of the bed is usually elevated 30 to 45 degrees to drain the venous sinuses and thus decrease the ICP. Trendelenburg's position places the client's head lower than the body, which would increase ICP. The Sims position (side lying) and elevating the head on two pillows may extend or flex the neck, which increases ICP.

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? 1. An oral anticoagulant medication. 2. A beta blocker medication. 3. An anti-hyperuricemic medication. 4. A thrombolytic medication.

1.The nurse would anticipate an oral anticoagulant, warfarin (Coumadin), to be prescribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. The thrombi can become embolic and may cause a TIA or CVA (stroke).

The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication? 1. "I will brush my teeth after every meal." 2. "I will check my Dilantin level daily." 3. "My urine will turn orange while on Dilantin." 4. "I won't have any seizures while on this medication."

1.Thorough oral hygiene after each meal, gum massage, daily flossing, and regular dental care are essential to prevent or control gingival hyperplasia, which is a common occurrence in clients taking Dilantin.

A patient has suffered a stroke. Which neurologic factor will the nurse assess and record? 1.Speech 2.Mobility 3.Respiratory function 4.Level of consciousness

4.The nurse will assess the patient's level of consciousness and record it as a neurologic finding. Though related to neurologic functioning, speech, mobility, and respiratory function are motor function assessments.

The nurse is caring for a patient whose recent health history includes an altered LOC. What should be the nurses first action when assessing this patient? A) Assessing the patients verbal response B) Assessing the patients ability to follow complex commands C) Assessing the patients judgment D) Assessing the patients response to pain

A) Assessing the patients verbal response

A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? (Select all that apply.) A. avoid overwhelming fatigue B. remove caffeinated products from the diet C. limit looking at flashing lights D. perform aerobic exercise E. limit episodes of hypoventilation F. use of aerosol hairspray is

A. avoid overwhelming fatigue B. remove caffeinated products from the diet C. limit looking at flashing lights

A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply.) A. have suction equipment available for use B. feed the client thickened liquids C. place food on the unaffected side of the client's mouth D. assign an assistive personnel to feed the client slowly E. teach the client to swallow with the neck flexed

A. have suction equipment available for use B. feed the client thickened liquids C. place food on the unaffected side of the client's mouth E. teach the client to swallow with the neck flexed

A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first?A. keep the client in a side-lying position B. document the duration of the seizure C. reorient the client to the environment D. provide client hygiene

A. keep the client in a side-lying position. The greatest risk to the client is aspiration during the postictal phase. Therefore, the priority intervention is to keep the client in a side-lying position so secretions can drain from the mouth keeping the airway patent.

A nurse is assessing a client who has a seizure disorder. The client tells the nurse, "I am about to have a seizure." Which of the following actions should the nurse implement? (Select all that apply.) A. provide privacy B. ease the client to the floor if standing C. move furniture away from the client D. loosen the client's clothing E. protect the client's head with padding F. restrain the clien

A. provide privacy B. ease the client to the floor if standing C. move furniture away from the client D. loosen the client's clothing E. protect the client's head with padding

A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (Select all that apply.) A. speak to the client at a slower rate B. assist the client to use cards with pictures C. speak to the client in a loud voice D. complete sentences that the client cannot finish E. give instructions one step at a time

A. speak to the client at a slower rate B. assist the client to use cards with pictures E. give instructions one step at a time

A nurse is performing hourly neurological assessment checks on a client who is admitted with changes in mental status. The nurse understands that frequent assessments are used to determine if a client is developing increased intracranial pressure (ICP). Which option correctly describes the outcome if ICP is untreated and progresses? 1. Displacement of brain tissue 2. Increase in cerebral circulation and perfusion 3. Increase in serum pH 4. Improved brain tissue oxygenation

ANSWER: 1 The outcome of undetected and untreated ICP is displacement of brain tissue, also referred to as brain herniation. Unchecked ICP pro- gresses to cause shifts in brain tissue, resulting in irreversible brain damage and possibly death. ICP compresses structures within the cra- nium and leads to a decrease in cerebral perfusion, hypoxia, and acidosis. In acidosis, the pH level is decreased.

A client seeks medical attention at an emergency department after experiencing left-sided weakness and slurred speech. The client receives a diagnosis with an ischemic stroke and is evaluated for treatment with thrombolytic therapy. A definite contraindication for thrombolytic therapy is: 1.a normal computed tomography (CT) scan of the brain. 2.a serious head injury 4 weeks earlier. 3.a history of diabetes mellitus. 4.the onset of neurological deficits 2 hours earlier.

ANSWER: 2 Contraindications to thrombolytic therapy for a client with an ischemic stroke include a serious head injury within the previous 3 months. This would put the client at risk of developing serious bleeding problems, specifically cerebral hemorrhage. A negative CT scan and onset of neuro- logical deficits within 3 hours are criteria for administering the throm- bolytic therapy. History of diabetes is not a contraindication.

A client who has had a stroke stares at a nurse but does not attempt to verbally respond to the nurse's questions. The client follows instructions without any problems. The nurse understands that the client is displaying symptoms consistent with: 1. receptive aphasia. 2. global aphasia. 3. expressive aphasia. 4. both receptive and expressive aphasia.

ANSWER: 3 The client is showing symptoms of expressive aphasia (Broca's aphasia). The client has difficulty and is nonfluent with speech. Clients are often aware of their speech errors and are reluctant to speak. The client is able to comprehend and responds appropriately.

A client with epilepsy is prescribed phenytoin sodium (Dilantin®) 100 mg 3 times per day orally as anticonvulsant therapy. The most precise method for a nurse to determine if this is the proper dose for the client is: 1.observation of the client for seizures. 2.observation of the client for adverse effects. 3.determining whether the client is able to 4.participate in usual activities. 5.monitoring serum phenytoin levels.

ANSWER: 4 Dosages of anticonvulsant medications are individualized and monitored by measuring medication levels in the blood of the client. Observing client for symptoms and seizure activity is not as specific as monitoring drug levels for therapeutic range. normal range: 10-20

A client is seen by a primary care provider because of difficulty walking. A neurological assessment is done. A nurse informs the client that which assess- ment procedure was done to test the functioning of the cerebellum? 1.Ask the client to shut the eyes and distinguish whether the touch is with a sharp or dull object (either end of a cotton-tipped applicator). 2.Ask the client to hold hands with palms up perpendicular to the body with eyes closed. 3.Ask the client to grasp and squeeze 2 fingers of each of the examiner's hands. 4.Ask the client to alternate placing hands up and then hands down on thighs as fast as possible.

ANSWER: 4 Repetitive, alternating motion tests the client's coordination; an indi- cator of cerebella function. Detecting sharp or dull touch is a test for pe- ripheral nerve function. Assessing for pronator drift is a test for muscle weakness due to cerebral or brainstem dysfunction. Assess

A client with a deteriorating mental status after suffering a stroke has a rectal temperature of 102.3°F (39.1°C). For which reason should a nurse initiate interventions to bring the temperature to a normal level? 1.A normal temperature will strengthen the client's immune system against infection. 2.Hyperthermia lowers the incidence of mortality. 3.A normal temperature will decrease the score on the Glasgow coma scale. 4.Hyperthermia increases the likelihood of a larger area of brain infarct.

ANSWER: 4 Temperature elevation in neurological cases is thought to be associated with dysfunction of the hypothalamus. Research has shown that tem- perature elevations in the client post stroke result in an increase in the size of the infarct. Hyperthermia was associated with higher mortality rates and lower scores on the Glasgow coma scale. A normal temperature does not strengthen the immune system

A patient is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this patient, the nurse has the patient stick out her tongue and move it back and forth. What is the nurse assessing? A) Function of the hypoglossal nerve B) Function of the vagus nerve C) Function of the spinal nerve D) Function of the trochlear nerve

Ans: A Feedback: The hypoglossal nerve is the 12th cranial nerve. It is responsible for movement of the tongue. None of the other listed nerves affects motor function in the tongue.

When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of which the nurse should be aware? A) Generalized pain B) Alteration in level of consciousness (LOC) C) Tonicclonic seizures D) Shortness of breath

Ans: B Feedback: Alteration in LOC is the earliest sign of deterioration in a patient after a hemorrhagic stroke, such as mild drowsiness, slight slurring of speech, and sluggish papillary reaction. Sudden headache may occur, but generalized pain is less common. Seizures and shortness of breath are not identified as early signs of hemorrhagic stroke.

While completing a health history on a patient who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state? A) Epileptic cry B) Confusion C) Urinary incontinence D) Body rigidity

Ans: B Feedback: In the postictal 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 that occur during the seizure. Urinary incontinence and intense rigidity of the entire body are followed by alternating muscle relaxation and contraction (generalized tonicclonic contraction) during the seizure.

A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the ED. The physician determines the patients injury is causing increased intracranial pressure (ICP). The nurse should gauge the patients LOC on the results of what diagnostic tool? A) Monro-Kellie hypothesis B) Glasgow Coma Scale C) Cranial nerve function D) Mental status examination

Ans: B Feedback: 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. 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 examination would be part of the neurologic examination for this patient, but would not be the priority in evaluating LOC.

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

Ans: B Feedback: Medical management of status epilepticus includes IV diazepam (Valium) and IV lorazepam (Ativan) given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state. Oral medications are not given during status epilepticus.

The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four patients who might be at risk for a stroke. Which patient 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

Ans: B Feedback: 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 African Americans, where the incidence of first stroke is almost twice that as in Caucasians.

A patient has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? A) Unclassified seizure B) Absence seizure C) Generalized seizure D) Focal seizure

Ans: C Feedback: Generalized seizures often involve both hemispheres of the brain, causing both sides of the body to react. Intense rigidity of the entire body may occur, followed by alternating muscle relaxation and contraction (generalized tonicclonic contraction). This pattern of rigidity does not occur in patients who experience unclassified, absence, or focal seizures.

A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the patients plan of care? A) Monitoring of pulse oximetry B) Administration of a low-protein diet C) Administration of thorough oral hygiene D) Fluid restriction as ordered

Ans: C Feedback: Gingival hyperplasia (swollen and tender gums) can be associated with long-term phenytoin (Dilantin) use. Thorough oral hygiene should be provided consistently and encouraged after discharge. Fluid and protein restriction are contraindicated and there is no particular need for constant oxygen saturation monitoring.

A patient is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this patients care, the nurse would expect to administer what priority medication? A) Hydrochlorothiazide (HydroDIURIL) B) Furosemide (Lasix) C) Mannitol (Osmitrol) D) Spirolactone (Aldactone)

Ans: C Feedback: The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce cerebral edema. This drug acts by reducing the volume of brain and extracellular fluid. Spirolactone, furosemide, and hydrochlorothiazide are diuretics that are not typically used in the treatment of increased ICP resulting from cerebral edema.

The nurse is providing care for a patient who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the patient has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following? A) The ability of the patient to follow instructions during the seizure. B) The success or failure of the care team to physically restrain the patient. C) The patients ability to explain his seizure during the postictal period. D) The patients activities immediately prior to the seizure.

Ans: D Feedback: Before and during a seizure, the nurse observes the circumstances before the seizure, including visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; and hyperventilation. Communication with the patient is not possible during a seizure and physical restraint is not attempted. The patients ability to explain the seizure is not clinically relevant.

A nurse is completing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following statements should the nurse include in the teaching? A. "It is safe to use microwaves that are 1,200 watts or less." B. "You should avoid the use of CT scans with contrast." C. "You should place a magnet over the implantable device when you feel an aura occurring. D. "It is recommended that you use ultrasound diathermy for pain management."

C. "You should place a magnet over the implantable device when you feel an aura occurring.

If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with: A. Body temperature control B. Balance and equilibrium C. Visual acuity D. Thinking and reasoning

Correct Answer: A. Body temperature control The body's thermostat is located in the hypothalamus; therefore, injury to that area can cause problems of body temperature control. The spinothalamic tract is the sensory pathway for pain, temperature and crude touch that originates in the spinal cord and feeds into the ventral posterolateral nucleus of the thalamus for further processing, while the ventral posteromedial nucleus receives sensory information from the trigeminal nerve about the face.

A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment? A. Time of onset of current stroke B. Complete physical and history C. Current medications D. Upcoming surgical procedures

Correct Answer: A. Time of onset of current stroke The time of onset of a stroke to t-PA administration is critical. Administration within 3 hours has better outcomes. Tissue plasminogen activator (tPA) is classified as a serine protease (enzymes that cleave peptide bonds in proteins). It is thus one of the essential components of the dissolution of blood clots. Its primary function includes catalyzing the conversion of plasminogen to plasmin, the primary enzyme involved in dissolving blood clots.

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

Correct Answer: B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise. Cushing triad is a clinical syndrome consisting of hypertension, bradycardia and irregular respiration and is a sign of impending brain herniation. This occurs when the ICP is too high the elevation of blood pressure is a reflex mechanism to maintain CPP.

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? A. Cholesterol level B. Pupil size and pupillary response C. Bowel sounds D. Echocardiogram

Correct Answer: B. Pupil size and pupillary response It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining whether the brain stem is intact. Pupil size and equality is determined by a balance between parasympathetic and sympathetic innervation. Response to light reflects the combined function of the optic (II) and oculomotor (III) cranial nerves.

What is the expected outcome of thrombolytic drug therapy? A. Increased vascular permeability B. Vasoconstriction C. Dissolved emboli D. Prevention of hemorrhage

Correct Answer: C. Dissolved emboli. Thrombolytic therapy is used to dissolve emboli and reestablish cerebral perfusion. Thrombolytic treatment is also known as fibrinolytic or thrombolysis, to dissolve dangerous intravascular clots to prevent ischemic damage by improving blood flow. Thrombosis is a significant physiological response that limits hemorrhage caused by large or tiny vascular injury.

Which of the following signs and symptoms of increased ICP after head trauma would appear first? A. Bradycardia B. Large amounts of very dilute urine C. Restlessness and confusion D. Widened pulse pressure

Correct Answer: C. Restlessness and confusion The earliest symptom of elevated ICP is a change in mental status. Following the neurological exam closely is very important. Usually, there is an altered mental status and development of a fixed and dilated pupil. Patients presenting with findings suggestive of cerebral insult should undergo computed tomography (CT) scan of the brain; this can show the edema, which is visible as areas of low density and loss of gray/white matter differentiation, on an unenhanced image.

You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to LPN/LVN? A. Complete admission assessment. B. Place a padded tongue blade at the bedside. C. Set up oxygen and suction equipment. D. Pad the side rails before the patient arrives.

Correct Answer: C. Set up oxygen and suction equipment. The LPN/LVN can set up the equipment for oxygen and suctioning. Supportive care with attention to airway, breathing, and circulation issues are vital. Clear communication between team members is essential since patients' clinical status may abruptly change. Most patients will have a single, brief, uncomplicated event and return to full consciousness. Detection of any underlying cause of the seizure or seizures is important, so that appropriate therapy or counseling is available.

A patient with a seizure disorder asks the purpose of staying awake all night prior to having an electroencephalogram in the morning. What should the nurse explain to this patient? 1. You will be expected to sleep during the test. 2. Most people with seizure disorders receive too much sleep. 3. This is the only way to prove that you really have a seizure disorder. 4. Sleep deprivation can cause a seizure which will be helpful during the test.

"Sleep deprivation can cause a seizure, which will be helpful during the test."

The nurse finds that the patient is unable to recognize familiar objects after a stroke. What term does the nurse chart in the patient's medical record? 1.Alexia 2.Agnosia 3.Aphasia 4.Agraphia

2.Agnosia is the inability to recognize familiar objects. Aphasia is difficulty in speaking or understanding speech. Alexia is difficulty reading. Agraphia is difficulty writing

A patient with increased intracranial pressure (ICP) is sensitive to fluid-volume shifts. Which approach would be the safest to reduce this patient's cerebral edema? 1) Mannitol 2) 3% normal saline 3) Bacteriostatic saline 4) Preservative-free saline

2.High-concentration sodium chloride solutions pull water from the interstitial spaces into the vascular space without the dramatic fluid shifts caused when osmotic diuretics are utilized

A patient is experiencing changes in eye movements. Which part of the central nervous system is most likely causing these changes? 1) Pons 2) Midbrain 3) Medulla oblongata 4) Reticular formation

2.The midbrain contains the nerve pathways between the cerebrum and the medulla oblongata. Cranial nerves III and IV, which control eye movements, have their origins here.

51. The male client diagnosed with a brain tumor is scheduled for a magnetic resonance imaging (MRI) scan in the morning. The client tells the nurse that he is scared. Which response by the nurse indicates an appropriate therapeutic response? 1. "MRIs are loud but there will not be any invasive procedure done." 2. "You're scared. Tell me about what is scaring you." 3. "This is the least thing to be scared about— there will be worse." 4. "I can call the MRI tech to come and talk to you about the scan."

2.This is restating and offering self. Both are therapeutic responses.

Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)? ■ 1. Deep breathing. ■ 2. Turning. ■ 3. Coughing. ■ 4. Passive range-of-motion (ROM) exercises.

3. Coughing is contraindicated for a client at risk for increased ICP because coughing increases ICP. Deep breathing can be continued. Turning and passive ROM exercises can be continued with care not to extend or flex the neck.

The male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first? 1. Push aside any furniture. 2. Place the client on his side. 3. Assess the client's vital signs. 4. Ease the client to the floor.

4. The client should not remain in the chair during a seizure. He should be brought safely to the floor so that he will have room to move the extremities.

A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (Select all that apply) A. headache B. dilated pupils C. tachycardia D. decorticate posturing E. hypotension

A.headache; B. dilated pupils; D. decorticate posturing Decorticate posture is an abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held out straight. The arms are bent in toward the body and the wrists and fingers are bent and held on the chest. This type of posturing is a sign of severe damage in the brain

A client is scheduled for an outpatient electroencephalogram (EEG). A nurse instructs the client to prepare for the test by: 1.removing all hair pins. 2.avoiding eating or drinking at least 6 hours prior to the test. 3.being prepared to have some of the scalp shaved. 4.having blood drawn for a glucose level 2 hours before the test.

ANSWER: 1 In an EEG, electrodes are placed on the scalp over multiple areas of the brain to detect and record patterns of electrical activity. Prepara- tion includes clean hair without any objects in the hair to prevent in- accurate test results.

The nurse has created a plan of care for a patient who is at risk for increased ICP. The patients care plan should specify monitoring for what early sign of increased ICP? A) Disorientation and restlessness B) Decreased pulse and respirations C) Projectile vomiting D) Loss of corneal reflex

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

A patient with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? A) Restrain the patient to prevent injury. B) Open the patients jaws to insert an oral airway. C) Place patient in high Fowlers position. D) Loosen the patients 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.

A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA? a. Caucasian race b. Female sex c. Obesity d. Bronchial asthma

Answer C. Obesity is a risk factor for CVA. Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, oral contraceptive use, emotional stress, family history of CVA, and advancing age. The client's race, sex, and bronchial asthma aren't risk factors for CVA.

What assessment finding requires immediate intervention if found while a patient is receiving Mannitol?* A. An ICP of 10 mmHg B. Crackles throughout lung fields C. BP 110/72 D. Patient complains of dry mouth and thirs

B. Crackles throughout lung fields The answer is B. Mannitol can cause fluid volume overload that leads to heart failure and pulmonary edema. Crackles in the lung fields represent pulmonary edema and requires immediate intervention. Option A is a normal ICP reading and shows the mannitol is being effective. BP is within normal limits, and dry mouth/thirst will occur with this medication because remember we are trying to dehydrate the brain to keep edema and intracranial pressure decreased.

A patient is receiving Mannitol for increased ICP. Which statement is INCORRECT about this medication?* A. Mannitol will remove water from the brain and place it in the blood to be removed from the body. B. Mannitol will cause water and electrolyte reabsorption in the renal tubules. C. When a patient receives Mannitol the nurse must monitor the patient for both fluid volume overload and depletion. D. Mannitol is not for patients who are experiencing anuria.

B. Mannitol will cause water and electrolyte reabsorption in the renal tubules.The answer is B. All the other options are correct. Mannitol will PREVENT (not cause) water and electrolytes (specifically sodium and chloride) from being reabsorbed....hence it will leave the body as urine.

A nurse is caring for a client who has a closed-head injury with ICP readings ranging from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (Select all that apply) A. suction the endotracheal tube frequently B. decrease the noise level in the client's room C. elevate the client's head on two pillows D. administer a stool softener E. keep the client well hydrated

B. decrease the noise level in the client's room; D. administer a stool softener

A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? A. hyperglycemia B. hyponatremia C. hypervolemia D. oliguria

B. hyponatremia- complications are value expansion, hyponatrema, hyperkalemia, hypokalemia, ad metabolic acidosis

A nurse is caring for a client who has experienced right-hemispheric stroke. The nurse should expect the client to have difficulty with which of the following? (Select all that apply.) A. impulse control B. moving the left side C. depth perception D. speaking E. situational awareness

B. moving the left side, C. depth perception

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? A. A thrombolytic medication B. A beta-blocker medication C. An anti-hyperuricemic medication D. An oral anticoagulant medication

Correct Answer: D. An oral anticoagulant medication. Thrombi form secondary to atrial fibrillation. Therefore, an anticoagulant would be anticipated to prevent thrombus formation; and oral (warfarin [Coumadin]) at discharge versus intravenous. Oral anticoagulation is indicated for patients with atrial fibrillation or other sources of cardioembolic sources of TIA

A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure the client to ensure client safety? A. Speak loudly to the client. B. Test the temperature of the shower water. C. Check the temperature of the food on the delivery tray. D. Provide a clear path for ambulation without obstacles.

Correct Answer: D. Provide a clear path for ambulation without obstacles. Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating. Compromise of the optic nerve results in visual field defects and/or visual loss. The type of visual field defect depends on which region of the optic pathway is disrupted.

Which of the following medical treatments should the nurse anticipate administering to a client with increased intracranial pressure due to brain hemorrhage, except? A. acetaminophen (Tylenol) B. dexamethasone (Decadron) C. mannitol (Osmitrol) D. phenytoin (Dilantin) E. nitroglycerin (Nitrostat)

E

A patient has been experiencing a tonic-clonic seizure for five minutes. What should the nurse do first? 1) Assess carotid pulse 2) Prepare to insert an airway 3) Provide rescue breathing 4) Insert an intravenous access line

Prepare to insert an airway

The nurse suspects that a patient with a brain tumor is developing increased intracranial pressure (ICP). What assessment findings caused the nurse to make this conclusion? Select all that apply. 1) Ataxia 2) Nausea 3) Diarrhea 4) Vomiting 5) Headache

1,2,3,5

The client has been newly diagnosed with epilepsy. Which discharge instructions should be taught to the client? Select all that apply. 1. Keep a record of seizure activity. 2. Take tub baths only; do not take showers. 3. Avoid over-the-counter medications. 4. Have anticonvulsant medication serum levels checked regularly. 5. Do not drive alone; have someone in the car.

1,3,4 Keeping a seizure and medication chart will be helpful when keeping follow-up appointments with the health-care pro- vider and in identifying activities that may trigger a seizure. 3. Over-the-counter medications may contain ingredients that will interact with antisei- zure medications or, in some cases, as with use of stimulants, possibly cause a seizure. 4. Most of the anticonvulsant medications have therapeutic serum levels that should be maintained, and regular checks of the se- rum levels help to ensure the correct level.

Regular oral hygiene is essential for the client who has had a stroke. Which of the following nursing measures is not appropriate when providing oral hygiene? 1.Placing the client on the back with a small pillow under the head. 2.Keeping portable suctioning equipment at the bedside. 3.Opening the client's mouth with a padded tongue blade 4..Cleaning the client's mouth and teeth with a toothbrush.

1. A helpless client should be positioned on the side, not on the back, with the head on a small pillow. A lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction the client if he aspirates. Suction equipment should be nearby. It is safe to use a padded tongue blade, and the client should receive oral care, including brushing with a toothbrush.

Which client would the nurse identify as being most at risk for experiencing a CVA? 1. A 55-year-old African American male. 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female.

1. African Americans have twice the rate of CVAs as Caucasians and men have a higher incidence than women; African Americans suffer more extensive damage from a CVA than do people of other cul- tural groups.

A patient reports a change in the taste of food. Which cranial nerve should the nurse suspect as being affected? 1) CN VII Facial 2) CN V Trigeminal 3) CN XI Accessory 4) CN XII Hypoglossal

1. CN VII Facial influences taste.

A client is at risk for increased intracranial pressure (ICP). Which of the following would be the priority for the nurse to monitor? 1. Unequal pupil size. 2. Decreasing systolic blood pressure. 3. Tachycardia .4. Decreasing body temperature.

1. Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increas- ing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to per- fuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causesan increase in body temperature from hypothalamic

The nurse asks the male client with epilepsy if he has auras with his seizures. The client says,"I don't know what you mean. What are auras?" Which statement by the nurse would be the best response? 1. "Some people have a warning that the seizure is about to start." 2."Auras occur when you are physically and psychologically exhausted." 3."You're concerned that you do not have auras before your seizures?" 4."Auras usually cause you to be sleepy after you have a seizure."

1.An aura is a visual, an auditory, or an olfactory occurrence that takes place prior to a seizure and warns the client a seizure is about to occur. The aura often allows time for the client to lie down on the floor or find a safe place to have the seizure.

Which technique should the nurse use to assess a patient's CN IX Glossopharyngeal? 1) Apply a tongue depressor to the back of the throat 2) Ask the patient to read from a book or a newspaper 3) Ask the patient to smile, frown, puff cheeks, and raise eyebrows 4) Ask the patient to follow the examiner's finger as it moved toward the patient's nose

1.CN XI Glossopharyngeal is assessed by applying a tongue depressor to the back of the throat to check for a gag reflex.

The occupational health nurse is concerned about preventing occupation-related acquired seizures. Which intervention should the nurse implement? 1. Ensure that helmets are worn in appropriate areas. 2.Implement daily exercise programs for the staff. 3.Provide healthy foods in the cafeteria. 4.Encourage employees to wear safety glasses.

1.Head injury is one of the main reasons for epilepsy that can be prevented through occupational safety precautions and highway safety programs.

Which modifiable risk factors for stroke would be most important for the nurse to include when planning a community education program?1.Hypertension 2.Hyperlipidemia 3.Alcohol consumption 4.Oral contraceptive use

1.Hypertension is the single most important modifiable risk factor but still it is undetected often and treated inadequately. The public is often more aware of hyperlipidemia and oral contraceptive use as risk factors for stroke. Alcohol is also a modifiable risk factor.

The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. 1. Position the client to prevent shoulder adduction. 2. Turn and reposition the client every shift. 3. Encourage the client to move the affected side. 4. Perform quadriceps exercises three (3) times a day. 5. Instruct the client to hold the fingers in a fist.

1.Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture. 3.The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible; a written schedule may assist the client in exercising.

The nurse administers mannitol (Osmitrol) to the client with increased intracranial pressure. Which parameter requires close monitoring? 1. Muscle relaxation. 2. Intake and output. 3. Widening of the pulse pressure. 4. Pupil dilation.

2. After administering mannitol, the nurse closely monitors intake and output because manni- tol promotes diuresis and is given primarily to pull water from the extracellular fluid of the edematous brain. Mannitol can cause hypokalemia and may lead to muscle contractions, not muscle relaxation. Signs and symptoms, such as widening pulse pres- sure and pupil dilation, should not occur because mannitol serves to decrease ICP.

When preparing to teach a client about phenytoin sodium (Dilantin) therapy, the nurse should urge the client not to stop the drug suddenly because: 1.Physical dependency on the drug develops over time. 2.Status epilepticus may develop. 3.A hypoglycemic reaction develops. 4.Heart block is likely to develop.

2. Anticonvulsant drug therapy should never be stopped suddenly; doing so can lead to life- threatening status epilepticus. Phenytoin sodium does not carry a risk of physical dependency or lead to hypoglycemia. Phenytoin has antiarrhythmic properties, and discontinuation does not cause heart block.

A nurse is providing discharge instructions to a client who has a prescription for phenytoin. Which of the following information should the nurse include? A. consider taking an antacid when on this medication B. watch for receding gums when taking the medication C. take the medication at the same time every day D. provide a urine sample to determine therapeutic levels of the medication

C. take the medication at the same time every day to keep same level through out body

A client states that she is afraid she will not be able to drive again because of her seizures. Which response by the nurse would be best? 1.A person with a history of seizures can drive only during daytime hours. 2.A person with evidence that the seizures are under medical control can drive. 3.A person with evidence that seizures occur no more often than every 12 months can drive. 4.A person with a history of seizures can drive if he carries a medical identification card.

2. Specific motor vehicle regulations and restrictions for people who experience seizures vary locally. Most commonly, evidence that the seizures are under medical control is required before the person is given permission to drive. Time of dayis not a consideration when determining driving restrictions related to seizures. The amount of time a person has been seizure-free is a consideration for lifting driving restrictions; however, the time frame is usually 2 years. It is recommended, not required, that a person who is subject to seizures carry a card or wear an identification bracelet describing the ill- ness to facilitate quick identification in the event of an emergency.

The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse document? 1. Hemiparesis of the client's left arm and apraxia. 2. Paralysis of the right side of the body and ataxia. 3. Homonymous hemianopsia and diplopia 4. Impulsive behavior and hostility toward family.

2. The most common motor dysfunction of a CVA is paralysis of one side of the body, hemiplegia; in this case with a left-sided CVA, the paralysis would affect the right

The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? 1. Potential for injury. 2. Powerlessness. 3. Disturbed thought processes. 4. Sexual dysfunction.

2.Expressive aphasia means that the client cannot communicate thoughts but understands what is being communicated; this leads to frustration, anger, depression, and the inability to verbalize needs, which, in turn, causes the client to have a lack of control and feel powerless.

The unlicensed assistive personnel (UAP) is attempting to put an oral airway in the mouth of a client having a tonic-clonic seizure. Which action should the primary nurse take? 1. Help the UAP to insert the oral airway in the mouth. 2. Tell the UAP to stop trying to insert anything in the mouth. 3. Take no action because the UAP is handling the situation. 4. Notify the charge nurse of the situation immediately.

2.The nurse should tell the UAP to stop trying to insert anything in the mouth of the client experiencing a seizure. Broken teeth and injury to the lips and tongue may result from trying to place anything in the clenched jaws of a client having a tonic-clonic seizure.

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for a STAT computed tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult.

3. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or ischemic accident and guide treatment.

The nurse educator is presenting an in-service on seizures. Which disease process is the leading cause of seizures in the elderly? 1. Alzheimer's disease. 2. Parkinson's disease. 3. Cerebral vascular accident (stroke). 4. Brain atrophy due to aging.

3. A CVA (stroke) is the leading cause of seizures in the elderly; increased intracranial pressure associated with the stroke can lead to seizures.

During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's: 1. Pulse. 2. Respirations. 3. Blood pressure. 4. Temperature.

3. Control of blood pressure is critical during the first 24 hours after treatment because an intrac- erebral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored, and blood pressure is maintained as identified by the physician and specific to the client's ischemic tissue needs and risk of bleeding from treatment. The other vital signs are important, but the priority is to moni- tor blood pressure.

The client who just had a three (3)-minute seizure has no apparent injuries and is oriented to name, place, and time but is very lethargic and just wants to sleep. Which intervention should the nurse implement? 1. Perform a complete neurological assessment. 2. Awaken the client every 30 minutes. 3. Turn the client to the side and allow the client to sleep. 4. Interview the client to find out what caused the seizure.

3. During the postictal (after-seizure)phase, the client is very tired andshould be allowed to rest quietly; placing the client on the side will helpprevent aspiration and maintain apatent airway.

A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. The nurse should first: 1.Ask what medications the client is taking. 2.Complete a history and health assessment. 3.Identify the time of onset of the stroke. 4.Determine if the client is scheduled for any surgical procedures.

3. Studies show that clients who receive recombinant t-PA treatment within 3 hours after the onset of a stroke have better outcomes. The time from the onset of a stroke to t-PA treatment is criti- cal. A complete health assessment and history is not possible when a client is receiving emergency care. Upcoming surgical procedures may need tobe delayed because of the administration of t-PA, which is a priority in the immediate treatment of the current stroke. While the nurse should identify which medications the client is taking, it is more important to know the time of the onset of the stroke to determine the course of action for admin- istering t-PA.

Which statement by the female client indicates that the client understands factors that may precipitate seizure activity? 1. "It is all right for me to drink coffee for breakfast." 2. "My menstrual cycle will not affect my seizure disorder." 3. "I am going to take a class in stress management." 4. "I should wear dark glasses when I am out in the sun."

3. Tension states, such as anxiety and frustration, induce seizures in some clients, so stress management may be helpful in preventing seizures.

The client is scheduled for an electroencephalogram (EEG) to help diagnose a seizure disorder. Which preprocedure teaching should the nurse implement? 1. Tell the client to take any routine antiseizure medication prior to the EEG. 2. Tell the client not to eat anything for eight (8) hours prior to the procedure. 3. Instruct the client to stay awake for 24 hours prior to the EEG. 4. Explain to the client that there will be some discomfort during the procedure.

3. The goal is for the client to have a seizure during the EEG. Sleep deprivation, hyperventilating, or flashing lights may induce a seizure.

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? 1. A blood glucose level of 480 mg/dL. 2. A right-sided carotid bruit. 3. A blood pressure of 220/120 mm Hg. 4. The presence of bronchogenic carcinoma.

3. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, whichis a ruptured blood vessel inside the cranium.

A patient is admitted with a hemorrhagic stroke. Which prescription should a nurse question? 1.Diltiazem 30 mg PO every eight hours 2Metoprolol succinate 50 mg PO once daily 3Clopidogrel 75 mg by mouth (PO) once daily 4Cefazolin 1 gm intravenous piggyback (IVPB) every eight hours

3.Clopidogrel, an anticoagulant, is contraindicated for patients who have had a hemorrhagic stroke. The anticoagulant effect of clopidogrel could cause further hemorrhage.

The nurse is caring for several clients. Which client would the nurse assess first after receiving the shift report? 1. The 22-year-old male client diagnosed with a concussion who is complaining someone is waking him up every two (2) hours. 2. The 36-year-old female client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan. 3. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale (GCS) score of 6. 4. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia.

3.The Glasgow Coma Scale is used to determine a client's response to stimuli (eye opening response, best verbal response, and best motor response) secondary to a neurological problem; scores range from 3 (deep coma) to 15 (intact neurological function). A client with a score

The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? 1. Obtain a rubber mat to place under the dinner plate. 2. Purchase a long-handled bath sponge for showering. 3. Purchase clothes with Velcro closure devices. 4. Obtain a raised toilet seat for the client's bathroom.

4. Raising the toilet seat is modifying the home and addresses the client's weakness in being able to sit down and get up without straining muscles or requiring lifting assistance from the wife.

48. The nurse is caring for clients on a medical unit. Which client would be most at risk for experiencing a stroke? 1. A 92-year-old client who is an alcoholic. 2. A 54-year-old client diagnosed with hepatitis. 3. A 60-year-old client who has a Greenfield filter. 4. A 68-year-old client with chronic atrial fibrillation.

4.A client with atrial fibrillation is at high risk to have a stroke and is usually given oral anticoagulants to prevent a stroke.

30.The client is diagnosed with an SCI and is scheduled for a magnetic resonance imaging (MRI) scan. Which question would be most appropriate for the nurse to ask prior to taking the client to the diagnostic test? 1. "Do you have trouble hearing?" 2."Are you allergic to any type of dairy products?" 3."Have you eaten anything in the last eight (8) hours?" 4."Are you uncomfortable in closed spaces?"

4.MRI scans are often done in a very confined space; many people who have claustrophobia must be medicated or even rescheduled for the procedure in an open MRI machine, which may be available if needed.

The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? 1. Administer a nonnarcotic analgesic. 2. Prepare for STAT magnetic resonance imaging (MRI). 3. Start an intravenous infusion with D5W at 100 mL/hr. 4. Complete a neurological assessment.

4.The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action.

The nurse educator is reviewing the assessment of cranial nerves. What should the educator identify as the specific instances when cranial nerves should be assessed? Select all that apply. A) When a neurogenic bladder develops B) When level of consciousness is decreased C) With brain stem pathology D) In the presence of peripheral nervous system disease E) When a spinal reflex is interrupted

Ans: B, C, D Feedback: Cranial nerves are assessed when level of consciousness is decreased, with brain stem pathology, or in the presence of peripheral nervous system disease. Abnormalities in muscle tone and involuntary movements are less likely to prompt the assessment of cranial nerves, since these nerves do not directly mediate most aspects of muscle tone and movement.

When caring for a patient with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would the nurse use to elicit a response from cranial nerve VII? A. trapezius muscle while patient shrugs should against resistance. B. Administer the whisper or watch-tick test. C. Observe for facial movement symmetry, such as a smile. D. Note any hoarseness in the patients voice.

Ans: C Feedback: Cranial nerve VII is the facial nerve. An appropriate assessment technique for this cranial nerve would include observing for symmetry while the patient performs facial movements: smiles, whistles, elevates eyebrows, and frowns. Palpating and noting strength of the trapezius muscle while the patient shrugs shoulders against resistance would be completed to assess cranial nerve XI (spinal accessory). Assessing cranial nerve VIII (acoustic) would involve using the whisper or watch-tick test to evaluate hearing. Noting any hoarseness in the patients voice would involve assessment of cranial nerve X (vagus).