Patho PrepU Chapter 16
The nurse assessing a client with a traumatic brain injury assesses for changes in which neurologic component? Select all that apply.
-Cognition -Level of consciousness -Motor function -Sensory function Explanation: Brain injuries can cause changes in level of consiousness and alterations in cognition, motor, and sensory function; therefore, the nurse assessing a client with a traumatic brain injury should assess for changes in these areas.
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 Explanation: Severe brain injury that results in seriously compromised brain function can result in brain death.
Which intracranial volume is most capable of compensating for increasing intracranial pressure?
Cerebrospinal fluid Explanation: Initial increases in intracranial pressure (ICP) are largely buffered by a translocation of cerebrospinal fluid (CSF) to the spinal subarachnoid space and increased reabsorption of CSF. Of the intracranial volumes, the tissue volume is least capable of undergoing change. Surface sulcus fluid is negligible and not a factor in increased ICP. The compensatory ability of the intravascular blood compartment is also limited by the small amount of blood that is in the cerebral circulation. As the volume-buffering capacity of this compartment becomes exhausted, venous pressure increases and cerebral blood volume and ICP rise.
A client's emergency room report includes the presence of a contrecoup injury. The nurse plans care for a client with which of the following?
Closed head injury opposite the area of impact Explanation: In a contrecoup injury, the client experiences a rebound injury on the side of the brain opposite the site of external force.
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 Explanation: 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 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 Explanation: 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. Bacterial and viral meningitis are caused by bacterial and viral infections. Meningiomas are a type of brain tumor that are seen in the middle or later years of life.
Excessive activity of the excitatory neurotransmitters and their receptor-mediated effects is the cause of which type of brain injury?
Excitotoxic Explanation: Excitotoxicity is a final common pathway for neuronal cell injury and death. It is associated with excessive activity of excitatory amino acid neurotransmitters. Hypoxic injury involves oxygen deprivation. Ischemic injury is caused by a decrease of blood flow. Increased intracranial pressure may result in all three but is not caused by the excitotoxic effects.
The nurse assessing for the doll's head response (doll's eye response) in an unconscious client documents which eye movement as an abnormal response?
Eyes turn right when head is turned right Explanation: The normal doll's head response (doll's eye response) is movement of the eyes in conjugate gaze to the opposite side or direction when the head is moved from side to side or up and down. An abnormal response is fixed position of the eyes or movement in the same direction as the head.
A client's emergency magnetic resonance imaging (MRI) has been examined by the physician and tissue plasminogen activator (tPA) has been administered to the client. What was this client's most likely diagnosis?
Ischemic stroke Explanation: Thrombolytic therapy for the acute treatment of ischemic stroke consists of the intravenous administration of tPA. This drug would exacerbate a subarachnoid hemorrhage by inhibiting the clotting mechanism, and it is not relevant to the care of clients with encephalitis or status epilepticus.
The nurse reading a client's lumbar puncture results notifies the physician of findings consistent with meningitis when which sign/symptom is noted?
Large number of polymorphonulcear neutrophils Explanation: Lumbar puncture findings, which are necessary for accurate diagnosis, include a cloudy and purulent CSF under increased pressure. The CSF typically contains large numbers of polymorphonuclear neutrophils (up to 90,000/mm3), increased protein content, and reduced sugar content.
The nurse is caring for an older adult client with hemiplegia following a stroke. While planning the client's care, the nurse knows the client is at risk for developing which condition?
Muscle atrophy Explanation: Muscle atrophy can occur with prolonged immobilization following a chronic illness. The client suffering from hemiplegia will have paralysis and immobility. Muscular dystrophy is a genetic disorder characterized by muscle necrosis and increased muscle size. Pseudohypertrophy is associated with muscular dystrophy. Involuntary movements are associated with extrapyramidal tract disorders. Stroke is a pyramidal tract disorder with extrapyramidal tract disorder.
As a client explains to the nurse what occurred prior to the onset of seizure activity, the client describes perceiving a feeling or warning that the seizure would occur. The nurse documents the perceived warning as which of the following?
Prodrome Explanation: The nurse should document the perception of a warning of impending seizure activity as a prodrome; it is also referred to as an aura.
The nursing assistant reports to the registered nurse that a client with a brain tumor has a blood pressure of 180/100 mm Hg and a pulse of 50 bpm. Which action is the correct nursing intervention?
Report to physician the client's signs of increased intracranial pressure. Explanation: Hypertension, together with bradycardia and a widened pulse pressure make up the Cushing reflex, an indicator of increased intracranial pressure that should be reported to the physician.
A client has started having uncontrolled seizures that are not responding to usual medications. Nurses working with the client must pay special attention to which priority aspects of this client's care? Assessment of:
Respiratory status and oxygen saturation Explanation: 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.
The nurse taking a report on a client coming into the emergency room plans care for a client with brain dysfunction based on which symptom?
Stupor Explanation: The most frequent sign of brain dysfunction is an altered level of consciousness such as stupor. Pupils that react to light, wheezing, and chest pain are not symptoms of brain function.
The MRA scan of a client with a suspected stroke reports ruptured berry aneurysm. The nurse plans care for a client with:
Subarachnoid hemorrhage Explanation: The rupture of a berry aneurysm leads to a subarachnoid hemorrhage.
The nurse is explaining to a client's family how vasogenic brain edema occurs. 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. Explanation: 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. Increased production of CSF and decreased absorption result in hydrocephalus. It occurs in conditions such as hemorrhage, brain injury, and infectious processes.
A client 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 purpose?
Thrombolysis Explanation: 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 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) Explanation: 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. Lacunar infarcts produce classic recognizable "lacunar syndromes" such as pure motor hemiplegia, pure sensory hemiplegia, and dysarthria with clumsy hand syndrome.
The spouse of a client admitted to the hospital after a motor vehicle accident reports to the nurse that the client has become very drowsy. The nurse should:
assess the client for additional signs/symptoms of increased intracranial pressure. Explanation: Since decreased alertness and/or drowsiness can be an early sign of increased intracranial pressure, the nurse should assess for additional signs/symptoms of increased intracranial pressure. Then, once the assessment is complete, the nurse should contact the physician as needed. There is no indication that the client will undergo EEG testing at this time and the spouse should not be instructed to keep the client awake.
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. Explanation: The nurse reports that the client exhibited automatisms, defined as repetitive nonpurposeful activities such as lip smacking, grimacing, patting and/or rubbing clothing.
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 communicate spontaneously with ease or translate thoughts or ideas into meaningful speech or writing. Explanation: Expressive or nonfluent aphasia is characterized by an inability to communicate spontaneously with ease or translate thoughts or ideas into meaningful speech or writing. Conduction aphasia manifest as impaired repetition and speech riddled with letter substitutions, despite good comprehension and fluency. Anomic aphasia is speech that is nearly normal except for difficulty with finding singular words. Wernicke aphasia is characterized by an inability to comprehend the speech of others or to comprehend written material.
A client 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 client paralyzed with medications and on the ventilator. The most appropriate response would be that these therapies:
decrease metabolic needs and increase oxygenation. Explanation: 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 client paralyzed decreases the body's metabolic needs.
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:
generalized seizure. Explanation: When seizure activity begins simultaneously in both cerebral hemispheres, it is considered a generalized seizure.
A client has developed global ischemia of the brain. The nurse determines this is:
inadequate to meet the metabolic needs of the entire brain. Explanation: 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 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. Explanation: 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. Flexion of the arms, wrists, and fingers, with abduction of the upper extremities, internal rotation, and plantar flexion of the lower extremities, would be a response of decorticate posturing. The other options are not specific to a diagnosis.
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 Explanation: 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.
A teenager has been in a car accident and experienced an 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 Explanation: 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 an 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. TIAs and cerebral vascular infarction (stroke) are often caused by atherosclerotic brain vessel occlusions that cause ischemic injuries. In mild concussion head injury, there may be momentary loss of consciousness without demonstrable neurologic symptoms or residual damage, except for possible residual amnesia. Status epilepticus is not related to this situation.
Following surgical removal of a large malignant brain tumor, the nurse should anticipate discussing which treatment option that allows delivery of high-dose radiation to deep tumors while sparing surrounding brain tissue?
Gamma knife radiation Explanation: Most malignant brain tumors respond to external irradiation. Irradiation can increase longevity and sometimes can allay symptoms when tumors recur. The treatment dose depends on the tumor's histologic type, responsiveness to radiation, and anatomic site and on the level of tolerance of the surrounding tissue. A newer technique called gamma knife combines stereotactic localization of the tumor with radiosurgery, allowing delivery of high-dose radiation to deep tumors while sparing the surrounding brain. Chemotherapy for brain tumors is somewhat limited by the blood-brain barrier, although in some cases it can be administered directly into the spinal canal.
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 plasminogen activator (tPA). Explanation: tPA administration is the treatment of choice for an ischemic stroke after confirmation that it is not a hemorrhagic stroke. Monitor vital signs and provide pain relief to prevent complications.
