Neurological (Level 1)
Ergotamine tartrate is prescribed for a client's migraine headaches. Which is an expected outcome of this drug? a. Prevention of the migraine b. Aborting of the developing migraine c. Relief from the sleeplessness experienced in the past after a migraine d. Relief from the vision problems experiencing in the past after a migraine
Correct answer: B Ergotamine tartrate is used to help abort a migraine attack. The should be taken as soon as prodromal symptoms appear. Reduced migraine severity and relief from sleeplessness and vision problems address symptoms that occur after the migraine has occurred and are not effects of ergotamine.
The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will: a. Have a preference for foods high in salt b. Eat food on only half of the plate c. Forget the names of foods d. Not be able to swallow liquids
Correct answer: B Homonymous hemianopia is a blindness in half of the visual field; therefore, the client would see only half of the plate. Eating only the food on half of the plate results from an inability to coordinate visual images and spatial relationships. There may be an increased preference for foods high in salt after a stroke, but this would not be related to homonymous hemianopia. Forgetting the names of food is a sign of aphasia, which involves a cerebral cortex lesion. Being unable to swallow liquids is dysphagia, which involves motor pathways of cranial nerves IX and X, including the lower brain stem.
A patient is admitted to the unit after traumatic brain injury. The nurse notices that the patient has developed foot drop. Which of the following is the most appropriate intervention? a. Daily massage of the affected extremity b. Placement of an orthotic boot c. Elevation of the foot on a pillow d. Placement of an elastic stocking
Correct answer: B Placement of an orthotic boot is the most appropriate treatment for foot drop. For severe cases, surgery may be indicated. Foot drop causes the foot to be extended with limited to no ability to dorsiflex; it is most often caused by trauma or disease affecting the muscles or the nerves. Keeping the foot propped up on the pillow or massaging the foot would be ineffective treatments since the foot itself is not being treated. Placement of an elastic stocking would help with circulation, but foot drop is not caused by a circulatory disorder.
The nurse is performing the Glasgow coma scale on a client. The assessment is as follows: eye opening, to pain; motor response, localizes pain; verbal response, inappropriate words. The nurse interprets which score is correct for this client? a. 9 b. 10 c. 11 d. 12
Correct answer: B The Glasgow Coma Scale ranges from 3 to 15 and is a measure of neurological function. Based on these findings for this client, the score is 10.
A client has sustained damage to Wernicke's area from a stroke (brain attack). On assessment of the client, which sign or symptom would be noted? a. Difficulty speaking b. Problems with understanding language c. Difficulty controlling voluntary motor activity d. Problems with articulating events from the remote past
Correct answer: B Wernicke's area consists of a small group of cells in the temporal lobe whose function is the understanding of language. Damage to Broca's area is responsible for aphasia. The motor cortex in the precentral gyrus controls voluntary motor activity. The hippocampus is responsible for the storage of memory.
A 49-year-old female suffered a stroke that resulted in dysphagia. The dietician orders a diet of dysphagia pureed foods. Which of the following foods would be an appropriate choice? a. Beef stew b. Hard-boiled egg c. Custard d. Sliced peaches
Correct answer: C Clients who follow a dysphagia- pureed diet have difficulty swallowing and need foods that have been pureed or blended until smooth. Custard would be an acceptable choice. The other food choices would be too difficult to swallow and place the client at risk for choking.
A patient with a subarachnoid hemorrhage is in moderate vasospasm. The family sees the nurse administering nimodipine to their family member and asks the nurse why she is doing so. Which of the following is the most appropriate response? a. "It is a beta-blockers which causes the vessels to vasoconstrict" b. "It is a potassium channel blocker which causes the vessels to vasodilate" c. "It is a calcium channel blocker which causes the vessels to vasodilate" d. "It is a sodium channel blocker which causes the vessels to vasoconstrict"
Correct answer: C Nimodipine or Nimotop is a calcium channel blocker that causes vasodilation of the blood vessels. This is important when treating a patient with a subarachnoid hemorrhage in vasospasm. The "triple H" therapy for subarachnoid hemorrhage- induced vasospasm is hypervolemia, hypertension, and hemodilution. These three factors will maintain the patency of vessels, making it difficult for them to vasoconstrict. Vasospasm left unchecked can cause stroke, neurological compromise, and death.
The client with a head injury opens eyes to sound, has no verbal response, and localizes to painful stimuli when applied to each extremity. How should the nurse document the Glasgow Coma Scale (GCS) score? a. GCS = 3 b. GCS = 6 c. GCS = 9 d. GCS = 11
Correct answer: C The GCS is a method for assessing neurological status. The highest possible GCS score is 15. A score lower than 8 indicates that coma is present. Motor response points are as follows: Obeys a simple response = 6; Localizes painful stimuli = 5; Normal flexion (withdrawal) = 4; Abnormal flexion (decorticate posturing) = 3; Extensor response (decerebrate posturing) = 2; No motor response to pain = 1. Verbal response points are as follows: Oriented = 5; Confused conversation = 4; Inappropriate words = 3; Responds with incomprehensible sounds = 2; No verbal response = 1. Eye opening points are as follows: Spontaneous = 4; In response to sound = 3; In response to pain = 2; No response, even to painful stimuli = 1. Using the GCS, a score of 3 is given when the client opens the eyes to sound. Localization to pain is scored as 5. When there is no verbal response the score is 1. The total score is then equal to 9.
The nurse is performing an assessment on a client with a diagnosis of thrombotic stroke (brain attack). Which assessment question would elicit data specific to this type of stroke? a. "Have you had any headaches in the past few days?" b. "Have you recently been having difficulty with seeing at nighttime? c. "Have you had any sudden episodes of passing out in the past few days?" d. "Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?"
Correct answer: D Cerebral thrombosis (thrombotic stroke) does not occur suddenly. In the few days or hours preceding the thrombotic stroke, the client may experience a transient loss of speech, hemiparesis, or paresthesias on 1 side of the body. Signs and symptoms of this type of stroke vary but may also include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage. The client does not complain of difficulty with night vision as part of this clinical problem. In addition, most clients do not have repeated episodes of loss of consciousness.
The nurse is caring for a client with a diagnosis of right (non-dominant) hemispheric stroke. The nurse notes that the client is alert and oriented to time and place. On the basis of these assessment findings, the nurse should make which interpretation? a. Had a very mild stroke b. Most likely suffered a transient ischemic attack c. May have difficulty with language abilities only d. Is likely to have perceptual and spatial disabilities
Correct answer: D The client with a right (nondominant) hemispheric stroke may be alert and oriented to time and place. These signs of apparent wellness often suggest that the client is less disabled than is the case. However, impulsivity and confusion in carrying out activities may be very real problems for these clients as a result of perceptual and spatial disabilities. The right hemisphere is considered specialized in sensory-perceptual and visual-spatial processing and awareness of body space. The left hemisphere is dominant for language abilities.
The nurse is creating a plan of care for a client with dysphagia following a stroke (brain attack). Which should the nurse include in the plan? Select all that apply. a. Thicken liquids b. Assist the client with eating c. Assess for the presence of a swallow reflex d. Place the food on the affected side of the mouth e. Provide ample time for the client to chew and swallow
Correct answers: A, B, C, E Liquids are thickened to prevent aspiration. The nurse should assist the client with eating and place food on the unaffected side of the mouth. The nurse should assess for gag and swallowing reflexes before the client with dysphagia is started on a diet. The client should be allowed ample time to chew and swallow to prevent choking.
