Quiz 2

A client who is experienced an initial transient ischemic attack (TIA)states : "I'm glad it wasn't anything serious ." which is the best nurses respond to this statement?

"TIA is a warning sign. Let's talk about lowering your risks."

A client with a T4 levels spinal cord injury is complaining of a severe headache. The nurse notes profuse diaphoresis of the clients forehead and scalp. which of the following does the nurse suspect?

Autonomic dysreflexia

Which signs and symptoms were the nurse expect to see in a client who has had a large cerebral hemorrhage?

Breathing is noisy and labored, cheek on the side of the CVA blows out on exhalation, eyes deviate towards the affected side of the brain

When caring for a client who has had a stroke, a priority is reduction of ICP. what client position is most consistent with this goal?

Elevated head of bed 30°

The nurse is caring for a client who continues to have increasingly high intracranial pressure. which complication is expected in less intracranial pressure is resolved?

Herniation through the foreman magnum

A nurse is providing education to a community group about ischemic strokes. one group member asked if there are ways to reduce the risk for stroke. which of the following is a risk factor that can be modified?

Hypertension

The nurse practitioner advises the patient who is at high risk for a stroke to be vigilant in his medication regimen , to maintain a healthy weight and adopt a reasonable exercise program. this advice is based on research data that shows the most important risk factor for stroke is?

Hypertension

A client is being assessed for a possible transient ischemic attack. which of the following assessment findings suggest to the nurse that the client is experiencing a TIA?

Impaired muscle coordination

A client is admitted with a cervical spine injury sustained during a diving accident. when planning this client care of the nurse should assign highest priority to which nursing diagnosis?

Ineffective breathing pattern

A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. what action is a priority for the nurse?

Inform the primary care physician immediately

Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere?

Left-sided weakness

A client with ICP is receiving Mannitol vis intravenous infusion. which is a smart finding is most important in determining the effectiveness this treatment?

Level of consciousness is improving

Which are contraindications for administration of tissue plasminogen activator (t-PA) ? select all that apply

Major abdominal surgery within 10 days Intracranial hemorrhage

A nurse is reviewing a CT scan of the brain which state that the client has arterial bleeding with blood accumulation above the Dura. which of the following facts of the disease progression is essential to guide the nurse management of client care?

Monitoring is needed as rapid neurologic deterioration may occur

EMS says that they are transporting a 17-year-old male who has just saying spinal cord injury. the nurse recognizes of the most common cause of this type of injury is what?

Motor vehicle accident (MVA)

The nurse knows that symptoms associated with a TIA,usually a precursor of the future stroke,usually subsided in what period of time?

One hour

For a client was suspected ICP, an appropriate respiratory goal is to?

Promote carbon dioxide elimation

A client the nurse is caring for experiences a seizure. what would be a priority nursing action?

Protect the client from injury

The nurse is completing an assessment on a client with a history of migraines. the nurse would identify which of the following factors as a possible trigger for migraine headaches?select all that apply

Red wine Menstruation Flashing lights

A nurse is monitoring a client with Guillain-Barré syndrome. The nurse should assess the client for which responses? Select all that apply

Respiratory distress Difficulty swallowing

A client has just been diagnosed with Parkinson's disease and the nurse is planning the clients subsequent care for the home setting. what nursing diagnosis should the nurse address for educating the clients family?

Risk for injury

A nurse is completing discharge teaching for the client who has left-sided hemiparesis following a stroke. when investigating the clients home environment the nurse should focus on which nursing diagnosis?

Risk for injury

A nurse is providing care to a client with a brain tumor. the client has experience seizures as a result of the tumor. which area would be a priority for this client?

Safety

A client is admitted to the neurologic ICU with a spinal cord injury. when assessing the client the nurse notes that there is sudden depression of reflex activity in the spinal cord below the level of injury. what should the nurse expect?

Spinal shock

A client diagnosed with Huntington's disease has developed severe depression. what would be the most important for the nurse to assess?

Suicidal ideations

A client with meningitis has a history of seizures. Which activity should the nurse do while the client is actively seizing?

Turn the client to the side during a seizure and do not restrain movements

Which of the following assessment findings would indicate an increasing intercranial pressure ICP in a client with head trauma ?select all that apply

Widening pulse pressure Bradycardia Irregular respirations

A patient diagnosed with ischemic stroke should be treated within the first three hours of symptoms on set with which of the following?

tPA

While snowboarding, a client fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What was the nurse expect the clients diagnosis to be?

Concussion

The nurse is reviewing the medication administration record of a female client who possesses numerous risk factors for stroke. which of the woman's medication carries the greatest potential for reducing her risk of stroke?

Aspirin 81mg PO b.I.d.

An unresponsive patient was brought to the ED by a family member. the family states "we don't know what happened."which of the following is the priority nursing intervention?

Assess for patient airway

The sign is generally found and what type of school fracture?

Basilar skull fracture

A neurologic nurse is reviewing seizures with a group of staff nurses. how should this nurse best describe the cause of the seizure?

A dysrhythmia in the nerve called in one section of the brain

A client suffers a head injury. the nurse implements an assessment plan to monitor for potential subdural hematoma development. which manifestation does the nurse anticipate seeing first?

Altered level of consciousness

A client is experiencing severe pain related to increased ICP. which analgesic would be ordered for this client to help alleviate pain?

Codeine

A nurse is caring for a client diagnosed with Huntington's disease. the clients plan of care includes interventions to address the clients potential for injury. which would be included as a cause for this risk?

Choreiform movements

The nurse is caring for a client who has been admitted with a head injury and continually assesses for signs of increasing intracranial pressure. the earliest sign of increasing ICP is?

Dcreased LOC

The nurse is caring for a client who has had a hemorrhagic stroke what assessment findings constitutes an early sign of deterioration?

Decreased level of consciousness

A client experiences loss of consciousness,tongue biting, and incontinence along with tonic clonic phases of seizure activity. the nurse to document this episode as which type of seizure?

Generalized

The nurse is talking to the mother of a client who is diagnosed with a traumatic brain injury. the mother states that she has never seen the client lash out when frustrated or throw things across the room. which instructions made by the nurses most correct?

The client may be experiencing a change in affect due to the brain injury

A 13-year-old was brought to the ED after being hit in the head by a baseball and is subsequently diagnosed with a concussion. what assessment by noon would rule out discharging the client?

The client speech is slightly slurred

A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the clients current health status is most likely to have precipitated this event?

The clients urinary catheter became occluded

A nurse is helping a client understand the cause of ischemic stroke. which statements might be included in this discussion ?select all that apply

The type of stroke you had occurs in 80% of the people who have had a stroke. Your stroke occurred because of blood clot got lodged in an artery that carries blood to your brain.

A patient diagnosed with MS ask about a cure for her disease process. the nurse skills which of the following information?

There is no cure for MS

Medical management of a client with a cerebral aneurysm does not include

Thrombolytic therapy

A nurse is caring for a client who has returned to his room after carotid endarterectomy. Which action should the nurse take first?

Ask the client if he has trouble breathing

A client in any emergency department has bruising over the mastoid bone in rhinorrhea. the triage nurse suspects the client has which type of school fracture?

Basilar

A nurse is caring for a critically ill client with an autonomic dysreflexia. what clinical manifestation with the nurse expect in this client?

Bradycardia and hypertension

The nurse is caring for a client with a brain tumor. what drug with the nurse expect to be prescribed to reduce the edema surrounding the tumor?

Dexamethasone

The nurse is caring for a client with an in operable brain tumor. what is a major threat to the client?

Increased intracranial pressure