Porth's Ch 20 Disorders of Brain Function
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
A client's recent computed tomography (CT) scan has revealed the presence of hydrocephalus. Which of the following treatment measures is most likely to resolve this health problem?
Placement of a shunt
The significant other 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.
Global and focal brain injuries manifest differently. What is almost always a manifestation of a global brain injury?
Altered level of consciousness
A nurse is teaching a client newly diagnosed with a seizure disorder. Which statement is most important for the nurse to provide regarding their antiepileptic medications?
Antiepileptic medications should never be discontinued abruptly.
What medication teaching should be done for a woman of childbearing age with a seizure disorder?
Antiseizure drugs increase the risk for congenital abnormalities.
A family brings their elderly mom to the emergency department. The client had a short period of time where she was confused, had slurred speech and appeared to have a weak arm. Now she is back to her normal self. Suspecting a transient ischemic attacks (TIAs), the health care provider will order diagnostic testing looking for:
Atherosclerotic lesions in cerebral vessels
A client who has been living with Alzheimer's disease and spouse are at the doctor's office and the spouse asks the nurse why the patient cannot remember much of anything from the past. The best response by the nurse is that Alzheimer's disease affects which of the following
Cells located in the hippocampus
The intracranial volume that is most capable of compensating for increasing intracranial pressure is the:
Cerebrospinal fluid
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
The parents of an infant born with hydrocephalus are concerned about the size of the baby's head. The doctors are telling them that the infant needs the surgical placement of a shunt. The nurse caring for the infant in the neonatal intensive care unit explains that placement of a shunt will do which of the following?
Decrease the likelihood of further neurological deficits
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
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
Excessive activity of the excitatory neurotransmitters and their receptor-mediated effects is the cause of which type of brain injury?
Excitotoxic
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
A high school senior sustained a concussion during a football game. Which of the following signs and symptoms would indicate the presence of postconcussion syndrome in the days and weeks following his injury?
Headaches and memory lapses
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
The emergency room doctor suspects a client may have bacterial meningitis. The most important diagnostic test to perform would be:
Lumbar puncture
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
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
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 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
An adult client has been admitted to a rehabilitation center after hospital treatment for an ischemic stroke. Which aspect of the client's history would be considered to have contributed to his stroke?
The client's blood pressure has historically been in the range of 150s/90s.
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
The most common cause of an ischemic stroke is which of the following?
Thrombosis