Unit 4 AQ Questions

When assessing a patient's level of consciousness, which potential Glasgow Coma Scale (GCS) scores indicate the patient is in a comatose state? Select all that apply. 1) 4 2) 5 3) 6 4) 9 5) 11

123 A GCS score of 8 or less generally indicates coma. Scores of 9 or 11 are greater than 8, and do not indicate coma.

When developing the plan of care for a patient diagnosed with meningitis, which interventions would the nurse include? Select all that apply. 1 Monitor temperature. 2 Check for muscle pains. 3 Check for retinal damage. 4 Assess intraocular pressure. 5 Assess the eye for sensitivity to light.

125 The clinical manifestations associated with meningitis include fever, muscle pains, and photophobia. Thus, temperature, muscle pains, and sensitivity to light should be monitored in a patient with meningitis. Retinal damage and intraocular pressure are not associated with meningitis.

Which interpretation would the nurse associate with a patient's Glasgow Coma Scale score of 5 after sustaining a head injury? 1 The patient is alert and oriented. 2 The patient is unresponsive and comatose. 3 The patient is awake but lethargic and drowsy. 4 The patient responds appropriately to commands.

2 The Glasgow Coma Scale ranges from 3 to 14. A score of 7 or less indicates that a patient is in a coma. The lower the score, the more serious the patient's condition. A patient who is alert and orient, awake but lethargic, or responding appropriately to commands has a Glasgow Coma Scale score higher than 7.

Of the four assigned patients on the acute care unit, which patient has the highest risk for developing bacterial meningitis? 1 The patient with a skull fracture 2 The patient with prior brain trauma 3 The patient with a pulmonary infection 4 The patient with bacterial endocarditis

3 A patient with a pulmonary infection is at a risk for developing bacterial meningitis. A skull fracture, bacterial endocarditis, and prior brain trauma or surgery place the patient at risk for developing brain abscess.

For the patient whose right eye is fixed and dilated, for which cranial nerve (CN) would the nurse suspect nerve compression? 1 CN V 2 CN IV 3 CN III 4 CN VIII

3 Compression of CN III, the oculomotor nerve, is a result of the brain shifting from midline, compressing the trunk of the CN III, and paralyzing the muscles controlling pupillary size and shape. CN IV is the trochlear nerve, which moves the eye inward, down, and laterally. CN V (trigeminal nerve) is responsible for sensation in the face and motor functions such as biting and chewing. CN VIII is the vestibulocochlear nerve, which is responsible for hearing and balance.

When hydrocephalus develops, for which surgical procedure would the nurse begin preparing the patient? 1 Drainage of abscess 2 Excision of malformation 3 Placement of a ventriculoatrial shunt 4 Debridement of fragments and necrotic tissue

3 Hydrocephalus occurs due to overproduction of cerebrospinal fluid, which can be treated by placing a ventriculoatrial shunt, allowing excess cerebrospinal fluid to drain. Drainage of abscess is a surgical procedure indicated for brain abscess. Excision of malformation is a surgical procedure indicated for arteriovenous malformation. Debridement of fragments and necrotic tissue is a surgical procedure indicated for skull fractures.

When assessing a patient's neurologic status upon arrival to the emergency room, which reliable indicator would the nurse utilize first? 1 Dim vision 2 Papilledema 3 Body temperature 4 Level of consciousness

4 The level of consciousness is the most sensitive and reliable indicator of the patient's neurologic status. Dim vision can occur due to dysfunction of cranial nerves. Papilledema, which is an edematous optic disc seen on retinal examination, can be noted and is a nonspecific sign associated with persistent increases in intracranial pressure (ICP). A change in body temperature may also occur because increased ICP affects the hypothalamus.

Bilateral hemispheric disease causes a_______________ pattern of breathing

Cheyne-Stokes

lesions on mid or lower pons cause _________ breathing.

apneustic

Lesions on the brainstem between lower midbrain and upper pons cause central _________ hyperventilation.

neurogenic

Compression of CN III, the ________________ nerve, is a result of the brain shifting from midline, compressing the trunk of the CN III, and paralyzing the muscles controlling pupillary size and shape.

oculomotor

Tumors in the ______________ lobe present with speech disturbance (if the tumor is in the dominant hemisphere), dystopia, spatial disorders, and unilateral neglect.

parietal

Clinical manifestations such as stiff neck and cranial nerve deficits indicate a _________________ hemorrhage.

subarachnoid

Manifestations of tumors in the _____________ region include hemiplegia;

subcortical

Tumors in the ______________ lobe present with few symptoms and few instances of seizures and dysphagia.

temporal

A _________________ stroke has clinical manifestations of decreased level of consciousness in the first 24 hours.

thrombotic

CN V (_______________ nerve) is responsible for sensation in the face and motor functions such as biting and chewing.

trigeminal

CN IV is the ___________ nerve, which moves the eye inward, down, and laterally.

trochlear

CN VIII is the __________________ nerve, which is responsible for hearing and balance.

vestibulocochlear

When assessing a patient's intracranial pressure (ICP) after they sustained a head trauma, which normative value would the nurse utilize to compare the assessment data? 1 5 to 15 mm Hg 2 25 to 35 mm Hg 3 45 to 60 mm Hg 4 80 to 120 mm Hg

1 A normal ICP reading is 5 to 15 mm Hg. Any ICP value greater than 25 mm Hg represents a life-threatening condition requiring immediate intervention.

Which action would the nurse take first for a patient arriving at the emergency department with headache, nausea, hypertension, and difficulty talking? 1 Prepare the patient for a CT scan. 2 Place antiembolism stockings on the patient. 3 Place a stat consult for the speech-language pathologist (SLP). 4 Prepare to administer recombinant tissue plasminogen activator (tPA).

1 A patient arriving at the hospital with signs and symptoms of a stroke must undergo a CT or MRI in a very timely manner. Placing antiembolism stockings on the patient and placing a stat consult for the SLP would be appropriate for the post-acute period. tPA should never be administered until after the CT or MRI is completed to rule out hemorrhagic stroke.

Which clinical manifestation is associated with a stroke on the right side of the brain? 1 Impulsiveness 2 Impaired speech 3 Slow performance 4 Paralyzed right side

1 A patient who sustains a stroke on the right side of the brain shows impulsiveness. Impaired speech, slow performance, and a paralyzed right side occur when a patient has had a stroke on the left side of the brain.

Which data, obtained during the nurse's assessment of the patient, indicates that the patient in the neurologic intensive care unit with an increased intracranial pressure (ICP) is deteriorating? 1 Presence of fixed unresponsive pupils 2 Sluggish reaction of pupil in response to light 3 Brisk constriction of pupil in response to light 4 Slight constriction in the opposite pupil in response to light

1 A penlight is used to test the papillary reaction. Fixed pupils that are unresponsive to light indicate ICP. An increase in the ICP causes suppression of nerves, which leads to fixed unresponsive pupils. Sluggish reaction of the pupil indicates an early pressure*******. Brisk constriction of the pupils is a normal reaction. Slight constriction in the opposite pupil is a consensual response, which is a normal finding.

Which method of measurement is the gold standard for obtaining intracranial pressures (ICPs)? 1 Ventriculostomy 2 Fiberoptic catheter 3 Air pouch/pneumatic 4 Transcranial Doppler

1 A ventriculostomy is the gold standard for measurement of ICP. A fiberoptic catheter and air pouch/pneumatic are other measures for monitoring ICP, but they are not considered the gold standard. A transcranial Doppler evaluates blood flow in the brain.

he nurse will prioritize management of which problem in a patient recovering from a stroke? 1 Dysphagia 2 Vision problems 3 Impaired communication 4 Impaired physical mobility

1 Addressing the dysphagia would be the priority for a patient recovering from a stroke because aspiration could be fatal. Vision problems, impaired communication, and reduced physical mobility should also be part of the care plan but are less likely to cause serious health problems in the immediate future.

The nurse provides care for a patient with a cerebral cortex lesion. The nurse anticipates which assessment finding? 1 Apraxia 2 Anisocoria 3 Dysphagia 4 Dysarthria

1 Apraxia is the inability to perform learned movements despite having the desire and physical ability to perform them; a possible etiology is a cerebral cortex lesion. Anisocoria is the inequality of pupil size; possible etiologies include an oculomotor nerve injury or a sympathetic pathway injury. Dysphagia is difficulty in swallowing; a possible etiology includes lesions involving motor pathways of cranial nerve (CN) IX and CN X (including lower brainstem). Dysarthria is the lack of coordination in articulating speech; possible etiologies include a cerebellar or a CN lesion.

Which intervention would the nurse implement when a patient has cerebrospinal fluid (CSF) rhinorrhea? 1 Elevate the head of the patient's bed to 30 degrees. 2 Have the patient blow the nose on a sterile 4x4 gauze. 3 Pack the nasal cavity with 4x4 gauze to stop the flow of CSF. 4 Insert a nasogastric tube with low, intermittent wall suction.

1 Assess CSF rhinorrhea by the presence of a halo or ring sign. Coalescence of blood in the center of the gauze with an outer yellowish ring indicates the leakage of CSF from the patient's nose. The first action by the nurse should be to elevate the head of the bed to decrease the CSF pressure so that the tear can heal. Do not request the patient to blow the nose. Do not insert packing, but place a loose collection dressing under the nose to catch the drainage. Do not insert a nasogastric tube, especially if suspecting a basilar skull fracture.

While assessing a patient who sustained a hemorrhagic stroke, the nurse finds that the patient has decreased gag, cough, and swallowing reflexes. Which complication would the nurse expect in the patient? 1 Risk of aspiration 2 Unilateral neglect 3 Impaired physical mobility 4 Decreased intracranial adaptive capacity

1 Decreased gag, cough, and swallowing reflexes may increase the risk of aspiration in the patient. Unilateral neglect is related to visual defects. Impaired physical mobility indicates neuromuscular and cognitive impairment. Decreased intracranial adaptive capacity is related to a decreased cerebral perfusion pressure.

Which medication would the nurse anticipate the health care provider to prescribe for a patient who has developed status epilepticus? 1 Diazepam 2 Lamotrigine 3 Gabapentin 4 Carbamazepine

1 Diazepam is used to treat status epilepticus. Lamotrigine, gabapentin, and carbamazepine are used as primary and adjunct treatment of generalized seizures and will not be effective in stopping seizures during status epilepticus.

When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/minute, and respirations 24 breaths/minute, which subsequent vital signs would the nurse report immediately to the health care provider? 1 BP 172/54 mm Hg, pulse 58 beats/minute, respirations 10 breaths/minute 2 BP 136/84 mm Hg, pulse 88 beats/minute, respirations 26 breaths/minute 3 BP 112/56 mm Hg, pulse 98 beats/minute, respirations 28 breaths/minute 4 BP 126/68 mm Hg, pulse 110 beats/minute, respirations 32 breaths/minute

1 Fluctuations in vital signs are expected. The nurse will report a BP of 172/54 mm Hg, pulse of 58 beats/minute, and respiration rate of 10 breaths/minute because these values may indicate Cushing's triad or systolic hypertension with a widening pulse pressure, bradycardia, and irregular or low respirations. These values are indicative of an increased intracranial pressure. BPs of 136/84, 126/68, and 112/56; pulses of 88, 110, and 98; and respiration rates of 26, 32, and 28 are not values linked to ICP when compared to the patient's initial vital signs.

Which modifiable risk factor 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 it is still often undetected 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. Topics

An RN is teaching a student nurse about the management of increased intracranial pressure in a patient who sustained a stroke. Which statement made by the student nurse indicates the need for further teaching? 1 "The patient should be placed in a supine position." 2 "The patient's head and neck should be in alignment." 3 "The patient's bowel function status should be maintained." 4 "The patient's temperature should be maintained between 96.8°F to 98.6°F."

1 If the nurse suspects increased intercranial pressure, then the patient's head should be elevated, and the head and neck should be aligned to improve venous drainage. Constipation increases intracranial pressure; therefore, treating constipation is important. The patient's body temperature should be maintained at or near normal (96.8°F to 98.6°F) to avoid hyperthermia.

After assessing the breathing patterns of four assigned patients, which patient would the nurse suspect of having a lesion in the medulla of the brain? 1 The patient with cluster breathing 2 The patient with apneustic breathing 3 The patient with Cheyne-Stokes breathing Incorrect4 The patient with central neurogenic hyperventilation

1 Lesions in the medulla may affect the breathing pattern, resulting in clustered breathing with irregular pauses in between. Lesions on mid or lower pons cause apneustic breathing. Bilateral hemispheric disease causes a Cheyne-Stokes pattern of breathing. Lesions on the brainstem between lower midbrain and upper pons cause central neurogenic hyperventilation.

Which nursing intervention is a priority for a patient who is experiencing a hemorrhagic stroke? 1 Maintenance of the patient's airway 2 Positioning to promote cerebral perfusion 3 Control of fluid and electrolyte imbalances 4 Monitoring BP

1 Maintenance of a patent airway is the priority in the acute care of a patient with a hemorrhagic stroke. It supersedes the importance of positioning, fluid and electrolyte imbalance, and monitoring BP.

Which intervention would the nurse implement when providing care for a patient experiencing an increased intracranial pressure (ICP)? 1 Monitor fluid and electrolyte disturbances carefully. 2 Position the patient in a high Fowler's position. 3 Administer vasoconstrictors to maintain cerebral perfusion. 4 Maintain physical restraints to prevent episodes of agitation.

1 Monitor fluid and electrolyte disturbances vigilantly because they can have an adverse effect on ICP. Keep the head of the patient's bed at 30 degrees in most circumstances. Physical restraints are not applied unless necessary because agitation increases ICP. Do not administer vasoconstrictors, typically, in the treatment of ICP.

Which clinical manifestation does the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? 1 Bradycardia 2 Hypertension 3 Neurogenic spasticity 4 Bounding pedal pulses

1 Neurogenic shock is caused by the loss of vasomotor tone caused by injury and is characterized by bradycardia and hypotension. Loss of sympathetic innervations causes peripheral vasodilation, venous pooling, and a decreased cardiac output. Hypertension, neurogenic spasticity, and bounding pedal pulses are not seen in neurogenic shock.

Which population has the highest rate of malignant brain tumors? 1 White males 2 Asian males 3 Hispanic males 4 African American males

1 Of these groups, white males have the highest incidence of malignant brain tumors. Asian and Hispanic males have a lower incidence of brain tumors. African American males have a higher incidence of benign tumors.

The nurse identifies that a patient is at risk for failure of the diaphragm when the patient experiences which level of spinal cord injury? 1 C3-C5 2 T1-T5 3 T6-T12 4 L1-L2

1 Patients with high cervical injury (C3-5) have respiratory insufficiency due to loss of phrenic nerve innervation to the diaphragm and decreases in chest and abdominal wall strength. Patients with complete SCI above C5 should be intubated at once. The thoracic and lumbar spinal nerves do not innervate the diaphragm.

The RN is teaching a student nurse about airway management for a patient who is at risk of aspiration. Which statement made by the student nurse indicates effective learning? 1 "I will perform suctioning PRN." 2 "I will discourage the patient from coughing." 3 "I will encourage rapid breathing by the patient." 4 "I will provide a small amount of food before the swallow evaluation."

1 Suctioning helps to remove secretions and clear the airway. Coughing should be encouraged in the patient because it removes secretions and reduces the risk of aspiration. Slow, deep breaths should be encouraged to help in airway clearance. Before doing a swallow evaluation, the patient should be kept NPO to reduce the risk of aspiration.

Which lobe of the brain is affected if a patient has Broca's aphasia? 1 Frontal lobe 2 Parietal lobe 3 Occipital lobe 4 Temporal lobe

1 The frontal lobe of the brain is related to reasoning, planning, parts of speech, movement, emotions, and problem solving. Broca's aphasia causes the patient to speak in short fragments and is caused by damage to the frontal lobe of the brain. The parietal lobe, occipital lobe, and temporary lobes of the brain are not associated with Broca's aphasia.

Which intervention would the nurse implement when a patient, admitted with head trauma, has 300 mL/hr of urine output for the each of the last four hours, dry skin, and dry mucous membranes? 1 Evaluate the urine's specific gravity. 2 Prepare the patient for acute hemodialysis. 3 Continue to monitor urine output over the next hour. 4 Slow the IV rate and notify the health care provider.

1 The patient is experiencing manifestations of diabetes insipidus related to a decrease in the pituitary gland production of antidiuretic hormone (ADH) secondary to the head injury. Without an adequate amount of ADH, the kidneys are unable to conserve water, and therefore large fluid losses occur. The patient's problem is not related to renal failure, so there is no indication for hemodialysis. Notify the health care provider of the increased urine output and results of the urine-specific gravity, which will be low because of the diluted urine. After evaluation of the urine specific gravity, the patient requires continued close monitoring of the urine output until seen by the health care provider. If the patient has diabetes insipidus, then the IV rate should not be slowed and will likely have to be increased to prevent dehydration.

A nurse is updating the health history of a patient who is being admitted to the hospital with an evolving stroke. Which question is most important for the nurse to ask the patient's support person? 1 "What was the time of onset of symptoms?" 2 "Is the patient taking any medication?" 3 "Does the patient have any allergies?" 4 "Has the patient ever had stroke symptoms before?"

1 The time of onset of stroke is important for all types of stroke since it can affect the treatment decisions. It is the most important question to ask at the time of admission. It is also important to ask about medications, allergies, and history of stroke symptoms, but asking about the onset of these symptoms is more important because it may alter the treatment options.

A patient is admitted to the emergency department with right-sided facial drooping. When taking the patient's history, which information would be most significant? 1 "When did the facial drooping begin?" 2 "Do you have a family history of stroke?" 3 "Have you had facial drooping in the past?" 4 "Are you having any pain on the right side of your face?"

1 The time of onset of symptoms determines which treatments can be given and is the most critical information the nurse should obtain in the history assessment. The family history, past incidence, and pain are all important but do not impact treatment to the same extent as time of symptom onset.

The nurse finds the wife of a patient who experienced a stroke one week ago crying in the hallway. The wife tells the nurse, "I do not know if I can deal with this. He cries about everything and gets so moody with me." Which response by the nurse is most appropriate? 1 "This must be very frustrating for you." 2 "Depression is very common following a stroke." 3 "How did he react to stress before the stroke?" 4 "He cannot control how he reacts. This is something you need to accept."

1 Validating the wife's feelings and concern takes priority. Responding with an open-ended statement should encourage the wife to continue and expand on feelings. Although depression is common following a stroke, making a diagnosis of depression is not within the scope of practice for the nurse. The patient's behavior indicates difficulty with affect and controlling emotions, not necessarily depression. Asking how the patient reacts to stress moves the focus from the caregiver to the patient, which disregards the needs of the caregiver (wife). The response by the patient is a result of the stroke and not previous stress responses. Labile emotions are common following a stroke. Patients and caregivers will be taught management techniques to minimize frustration. Telling the patient's wife to "accept" the patient's behavior suggests that the concern or problem lies with her.

The patient with a spinal cord injury (SCI) is admitted to the intensive care unit. The nurse recalls which information about medications used to treat SCI? 1 Dopamine has more complications than phenylephrine in SCI. 2 Methylprednisolone (MP) needs to be given IV within the first few hours of injury. 3 Low-molecular-weight heparin is not used because of the increased risk of bleeding and hemorrhage. 4 Vasopressor agents are contraindicated because they can reduce the blood flow to vital organs

1 Vasopressor agents (e.g., phenylephrine, norepinephrine) are used in the acute phase of injury as adjuvants to treatment. They maintain the mean arterial pressure (MAP) to improve perfusion to the spinal cord. Use of vasopressors has significant risk for complications. These include ventricular tachycardia, troponin elevation, metabolic acidosis, and atrial fibrillation. Dopamine has more complications than phenylephrine in SCI. In patients with SCI, MP is no longer approved by the Food and Drug Administration (FDA). Unless contraindicated, low-molecular heparin is given to prevent venous thrombolytic embolism (VTE). Vasopressor agents are prescribed in the acute phase of the injury to keep the MAP above 90 mm Hg and to improve perfusion to the spinal cord.

Which observation would the nurse associate with a cerebrospinal fluid (CSF) leak when a patient with a suspected traumatic brain injury (TBI) develops a bloody nasal drainage? 1 A halo sign on the nasal-drip pad 2 Decreased BP and urinary output 3 A positive reading for glucose on a test-tape strip 4 Clear nasal drainage along with the bloody discharge

1 When drainage containing both CSF and blood is allowed to drip onto a white pad, within a few minutes the blood will coalesce into the center, and a yellowish ring of CSF will encircle the blood, giving a halo effect. The presence of glucose would be unreliable for determining the presence of CSF because blood also contains glucose. Decreased BP and urinary output would not be indicative of a CSF leak.

When performing the prescribed intermittent drainage of cerebrospinal fluid (CSF) from a previously inserted ventriculostomy system, in which order would the intensive care unit nurse drain the fluid? 1.Obtain the intracranial pressure (ICP) and determine whether the pressure is above the prescribed level. 2.Open the ventriculostomy system when ICP is greater than the prescribed pressure. 3.Allow the CSF to drain for two to three minutes into the collection bag. 4.Close the stopcock to return the ventriculostomy to a closed system.

1.Obtain the intracranial pressure (ICP) and determine whether the pressure is above the prescribed level. 2.Open the ventriculostomy system when ICP is greater than the prescribed pressure. 3.Allow the CSF to drain for two to three minutes into the collection bag. 4.Close the stopcock to return the ventriculostomy to a closed system. The first step is determining that the ICP is above the prescribed/desired level. If ICP is above the indicated level, opening the ventriculostomy system at the indicated ICP is the next step. After opening the stopcock, allow CSF to drain for two to three minutes to relieve the pressure in the cranial vault. Closing the stopcock to return the ventriculostomy to a closed system is the final step. Always maintain strict aseptic techniques when performing this intervention.

The nurse is providing care for a patient with a C7 spinal cord injury (SCI). Which instructions does the nurse give to the patient to prevent skin breakdown? Select all that apply. 1 Use a special mattress to reduce pressure. 2 Use wheelchair cushions to reduce pressure. 3 Use pillows to protect bony prominences when in bed. 4 If in a wheelchair, lift oneself up and shift weight every two to four hours. 5 If in bed, change positions using a regular turning schedule of six hours.

123 For preventing skin breakdown in the patient with spinal cord injury, the nurse should teach the patient and caregivers to use special mattresses and wheelchair cushions to reduce pressure. Pillows should be used to protect bony prominences when in bed. If in a wheelchair, the patient should be instructed to lift up and shift weight every 15 to 30 minutes to promote circulation. If in bed, the position should be changed every two hours.

Which interventions would be included in the plan of care for a patient who had a stroke and is at risk of venous thromboembolism (VTE)? Select all that apply. 1 Note unusual warmth of legs. 2 Measure the calf and thigh daily. 3 Observe swelling of lower extremities. 4 Ask the patient to minimize movements of limbs. 5 Ask the patient to maintain bed rest to avoid swelling.

123 Measuring the calves and thighs daily and observing the lower extremities will help the nurse to keep track of any swelling. Noting unusual warmth may help the nurse to indicate potential VTE. The most effective means to minimize the risk of VTE is to keep the patient moving. The patient should be taught active range-of-motion exercises. Maintaining bed rest and minimizing movements of the limbs may increase the risk of VTE.

A patient is admitted to the emergency department following a motor vehicle accident; a head injury is suspected. The patient is scheduled for a CT scan of the brain with contrast. Prior to the procedure, which actions does the nurse take? Select all that apply. 1 Evaluate renal function. 2 Implement NPO status. 3 Ask whether the patient is allergic to shellfish. 4 Instruct the patient to quickly drink several glasses of water. 5 Determine whether the patient has a history of surgical insertion of objects such as staples or dental bridges.

123 The nurse should evaluate renal function before contrast medium is used. Assess whether the patient is allergic to shellfish because the contrast is iodine based. The patient may need to be NPO prior to the test. While it is important to encourage patients to drink fluids after receiving contrast to avoid any renal problems, it is not desirable to drink several glasses of water prior to a CT scan. CT scans are safe for patients with metal implants such as staples or dental bridges; MRIs are not safe with these implants because they use magnets.

While utilizing the Glasgow Coma Scale (GCS) to assess a patient's level of consciousness, which potential responses would the nurse document under best motor response? Select all that apply. 1 Flexion withdrawal 2 Localization of pain 3 Obedience of command 4 Disorganized use of words 5 Opening the eyes in response to sound

123 Utilize flexion withdrawal, localization of pain, and obedience of command to record a patient's best motor response. Do not use opening of the eyes in response to stimuli and disorganized use of words under the scale's motor response.

Which functions would the nurse be able to assess when performing a pupillary assessment on an unconscious patient? Select all that apply. 1 Size 2 Shape 3 Reactivity 4 Convergence 5 Accommodation

123 he nurse will assess the pupil size, shape, and reactivity in the unconscious patient. Pupil convergence and accommodation require the patient to focus on the examiner's finger as it moves toward the patient's nose

For the patient admitted for surgical removal of a brain tumor, for which potential complications would the nurse integrate assessment interventions into a patient's plan of care? Select all that apply. 1 Vision loss 2 Cerebral edema 3 Pituitary dysfunction 4 Parathyroid dysfunction 5 Focal neurologic deficits 6 Diabetes mellitus

1235 Brain tumors can manifest themselves in a wide variety of symptoms depending on location, including vision loss and focal neurologic deficits. Tumors that put pressure on the pituitary can lead to dysfunction of the gland. As the tumor grows, clinical manifestations of increased intracranial pressure and cerebral edema appear. The cerebral cortex or the pituitary gland do not regulate the parathyroid gland. Trauma to the brain, or tumors of the thalamus and sellar tumors, may cause development of diabetes insipidus, not diabetes mellitus.

The nurse is administering phenytoin intravenously. Which interventions are appropriate? Select all that apply. 1 Administer using a filter. 2 Administer the medication through a large vein. 3 Administer the medication no faster than 50 mg/min. 4 Mix the medication in 5% dextrose with 0.9% saline. 5 Administer the medication through a 20-gauge or larger catheter.

1235 Parenteral phenytoin is adjusted chemically to a pH of 12 with propylene glycol (antifreeze) for drug stability. It is very irritating to veins when injected and must be given by slow intravenous (IV) push (not exceeding 50 mg/min in adults) directly into a large vein through a large-gauge (20-gauge or larger) venous catheter. Phenytoin is only to be diluted in normal saline for IV infusion, and a filter must be used. Follow each dose with an injection of a saline flush to avoid local venous irritation. Soft tissue irritation and inflammation can occur at the site of injection, with or without extravasation. This can vary from slight tenderness to extensive necrosis and sloughing, and in rare instances can require amputation. Avoid improper administration, including subcutaneous or perivascular injection, to prevent the possibility of such occurrences.

For the patient who experienced head trauma from a motor vehicle crash, place the progressive pathophysiology steps in order from the injury to severe increased intracranial pressure (ICP) and death. 1.Tissue edema from initial insult 2.Increased ICP 3.Compression of ventricles and blood vessels 4.Increased ICP from increased blood volume 5.Decreased cerebral blood flow 6.Increased ICP with brainstem compression

123564 After initial insult to the brain, there is tissue edema, which causes an initial increase in ICP; then compression of ventricles and blood vessels occurs, which decreases cerebral blood flow, thus decreasing O2 and causing death of brain cells. Edema occurs around this necrotic tissue, and increased ICP with compression of the brainstem and respiratory center occurs, leading to accumulation of CO2. Further increases in ICP occur from increased blood volume, which leads to death.

A patient with a new cervical spinal cord injury is hospitalized. The nurse identifies that which interventions are appropriate to include in the patient's nutrition plan? Select all that apply. 1 Insert a nasogastric tube. 2 Evaluate swallowing before starting oral feeding. 3 Prescribe a low-protein, low-carbohydrate diet. 4 If oral feeding is not possible, enteral nutrition must be provided. 5 Gradually introduce oral food and fluids, irrespective of bowel sounds

124 During the first 48 to 72 hours after the injury, the gastrointestinal (GI) tract may stop functioning (paralytic ileus), and hence a nasogastric tube should be inserted. In patients with high cervical cord injuries, evaluate swallowing before starting oral feedings. If the patient is unable to resume eating, then enteral nutrition may be used to provide nutritional support. Once bowel sounds are present or flatus is passed, gradually introduce oral food and fluids. Because of severe catabolism, a high-protein, high-calorie diet is necessary for energy and tissue repair.

Which interventions would the nurse implement to comfort the patient with a brain tumor who is experiencing disorientation and confusion due to perceptual problems? Select all that apply. 1 Create a routine. 2 Use reality orientation. 3 Provide increased stimuli. 4 Make the patient drive a vehicle. 5 Minimize environmental stimuli.

125 Creating a routine, using reality orientation, and minimizing environmental stimuli are appropriate actions to comfort the confused patient and to familiarize the confused patient with the environment. Providing increased stimuli and making the patient drive a vehicle are not advisable because they increase the risks for confusion.

A patient with quadriplegia who has been hospitalized for one month is at a risk of developing pressure injury (PI). Which steps does the nurse take to prevent this complication? Select all that apply. 1 Evaluate the nutritional status of the patient. 2 Monitor urinary incontinence. 3 Change the position of the patient every six hours. 4 Avoid lifting the patient when changing the position. 5 Check bony prominences for signs of pressure sores.

125 Prevention of pressure ulcers and other types of injury to insensitive skin is essential for every patient with a spinal cord injury (SCI). Moisture from incontinence or any urine leakage can contribute to pressure ulcer development by macerating the skin and increasing friction injuries. Assess nutritional status regularly. A comprehensive visual and tactile examination of the skin should be done at least once daily, with special attention given to areas over bony prominences. The areas most vulnerable to breakdown include the ischia, trochanters, heels, and sacrum. Both body weight loss and weight gain can contribute to skin breakdown. When a patient is moved, it must be done in a way to prevent friction and shearing, because these forces will cause skin injury as readily as pressure. The patient must be lifted, not dragged, while repositioning, which also means that more than one person may be needed to move the patient. Pulling or dragging the patient will cause skin damage due to friction. Careful positioning and repositioning should be done every two hours.

When planning the care for a patient with an increased intracranial pressure (ICP), which interventions would the nurse integrate to provide the most comfort? Select all that apply. 1 Provide the patient a quiet and calm environment. 2 Minimize procedures that potentially produce agitation. 3 Facilitate an increased number of family visits to the patient. 4 Encourage the patient's family to increase patient interactions. 5 Observe the patient for signs of agitation or irritation and intervene.

125 When managing the patient with increased ICP, avoid procedures that can produce agitation. Observe the patient for signs of agitation or irritation. The environment should be quiet and calm to provide minimal stimulation to the patient. Decrease the stimulation levels and instruct patient's family to decrease stimulation and reduce noise, including not visiting too frequently.

A patient is not able to talk properly after having a stroke but is able to understand what the nurse is saying. While talking to the patient, which sentence stated by the patient will confirm Broca's aphasia? Select all that apply. 1 "Ice cream eat." 2 "My dog is thirsty." 3 "Bird bird two tree." 4 "You are very caring." 5 "I like to go to the park."

13 In Broca's aphasia, the patient speaks in short phrases and often omits small words such as "is," "and," and "the." It is considered a type of nonfluent aphasia. Also, the Broca's aphasia patient typically understands the speech of others fairly well. "My dog is thirsty," "You are very caring," and "I like to go to the park" are complete sentences.

While providing care for a patient with a closed head injury and increasing intracranial pressures, which clinical manifestations represent Cushing's triad and require notifying the health care provider? Select all that apply. 1 Bradycardia 2 Weak pulse 3 Irregular respirations 4 Increasing systolic BP 5 Decreasing systolic BP

134 Cushing's triad consists of bradycardia, irregular respiration, and a widening pulse pressure (increasing systolic pressure). The pulse is **full and bounding, not weak. The systolic BP increases, not decreases.

Which interventions would the nurse implement to avoid complications associated with the corticosteroid treatment prescribed for a patient with an increased intracranial pressure (ICP)? Select all that apply. 1 Monitor fluid intake and sodium levels regularly. 2 Monitor patient's sleep and diet routine regularly. 3 Perform blood glucose monitoring at least every six hours. 4 Avoid taking any antacids along with corticosteroid treatment. 5 Initiate concurrent treatment with antacids or proton pump inhibitors.

135 Regularly monitor patients on corticosteroid treatment for fluid intake and sodium levels. Perform blood glucose monitoring at least every six hours until ruling out hyperglycemia from the steroids. Starting concurrent treatment with antacids or proton pump inhibitors is important to prevent gastrointestinal ulcers and bleeding because complications associated with the use of corticosteroids include hyperglycemia, increased incidence of infections, and gastrointestinal bleeding. Regularly monitoring the patient's sleep and diet routine does not contribute to avoiding complications related to corticosteroid therapy. Administer antacids along with corticosteroids to prevent gastrointestinal complications.

Which potential factors would the nurse associate with explaining a patient's pupils becoming fixed and unresponsive to light stimulus? Select all that apply. 1 Previous eye surgery 2 Administration of diuretics 3 Increased intraocular pressure 4 Increased intracranial pressure (ICP) 5 Direct injury to the third cranial nerve (CN III)

145 A fixed pupil unresponsive to light stimulus usually indicates a previous eye surgery, increased ICP, direct injury to CN III, administration of atropine, and use of mydriatic eyedrops. Administration of diuretics and increased intraocular pressure do not cause fixed pupils.

For the patient with an increased intracranial pressure (ICP), which precautions would the nurse implement to protect the patient from potential seizure activity? Select all that apply. 1 Keep suction equipment readily available at the patient's bedside. 2 Provide sufficient stimulation of the patient to avoid comatose behaviors. 3 Implement seizure treatment only after confirming the seizure diagnosis. 4 Pad side rails and maintain an airway at the bedside per facility protocol. 5 Use prophylactic antiseizure therapy during first seven days after injury.

145 Using padded side rails helps to prevent injury from falling. Keeping an airway at the bedside and suction equipment readily available is helpful in managing seizures if they occur. Utilize prophylactic antiseizure therapy during the first seven days after injury to prevent seizures. Providing stimulation to the patient may aggravate the condition; therefore the environment should be quiet. Seizure treatment should be used prophylactically. Implement seizure treatment instead of waiting for the confirmation of diagnosis or the seizures to occur. The nurse should administer antiseizure treatment in this situation.

Which factors would the nurse associate with influencing a patient's intracranial pressure (ICP) readings? Select all that apply. 1 Posture 2 Swallowing 3 Drowsiness 4 Temperature 5 Carbon dioxide levels 6 Intraabdominal pressure

1456 Posture, temperature, intraabdominal pressure, and carbon dioxide levels all influence ICP. Swallowing does not affect ICP. Drowsiness may be a sign of increased ICP, but it does not influence it.

Which cranial nerves would the nurse assess when eliciting a patient's gag reflex? Select all that apply. 1 Vagus nerve 2 Facial nerve 3 Olfactory nerve 4 Trochlear nerve 5 Glossopharyngeal nerve

15 The gag reflex tests the performance of the motor component of the vagus nerve and the sensory component of the glossopharyngeal nerve. Perform the gag reflex test by touching the sides of the posterior pharynx or soft palate with a tongue blade. Assess the olfactory nerve by asking the patient to close each nostril one at a time and identify easily recognized odors. Assess the facial nerve by asking the patient to raise the eyebrows, close the eyes tightly, purse the lips, draw back the corners of the mouth in an exaggerated smile, and frown. Assess the trochlear nerve along with oculomotor and abducens nerves because all three nerves help to move the eyes.

Which criteria would the nurse use to assess the mental status of a patient? Select all that apply. 1 Alert and oriented 2 Intact sense of smell 3 Pupils reactive to light 4 Midline protrusion of tongue 5 Appropriate mood and affect

15 The patient's alertness and orientation, along with appropriate mood and affect, help the nurse to assess the mental status of the patient. An intact sense of smell, reaction of pupils to light, and a midline protrusion of the tongue suggest normal functioning of associated cranial nerves.

After sustaining head trauma from skiing, the patient briefly lost consciousness, then was awake and alert. Which head trauma complication would the nurse associate with this patient when bleeding between the dura and the inner surface of the skull develops? 1 Contusion 2 Epidural hematoma 3 Subdural hematoma 4 Intracerebral hematoma

2 An epidural hematoma is bleeding between the dura and the inner surface of the skull. The patient may lose consciousness followed by a period of being awake and alert. A subdural hematoma is bleeding between the dura and the arachnoid layer of the meninges. An intracerebral hematoma is bleeding into the brain tissue. A contusion is bruising of the brain tissue within a focal area.

Which intervention would the nurse implement when providing care for a patient with an increased intracranial pressure (ICP)? 1 Place the patient in a supine position. 2 Monitor ICP continuously. 3 Administer D5W IV infusions. 4 Withhold opiates to protect respiratory status

2 Because ICP is a dangerous condition, the nurse must monitor constantly. Patients with ICP need to be in a semi-Fowler's, not supine, position. The administration of D5W IV fluids will decrease serum osmolality and increase, not decrease, ICP. Opiates such as morphine and fentanyl are rapid acting and have little effect on cerebral perfusion; however, there is a need to monitor the patient's respiratory status closely.

For the patient admitted with a subdural hematoma following a motor vehicle accident, which vital sign change would the nurse interpret as a clinical manifestation of an increasing intracranial pressure (ICP)? 1 Tachypnea 2 Bradycardia 3 Hypotension 4 Narrowing pulse pressure

2 Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with increased ICP. The triad consists of increasing systolic pressure (not hypotension) with a widening pulse pressure (not narrowing), bradycardia with a full and bounding pulse, and irregular respirations (not tachypnea).

Which cranial nerve (CN) would the nurse identify as responsible for pupillary constriction? 1 CN II 2 CN III 3 CN IV 4 CN V

2 CN III (oculomotor) is responsible for pupillary constriction. CN II (optic) is the sensory nerve to the retina of eyes and is responsible for vision. CN IV (trochlear) controls motor eye movement. CN V (trigeminal) is a sensory motor nerve that has ophthalmic, maxillary, and mandibular branches.

Which clinical manifestation is associated with a left-hemispheric stroke? 1 Impulsivity 2 Impaired speech 3 Left-side neglect 4 Short attention span

2 Clinical manifestations of left-hemispheric stroke damage include right hemiplegia, impaired speech/language, impaired right/left discrimination, and slow and cautious performance. Impulsivity, left-sided neglect, and short attention span are all manifestations of right-sided brain damage.

Which information would the nurse include in a teaching plan about the onset of embolic stroke? 1 Embolic stroke rarely recurs. 2 Embolic stroke occurs rapidly. 3 Embolic stroke renders the patient unconscious. 4 It is common to have a warning sign with an embolic stroke.

2 Embolic stroke often occurs rapidly, whereby accommodation toward developing collateral circulation becomes difficult. It is not uncommon for embolic stroke to recur, unless the underlying causes are treated aggressively. During an embolic stroke, the patient may experience a headache but does not lose consciousness*. Warning signs are less common with embolic than with thrombotic stroke.

The nurse questions the use of mannitol for which patient? 1 A 21-year-old head-injury patient 2 A 47-year-old patient with anuria 3 A 67-year-old patient who ingested a poisonous substance 4 A 55-year-old patient receiving cisplatin to treat ovarian cancer

2 Mannitol is not metabolized but is excreted unchanged by the kidneys. Potential water intoxication could occur if mannitol is given to a patient without urine output, which would impact renal function. Mannitol reduces cellular edema and increases urine production, causing diuresis. However, it produces only a slight loss of electrolytes, especially sodium. Therefore mannitol is not indicated for patients with peripheral edema, patients with head injuries, or patients who have ingested poisonous substances. Mannitol does not promote sufficient sodium excretion. It does not have any effect on patients taking antiprotozoals.

A patient experiences a spinal cord injury as a result of a motor vehicle accident. The patient exhibits a loss of deep tendon and sphincter reflexes, loss of sensation, and flaccid paralysis below the level of injury. The nurse identifies that the findings are consistent with which condition? 1 Central cord syndrome 2 Spinal shock 3 Anterior cord syndrome 4 Neurogenic shock

2 Spinal shock may occur shortly after acute SCI. It is characterized by loss of deep tendon and sphincter reflexes, loss of sensation, and flaccid paralysis below the level of injury. This syndrome lasts days to weeks. Central cord syndrome is manifested by motor and sensory loss that is greater in the upper extremities than in the lower extremities. Anterior cord syndrome results in motor and sensory loss but not reflexes. In contrast to spinal shock, neurogenic (vasogenic) shock can occur in cervical or high thoracic injury (T6 or higher). It occurs from unopposed parasympathetic response due to loss of sympathetic nervous system (SNS) innervation. It causes peripheral vasodilation, venous pooling, and decreased cardiac output.

The nurse assesses a patient experiencing visual disturbances, difficulty swallowing, and decreased level of consciousness with a BP of 280/180 mm Hg. Which action by the nurse is a priority? 1 Call the stroke team. 2 Ensure patent airway. 3 Perform pulse oximetry. 4 Position head in midline

2 Symptoms such as decreased level of consciousness, visual disturbances, hypertension, and difficulty in swallowing indicate a stroke. The first, most important intervention provided to a patient who has sustained a stroke is ensuring a patent airway and preventing airway obstruction. Airway obstruction for few minutes results in death. After ensuring patent airway, the stroke team should be notified. Hypoxia is common in a stroke; therefore pulse oximetry should be performed. The head is positioned midline to improve venous drainage.

Which potential disorder would the nurse associate with a patient's inability to recognize an object's form by touch? 1 Lesions in the brainstem 2 Lesions in the parietal cortex 3 Lesions on the cranial nerves 4 Lesions in the left cerebral cortex

2 The inability to recognize an object by touch is known as astereognosis. The parietal cortex plays an important role in producing planned movements, and lesions in the parietal cortex result in astereognosis. Lesions on the cranial nerves cause visual disturbances, both sensory and motor, as well as dysarthria and a lack of coordination in articulating speech. Left cerebral cortex lesions cause aphasia or dysphasia. Lesions in the brainstem result in ophthalmoplegia, or paralysis of the eye muscle.

While monitoring a patient's intracranial pressure (ICP) via an intracranial device in the neurologic intensive care unit, which aspect of care requires collaborative actions by the nurse? 1 Using aseptic technique for intracranial device care 2 Monitoring the intracranial device for greater than five days 3 Assessing the intracranial device insertion site routinely 4 Monitoring the cerebrospinal fluid (CSF) for a change in color

2 Use of the intracranial device for monitoring ICP should not occur for more than five days because it can lead to severe infection. Using aseptic technique, routinely assessing the insertion site, and monitoring the CSF for a change in drainage color prevent complications; therefore all are appropriate aspects of patient care that do not require follow-up by the nurse.

Which patients may be administered tissue plasminogen activator (tPA) safely? Select all that apply. 1 A 30-year-old with a history of a gastrointestinal bleeding two months ago 2 A 70-year-old with blood sugar levels of 110 mg/dL 3 A 40-year-old with history of head injury six months ago 4 A 25-year-old with history of cholecystectomy two years previously 5 A 35-year-old with a CT scan showing hemorrhagic stroke

234 In ischemic stroke, recombinant tPA is used to produce localized fibrinolysis by binding to the fibrin thrombi. Patients are screened before tPA can be given. Screening includes a noncontrast CT or MRI to rule out hemorrhagic stroke; a blood test for glucose level and coagulation disorders; screening for recent history of gastrointestinal (GI) bleeding, stroke, or head trauma within the past three months; or major surgery within 14 days. The patient who underwent major surgery two years ago can be given tPA because there is no risk of bleeding. The patient with a blood sugar level of 110 mg/dL can be administered tPA safely because the blood sugar level is normal. The patient with a history of head injury six months previously can also be administered tPA because there is no risk of bleeding. The patient with a GI bleed would be unsafe because the GI bleed was two months ago, and the criteria is after three months. It is contraindicated to administer tPA to a patient with a hemorrhagic stroke.

When assessing the cranial nerves of a patient with a neurologic disorder, which findings would the nurse evaluate as a normal? Select all that apply. 1 Normal tandem walk 2 Full facial movements 3 Pupils reactive to light 4 Midline protrusion of tongue 5 Down-pointing toes with plantar stimulation

234 Pupils equally reactive to light suggest normal functioning of the oculomotor nerve. Midline protrusion of the tongue suggests normal functioning of the hypoglossal nerve. Full facial movements indicate normal functioning of the facial nerve. A normal tandem walk is associated with the motor system, and down-pointing toes with plantar stimulation is associated with reflexes.

Which factors would the nurse consider when assessing the surgical outcome of a patient with a brain tumor? Select all that apply. 1 Surgery provides a complete cure. 2 Surgery can reduce the tumor mass. 3 Surgery can provide relief of symptoms. 4 Surgery can help to extend survival time. 5 Surgery can increase intracranial pressure (ICP).

234 Surgery can reduce the tumor mass, provide relief of symptoms, and help to extend survival time. These factors should be considered while assessing the outcome of surgery in a patient with a brain tumor. Surgery does not provide a complete cure, or, in most cases, completely remove a tumor. However, surgery helps to decrease the ICP by removing the tumor mass.

Which interventions would the nurse implement as a part of nutritional therapy for the patient with an increased intracranial pressure (ICP)? Select all that apply. 1 Keep the patient in a hypovolemic fluid state. 2 Begin parenteral nutrition if oral intake is not adequate. 3 Initiate nutritional replacement within three days after injury. 4 If comatose, wait at least seven days to begin nutritional replacement. 5 Evaluate the patient's urine output, fluid loss, and electrolyte balance.

235 For a patient with increased ICP, begin parenteral nutrition or enteral feedings if oral intake is not adequate. Initiate nutritional replacement within three days after injury. Monitor the patient's urine output, fluid loss, and electrolyte balance to evaluate the effectiveness of nutritional therapy. Do not keep the patient in a hypovolemic fluid state; the patient needs to be in a normovolemic state. Instead of waiting, the desired treatment is to reach full nutritional replacement within seven days after injury. Do not confuse reducing brain edema with mannitol (Osmitrol) with the overall fluid balance in the body.

Which factors would the nurse consider prior to repositioning a patient with an increased intracranial pressure (ICP)? Select all that apply. 1 Raise the head of bed above 30 degrees 2 Take care to prevent extreme neck flexion of patient. 3 Adjust body position to decrease ICP. 4 Rotate the patient to a side-lying position to prevent skin breakdown. 5 Follow protocol standards to maintain a head-up position for the patient.

235 Maintaining a head-up position for the patient is important because elevation of the head of the bed promotes drainage and decreases the vascular congestion that can produce cerebral edema. The nurse should take care to prevent extreme neck flexion of the patient because it can cause venous obstruction and contribute to elevated ICP. Position the patient's body to decrease ICP and improve the cerebral perfusion pressure (CPP). Raising the head of the bed above 30 degrees is not advisable because it may decrease the CPP by lowering systemic BP.*** Rotating the patient to a side-lying position may further increase the ICP. Special air beds can alternate skin pressures to prevent tissue damage.

The nurse would instruct the patient recovering from a head injury and his or her caregiver to report the development of which symptoms immediately to the health care provider? Select all that apply. 1 Sneezing 2 Seizures 3 Stiff neck 4 Constipation 5 Increased drowsiness

235 Seizures, a stiff neck, and increased drowsiness are the important symptoms that the patient and caregivers should immediately relay to the health care provider. Sneezing and constipation are not alarming and can also be due to other reasons.

For the patient admitted for observation after a minor head injury, which assessment findings would support the nurse's suspicion of an increasing intracranial pressure? Select all that apply. 1 The patient is alert and oriented. 2 The patient is experiencing hemiplegia. 3 The patient has unilateral pupil dilation. 4 The patient has a regular respiratory rate of 14 breaths/min. 5 The patient is vomiting without preceding nausea.

235 Unilateral pupil dilation, vomiting, and hemiplegia are signs of increased intracranial pressure. A patient with increased intracranial pressure would likely have an impaired level of consciousness rather than being alert and oriented. He or she would also have an irregular, not regular, respiratory rate.

A patient with a T1 level spinal cord injury (SCI) is scheduled to be discharged from the hospital. The nurse creates a neurogenic bowel management plan and includes which information? Select all that apply. 1 Use of the Valsalva maneuver 2 Use of stool softeners 3 Dietary choices for a high-fiber diet 4 Fluid restriction guidelines 5 Use of suppositories for evacuation 6 Instructions for how to perform digital stimulation of the rectum

2356 Careful management of bowel evacuation is necessary in the patient with SCI because voluntary control of this function may be lost. This condition is called neurogenic bowel. A stool softener such as docusate sodium can be used to regulate stool consistency. A digital stimulation (performed 20 to 30 minutes after suppository insertion) by the nurse or patient may be necessary. In addition, suppositories (bisacodyl or glycerin) or small-volume enemas can be used. The usual measures for preventing constipation include a high-fiber diet and adequate fluid intake. However, these measures by themselves may not be adequate to stimulate evacuation. The Valsalva maneuver requires intact abdominal muscles, so it is used in those patients with injuries below T12. A high intake of fluid is advised for easier bowel evacuation.

hich objective data would the nurse record when assessing a patient with a head injury? Select all that apply. 1 Headache 2 Battle's sign 3 Projectile vomiting 4 Past health history 5 Mechanism of injury 6 Cranial nerve deficits

236 Battle's sign, projectile vomiting, and cranial nerve deficits are objective data that the nurse will record when assessing a patient with a head injury. A headache is subjective data. While the mechanism of injury may be helpful information, it is not part of the assessment itself. A patient's past health history is subjective data.

Which interventions would the nurse implement when preparing a patient for a prescribed cerebral angiography to detect a potential brain tumor? Select all that apply. 1 Explain that the procedure is noninvasive. 2 Assess the patient for stroke signs and symptoms. 3 Ensure that the patient has a full bladder prior to testing. 4 Instruct the patient about injection of a contrast medium. 5 Ensure completion of a full meal before the procedure

24 Cerebral angiography is a contrast-based test. The nurse should assess the patient for stroke before the test because of potential dislodging of any thrombi, if present, during the procedure. The nurse should explain that injection of a contrast medium occurs by inserting a small needle into the vein, making this procedure invasive. Ask the patient to empty the bladder before the procedure. Withhold the preceding meal to prevent aspiration if an adverse reaction to the contrast medium occurs.

Which cardiac manifestations will the nurse notify the health care provider about in a patient who suffered a severe closed head injury? Select all that apply. 1 Tachycardia 2 Systolic hypertension 3 Systolic hypotension 4 Widening pulse pressure 5 Bradycardia with a full and bounding pulse

245 A patient who has suffered a severe closed head injury is at risk for increased intracranial pressure. Systolic hypertension, a widening pulse pressure, and bradycardia with a full and bounding pulse are consistent with this complication, and the health care provider needs to be notified and the patient should be prepared for intubation. Tachycardia and systolic hypotension are more likely related to fluid volume deficit.

Which instructions would the nurse give a patient about methods to reduce the risk of having a stroke? Select all that apply. 1 Limit fluid and fiber intake. 2 Eat a diet low in saturated fats. 3 Decrease level of physical exercise. 4 Maintain a normal BP. 5 Limit consumption of alcohol to moderate levels.

245 Alcoholics and people with hypertension are prone to strokes. Hence, alcohol consumption should be limited, a diet low in fat should be consumed, and BP should be maintained. Also, physical exercise and adequate fluid and fiber intake will decrease the risk of stroke and should be promoted.

Which assessments would the nurse perform when utilizing the Glasgow Coma Scale (GCS) to assess a patient admitted with a head injury and requiring regular neurologic and vital sign assessments? Select all that apply. 1 Judgment 2 Eye opening 3 Abstract reasoning 4 Best verbal response 5 Best motor response 6 Cranial nerve function

245 The three dimensions of the GCS are eye opening, best verbal response, and best motor response. Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.

A patient is hospitalized with a new T2 level spinal cord injury. The nurse notes abnormal cardiovascular assessment findings. The nurse anticipates prescriptions for which medications? Select all that apply. 1 Digoxin 2 Atropine 3 Metoclopramide 4 Vasodilator drugs 5 Vasopressor drugs

25 Due to the spinal cord injury at the T2 level, the patient may have abnormal cardiac signs and symptoms like bradycardia, peripheral vasodilation, and hypotension. Atropine should be administered to increase the heart rate and prevent hypoxemia. Hypotension should be treated by administering IV fluids or vasopressor drugs. Vasodilators would accentuate the peripheral pooling of blood, thereby worsening the condition. Digoxin is used to treat arrhythmias like ventricular tachycardia, and they act by reducing the heart rate. The patient has bradycardia, so digoxin administration would worsen the condition. Metoclopramide is not given for cardiac condition; it is used to treat delayed gastric emptying.

Which instructions would the nurse provide the patient when assessing the accessory nerve? Select all that apply. 1 "Protrude your tongue." 2 "Shrug your shoulders." 3 "Close your eyes tightly." 4 "Read the Snellen chart." 5 "Turn your head against resistance to either side."

25 The accessory nerve controls the sternocleidomastoid and trapezius muscles that aid in head rotation, shoulder elevation, and abduction of the arm. Therefore while assessing the patient's accessory nerve, the nurse should ask the patient to shrug the shoulders and turn the head to either side against resistance. The nurse should ask the patient to protrude the tongue while assessing olfactory nerve function. The nurse should ask the patient to read the Snellen chart to assess optic nerve function. The nurse should ask the patient to close the eyes tightly while assessing facial nerve function.

Which patient condition contraindicates testing the doll's-eye reflex when performing a neurologic assessment? 1 An unconscious patient 2 An uncooperative patient 3 A patient with cervical spine injury 4 A patient who has intracranial lesion

3 A doll's-eye reflex test is performed to determine the oculocephalic reflex. It increases the risk of brainstem injury with a cervical spine problem. A doll's-eye reflex test can be performed in an unconscious and uncooperative patient. This test is used to determine the presence of intracranial lesions due to increased intracranial pressure.

A patient's systemic BP is 120/60 mm Hg and the intracranial pressure (ICP) is 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), which interpretation would the nurse apply to the results? 1 High blood flow to the brain 2 Normal ICP 3 Impaired blood flow to the brain 4 Adequate autoregulation of blood flow

3 A normal CPP is 60 to 100 mm Hg. Determine the calculated CPP by subtracting the ICP from the mean arterial pressure (MAP).MAP = (systolic blood pressure [SBP] + 2[diastolic blood pressure (DBP)])/3: (120 mm Hg + 2[60 mm Hg])/3 = 120 mm Hg + 120 mm Hg = 240 mm Hg; 240/3 = 80 mm Hg.MAP-ICP: 80 mm Hg (MAP) - 24 mm Hg (ICP) = a CPP of 56 mm Hg.The decreased CPP (<60 mm Hg) indicates an impaired cerebral blood flow and impaired autoregulation of the CPP. Because the ICP is 24 mm Hg, the pressure is elevated, preventing perfusion of the brain, and requires treatment.

A patient with a known history of hypertension presents to the emergency department with the complaint of sudden severe headache with no known cause. Which intervention would the nurse do first? 1 Perform eye examination. 2 Perform reflex examination. 3 Obtain orders and send the patient for a CT scan. 4 Obtain orders for administering antihypertensives

3 A patient with a history of hypertension is at risk of stroke. Sudden severe headache with no known cause is one of the warning signs of stroke. Hence, a CT scan should be obtained. This test can show areas of abnormalities in the brain and can help to determine whether these areas are affected by insufficient blood flow (ischemic stroke), a ruptured blood vessel (hemorrhage), or a different kind of problem. An eye examination may show abnormal eye movements and changes in the back of the eye. The patient may have abnormal reflexes. However, these findings do not necessarily mean a person is having a brain hemorrhage and could be the result of another medical condition. The patient is a hypertensive; therefore antihypertensives should be administered to reduce high BP. This intervention can be carried out once the patient has undergone CT scan.

Which intervention would the nurse implement to reduce the mental distortion experienced by the patient with meningitis? 1 Provide low lighting. 2 Elevate the head of the bed. 3 Minimize environmental stimuli. 4 Apply a cool cloth over the eyes.

3 A patient with a mental distortion may be frightened and misinterpret the environment. Therefore, minimizing environmental stimuli may help to calm the patient. Provide low lighting if the patient experiences photophobia. Slightly elevate the head of the bed if the patient experiences head and neck pain. Apply a cool cloth over the patient's eyes to decrease photophobia.

The patient was exhibiting symptoms of a stroke for 45 minutes before the symptoms resolved. Which condition may this patient have experienced? 1 Embolic brain stroke 2 Acute brain infarction 3 Transient ischemic attack 4 Subarachnoid hemorrhage

3 A transient ischemic attack is a transient episode of neurologic symptoms without acute brain infarction. Symptoms typically last less than one hour. With acute brain infarction, cell death occurs. An embolic brain stroke is associated with a clot to the brain, which causes permanent damage. Subarachnoid hemorrhage is bleeding in the subarachnoid area.

Which intervention would the nurse delegate to the experienced unlicensed assistive personnel (UAP) when working with a patient who had a stroke? 1 Suction oral pharynx PRN. 2 Assess orientation every four hours. 3 Perform passive range-of-motion exercises to flaccid extremities. 4 Ensure gag reflex is intact before offering fluids or food.

3 After appropriate training and evaluation, the UAP can perform passive-range of-motion exercises to patients who have had a stroke. Suctioning the oral pharynx, assessing the gag reflex, and level of orientation requires more advanced skills and evaluation than is in the scope of practice of the UAP.

When a patient suddenly exhibits hemiplegia, which assessment would the nurse complete prior to scheduling a prescribed CT of the patient's head? 1 Assess the patient's immunization history. 2 Screen the patient for any metal parts or a pacemaker. 3 Assess the patient for allergies to shellfish, iodine, or dyes. 4 Assess the patient's need for tranquilizers or antiseizure medications.

3 Allergies to shellfish, iodine, or dyes contraindicate the use of contrast media in CT. The patient's immunization history is not a central consideration, and the presence of metal in the body does not preclude the use of CT as a diagnostic tool. The need to assess for allergies supersedes the need for tranquilizers or antiseizure medications in most patients. NOTE: Check the contrast agent used for the CT as the agent gadolinium has a lower incidence of allergy than when using iodine.

When the patient experiences visual impairment and hallucinations, in which lobe of the brain would a CT scan indicate the presence of an abscess? 1 Frontal lobe 2 Parietal lobe 3 Occipital lobe 4 Temporal lobe

3 An abscess in the occipital lobe may lead to visual impairment and hallucinations. Abscesses in the frontal and parietal lobe may result in a local or systemic infection. A temporal lobe abscess can cause psychomotor seizures.

Which patient should the nurse assess first? 1 The patient taking valproic acid with an increased appetite 2 The patient taking carbamazepine who has bruises on his arms 3 The patient taking carbamazepine who is not oriented to place or time 4 The patient taking valproic acid who has lost 2 pounds since starting therapy

3 Any patient who is not oriented has a potential risk to his safety. The patient who is not oriented and taking carbamazepine could be experiencing adverse effects of therapy. This is the patient the nurse would assess first. The other patients are not experiencing adverse effects or have an immediate risk to their safety.

The nurse preparing to administer IV recombinant tissue plasminogen activator (tPA) to a patient status post-ischemic stroke prioritizes which action as needing to be done first? 1 Administer baby aspirin. 2 Verify the patency of the IV. 3 Assess for recent bleeding or surgeries. 4 Document the patient's estimated weight.

3 Assessing for recent bleeding or surgeries would be the priority in this scenario because administering tPA to a patient could be fatal if it causes excessive bleeding in the brain or throughout the body. Aspirin may be administered within 24 to 48 hours after the onset of an ischemic stroke, but it does not necessarily have to be given before the tPA. The patency of the IV would be verified throughout the treatment period. The patient's estimated weight will be necessary to calculate the appropriate dose of tPA, but screening for a recent history of internal bleeding, head trauma, stroke, or major surgery in the recent past should be done first.

The initial assessment of a patient in the postanesthesia care unit recovering from a brain tumor resection included a temperature of 100°F (37.7°C), BP of 130/76 mm Hg, pulse 64 beats/min, a urinary catheter in place, and oxygen at a rate of 2 L/min by nasal cannula. One hour later, which assessment finding would the nurse immediately report to the surgeon? 1 Presence of a gag reflex 2 Urine output of 50 mL during the past hour 3 BP of 148/58 mm Hg and pulse 48 beats/min 4 Temperature of 99.8°F (37.6°C) and pulse of 96 beats/min

3 Associate a BP with a widening pulse pressure, bradycardia, and irregular respirations with an increasing intracranial pressure (ICP) known as the Cushing's triad, which should be reported immediately. Presence of a gag reflex, urine output of 50 mL over an hour, and temperature of 99.8°F (37.6°C) and pulse of 96 beats/min are acceptable assessment findings in a postoperative patient.

Which clinical manifestation would the nurse identify when admitting a patient suspected of having lesions in Broca's area? 1 Visual defects 2 Difficulty in swallowing 3 Irregular speech patterns 4 Decreased sense of smell

3 Broca's area, located at the frontal lobe of the cerebrum, regulates verbal expression. Lesions in Broca's area affect speech production. Visual defects are common if the lesion is in the occipital lobe. Damage to the olfactory bulb may affect the sense of smell. Brainstem injuries may cause difficulty in swallowing.

For the patient who sustained a head trauma and has an increased intracranial pressure, which cranial nerve (CN) would the nurse assess to determine the patient's papillary response? 1 CN X 2 CN V 3 CN III 4 CNXII

3 CN III controls oculomotor function, so when the nurse assesses pupillary response, he or she is checking the viability of this nerve. CN XII controls tongue movement, CN X is the vagus nerve, and CN V is the trigeminal nerve.

Which component of the neurologic system is responsible for BP changes in an older adult patient? 1 Motor reflexes 2 Central nervous system (CNS) 3 Autonomic nervous system (ANS) 4 Peripheral nervous system (PNS)

3 Changes in the ANS may result in orthostatic hypotension or systolic hypertension. Changes that occur in the CNS result in many changes in the brain, including altered balance, gait, and the impaired ability to regulate environmental temperature. Motor reflexes decrease, resulting in sluggish reflexes and a slowed reaction time. Further changes occurring in the gerontologic patient affect the PNS resulting in a decreased reaction time in certain nerves and decreased speed and intensity of neuronal reflexes.

For the patient with a suspected neurologic injury, which assessment would the nurse prepare to assist the health care provider in determining the integrity of the patient's brainstem? 1 Balance 2 Reflexes 3 Cranial nerves 4 Cerebral spinal fluid

3 Cranial nerves exit the cranium via the brainstem. Assessment of cranial nerves gives a baseline of the brainstem integrity and function. Assessment of reflexes assesses the integrity of the reflex arc, which is the sensory message sent to the brain from the periphery and the motor response that follows. The cerebellum controls balance. Examination of cerebral spinal fluid aids in identifying the increase in diseases and conditions of the brain and spinal column, such as malignancy, infection, and problems with production or movement.

Which term would the nurse use to document a patient who is comatose from a head injury and displays flexion of the arms, wrists, and fingers, as well as adduction of the upper extremities? 1 Stroke 2 Epileptic seizure 3 Decorticate posturing 4 Decerebrate posturing

3 Decorticate posturing—described as flexion of the arms, wrists, and fingers—and adduction of the upper extremities indicate damage to the *primary motor areas of the sensorimotor cortex, both anterior and posterior. The described assessment findings do not specifically relate to describing a stroke or cerebrovascular accident and are not commonly seen in patients with epileptic seizure disorders. A nurse would describe decerebrate posturing as rigid extension of all four extremities with hyperpronation of the forearms and flexion of the feet. Decerebrate posturing results from disruption of motor fibers in the *midbrain and brainstem and indicates serious tissue damage.

A patient with a history of rheumatic heart disease arrives in the emergency department and informs the nurse of sudden loss of strength in the left arm without pain. The patient is unable to lift the arm and says that it "just fell." Which condition would the nurse suspect? 1 Myopathy 2 Fibromyalgia 3 Embolic stroke 4 Carpal tunnel syndrome

3 Embolic stroke occurs when an embolus lodges in and occludes a cerebral artery, resulting in infarction and edema of the area supplied by the involved vessel. Rheumatic heart disease is one cause of embolic stroke in young to middle-aged adults. Fibromyalgia presents as stiffness and pain in a particular part of the body. If there is no stiffness and pain, myopathy can be ruled out. The most common symptoms of carpal tunnel syndrome are tingling, numbness, weakness, or pain felt in the fingers or, less commonly, in the palm. Symptoms most often occur in the parts of the hand supplied by the median nerve: the thumb, index finger, middle finger, and half of the ring finger.

Which health promotion activity has the greatest impact in the prevention of spinal cord injury (SCI) in adults 65 years and older? 1 Hearing testing 2 Depression screenings 3 Fall prevention strategies 4 Monitoring BP

3 Falls are the leading cause of SCI in persons 65 years and older. Teaching patients to avoid climbing and using handrails on stairs are ways to prevent falls and injury. Hearing testing, depression screening, and BP monitoring are all ways to promote the health of persons 65 and older but do not prevent SCI directly.

Gamma-aminobutyric acid neurotransmitters regulate which activity of the body? 1 Sleep cycle 2 Motor control 3 Neuronal excitability 4 Fight-or-flight response

3 Gamma-aminobutyric acid neurotransmitters help to regulate neuronal excitability. Serotonin neurotransmitters regulate the sleep cycle. Dopamine neurotransmitters help to regulate motor control. Norepinephrine neurotransmitters regulate the fight-or-flight response.

A patient was brought to the emergency department with a sudden onset of a severe headache different from any other headache previously experienced. Which type of stroke is most likely occurring based on these symptoms? 1 Embolic stroke 2 Thrombotic stroke 3 Hemorrhagic stroke 4 Transient ischemic attack (TIA(

3 Headache is common in a patient who has a hemorrhagic stroke, either a subarachnoid hemorrhage or an intracerebral hemorrhage. A TIA is a transient loss of neurologic function, usually without a headache. A headache may occur with an ischemic embolic stroke, but severe neurologic deficits are the initial symptoms. The ischemic thrombotic stroke manifestations progress in the first 72 hours as infarction and cerebral edema increase.

Which information would the nurse include when teaching a patient about the use of hydantoins to control seizures? 1 "Avoid sun exposure." 2 "Have annual eye exams." 3 "Maintain careful oral care." 4 "Report respiratory infections."

3 Hydantoins can cause gingival hyperplasia, so good oral care is essential. Sun exposure is not a contraindicated with the use of hydantoins. Ezogabine can cause potential vision loss, which would necessitate annual eye exams. Respiratory infections can occur with barbiturates.

When the unlicensed assistive personnel (UAP) reports the vital signs (VS) of a patient with a suspected brain injury as temperature = 101.6° F (38.7° C) orally, heart rate = 58 beats/minute, respiratory rate = 14 breaths/minute, and BP = 162/48 mm Hg, which action would the nurse implement first? 1 Ask the UAP to repeat the BP. 2 Validate the VS by repeating the measurements. 3 Compare the current VS to recorded baseline VS. 4 Administer prescribed acetaminophen (Tylenol) for fever

3 Increasing pressure on the thalamus, hypothalamus, pons, and medulla changes a patient's VS. Manifestations, such as Cushing's triad (systolic hypertension with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations), are often late signs of markedly increased intracranial pressure (ICP). The nurse should compare the vital signs obtained with baseline vital signs recorded. If there is a deviation from baseline, the nurse should assess the patient, including a repeat set of VS to validate findings. More than just the BP can change with increased intracranial pressure; therefore asking the UAP to repeat the BP only will not provide any further data. An elevated temperature in a patient with a head injury may indicate a hypothalamic response from injury. The nurse should gather all assessment data before administering acetaminophen.

Which information is most important for the nurse to include when teaching a patient and the family about the administration of warfarin? 1 Avoid having international normal ratio (INR) tested if illness with fever is present. 2 Do not drink more than one or two glasses of grapefruit or cranberry juice a day. 3 Alert the health care provider if a fall or head injury is sustained, even if there are no symptoms. 4 Call the health care provider for excessive bruising while on warfarin.

3 It is of the utmost importance that all patients on warfarin be educated on the importance of calling their health care provider if they fall or suffer a head injury, regardless of their symptoms, as brain hemorrhages do not always cause apparent signs and symptoms. Patients must be educated on the effect of infections on INR results, the food and drug interactions associated with warfarin, including the possible impact of grapefruit or cranberry juice on INR, and the bruising that most patients on these medications will experience, but the risk for head injury has the potential to be most devastating. Topics

When a patient's clinical manifestations include visual disturbances and seizures, which area of the brain would the nurse identify as the most likely location of the diagnosed brain tumor? 1 Subcortical 2 Parietal lobe 3 Occipital lobe 4 Temporal lobe

3 Manifestations of tumors in the occipital lobe include vision disturbances and seizures. Manifestations of tumors in the subcortical region include hemiplegia; other symptoms may depend on area of infiltration. Tumors in the parietal lobe present with speech disturbance (if the tumor is in the dominant hemisphere), dystopia, spatial disorders, and unilateral neglect. Tumors in the temporal lobe present with few symptoms and few instances of seizures and dysphagia.

Which is the therapeutic goal for a patient undergoing mannitol therapy? 1 Increased urine osmolality 2 Decreased serum osmolality 3 Decreased intracranial pressure 4 Decreased excretion of medications

3 Mannitol is an osmotic diuretic that pulls fluid from extravascular spaces into the bloodstream to be excreted in urine. This will decrease intracranial pressure, decrease urine osmolality, increase serum osmolality, and increase excretion of medications.

When explaining normal intracranial pressure (ICP) balance to the patient's family, which three components would the nurse include? 1 BP, brain tissue, body mass index 2 Glucose level, BP, and brain tissue 3 BP, brain tissue, and cerebrospinal fluid 4 BP, brain tissue, and ventricles of the brain

3 Normal ICP involves a balance of BP, brain tissue, and cerebrospinal fluid. The ventricles of the brain, glucose level, and body mass index do not contribute to maintaining normal ICP.

Which deficit is associated with left-hemispheric stroke? 1 Overestimation of physical abilities 2 Difficulty judging position and distance 3 Slow and possibly fearful performance of tasks 4 Impulsivity and impatience at performing tasks

3 Patients with a left-hemispheric stroke are commonly slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-hemispheric stroke.

Which assessment is most important to conduct on a patient presenting with symptoms of an acute ischemic stroke? 1 Basic metabolic profile 2 Electrocardiogram 3 Pupillary response 4 Swallowing function

3 Pupillary response is a critical assessment when determining the severity of an acute ischemic stroke. Basic metabolic profile, electrocardiogram, and swallowing function are part of the secondary and tertiary assessments for a patient presenting with symptoms of an acute ischemic stroke.

Which type of stroke correlates with the clinical manifestations of a severe headache, hypertension, vomiting, dysarthria, and eye-movement disturbances? 1 Embolic stroke 2 Thrombotic stroke 3 Intracerebral hemorrhage 4 Subarachnoid hemorrhage

3 Symptoms such as headaches, high BP, vomiting, dysarthria, and eye-movement disturbances indicate intracerebral hemorrhage. An embolic stroke is mostly related to heart conditions such as atrial fibrillation, myocardial infarction, and infective endocarditis. A thrombotic stroke has the clinical manifestation of decreased level of consciousness in the first 24 hours. Clinical manifestations such as stiff neck and cranial nerve deficits indicate a subarachnoid hemorrhage.********

Which type of brain tumor would the nurse associate with a patient's clinical manifestations of uncontrolled urination, excessive thirst, high serum sodium levels, and involuntary eye movements? 1 Subcortical tumors 2 Cerebellopontine tumors 3 Thalamus and sellar tumors 4 Fourth ventricle and cerebellar tumors

3 Thalamus and sellar tumors may induce diabetes insipidus. This causes symptoms of diabetes insipidus such as excessive urine production, thirst, and elevated sodium and potassium levels. Tumors in the hypothalamic region may cause nystagmus or involuntary eye movements. Subcortical tumors cause hemiplegia. Cerebellopontine tumors cause tinnitus and vertigo. Fourth ventricle and cerebellar tumors cause headache, nausea, and papilledema.

Which Glasgow Coma Scale (GCS) score would the nurse assign an unconscious patient who opens the eyes in response to pain but who does not respond to any other stimulus, moans to any verbal communication, and demonstrates flexion withdrawal? 1 4 2 6 3 8 4 10

3 The GCS is a quick, practical, and standardized system for assessing loss of consciousness. According to this scale, the patient's ability to open his or her eyes in response to only pain stimulus merits a score of 2. Expressing incomprehensible words such as moaning merits a score of 2; and for flexion withdrawal, a score of 4 is given. Therefore, 2 + 2 + 4 = 8 indicates the value for the GCS for this patient.

Which Glasgow Coma Scale (GCS) score would the nurse anticipate for a patient with a moderate type of head injury? 1 3 2 5 3 10 4 14

3 The GCS range for patients with a moderate type of head injury is 9 to 12. Therefore, for the patient with a moderate type of head injury, a score of 10 is suitable. Patients with a severe type of head injury have a GCS score between 3 to 5. Patients who has a minor type of head injury have a GCS score of 14.

Which components would the nurse assess when using the Glasgow Coma Scale (GCS) to assess a patient who sustained a head injury and subsequently developed an increased intracranial pressure (ICP)? 1 Swallowing, speaking, and following verbal commands 2 Swallowing, pupillary response, and following verbal commands 3 Speaking, responding to stimuli, and following verbal commands 4 Responding to stimuli, swallowing, and following verbal commands

3 The GSC assesses a patient's ability to respond to stimuli, speak, and follow verbal commands. Swallowing and pupillary response are not components of the GSC.

A patient with a seizure disorder is taking oral phenytoin and is nothing by mouth for elective surgery. Which nursing action is appropriate? 1 Draw a serum phenytoin level after surgery. 2 Administer the medication immediately postoperatively. 3 Call the health care provider to clarify medication orders. 4 Administer the oral phenytoin before the patient goes to surgery.

3 The nurse would call the health care provider to ask about administering the medication preoperatively. The medication could be given intravenously, but the nurse will need an order. Taking a serum phenytoin level will not help the nurse determine what should be done before surgery. The patient should not wait to get the medication after surgery, because blood levels may drop and precipitate a seizure. The nurse would not administer the oral form of the medication before surgery without an order.

Which intervention would the nurse implement as the priority when providing care for a patient with a ventriculostomy to measure increased intracranial pressures (ICP) caused by a brain tumor? 1 Administer IV mannitol (Osmitrol). 2 Maintain hyperoxygenation through use of a ventilator. 3 Use strict aseptic technique with all procedural dressing changes. 4 Be aware of changes in ICP related to leaking cerebrospinal fluid (CSF).

3 The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection. Administer IV mannitol or hypertonic saline as prescribed. Potential ventilator use is to maintain oxygenation, not hyperoxygenation. CSF leaks may cause inaccurate ICP readings, or staff may drain CSF to decrease the patient's ICP, but strict aseptic technique to prevent infection is the nurse's priority of care.

How would the nurse explain a transient ischemic attack (TIA) to the spouse of a patient who just had a TIA? 1 It is usually neurologically damaging. 2 It is a signal of progressive brain damage. 3 It can be a warning of an impending stroke. 4 It is nothing to be concerned about because it is not a stroke.

3 Transient ischemic attacks (TIAs) can be a warning of an impending stroke or cerebrovascular accident. They may occur hours or days before. TIAs are usually not neurologically damaging or a sign of progressive brain damage. Patients should be instructed to report TIAs to the health care provider and not ignore them.

After receiving preprocedural instructions, which patient statement demonstrates an understanding of a scheduled ventriculostomy? 1 "I will have an internal transducer inserted into my head." 2 "I won't be able to have drugs instilled through this procedure." 3 "It will directly measure the pressure within the ventricles of my brain." 4 "The health care provider won't be able to get samples of my cerebrospinal fluid."

3 Ventriculostomy is a gold standard procedure for monitoring the intracranial pressure (ICP). In this procedure, the health care provider positions the catheter to measure the pressure within the ventricles. The ventriculostomy transducer is external and facilitates sampling of cerebrospinal fluid. The procedure permits intraventricular drug administration.

Which part of the cerebrum would the nurse recognize as affected by a recent stroke when the patient is unable to understand spoken words? 1 Parietal lobe 2 Broca's area 3 Wernicke's area 4 Superior temporal gyrus

3 Wernicke's area of the cerebrum is involved in the integration of auditory language and understanding of spoken words. Broca's area regulates the verbal expression. The parietal lobe integrates somatic and sensory output. The superior temporal gyrus registers the auditory input.

An RN is teaching a student nurse about tissue plasminogen activator (tPA) administration in a patient with ischemic stroke. Which statement made by the student nurse indicates a need for further teaching? 1 "tPA is administered IV." 2 "tPA is administered by intraarterial infusion." 3 "tPA should be administered within 12 hours of the onset of a stroke." 4 "tPA requires BP monitoring during and 24 hours after the treatment."

3 When tPA is administered to patients with an acute onset of ischemic stroke, it is administered IV and should be provided three to four-and-a-half hours from the onset of a stroke, not 12 hours. When administered by intraarterial infusion, tPA is delivered directly to the clot and can be administered up to six hours after the onset of stroke symptoms. It is important to monitor BP during the treatment and for 24 hours after the fibrinolytic treatment. If BP is not controlled, it can alter the fibrinolytic treatment.

A patient with a spinal cord injury (SCI) at the C7 level experiences autonomic dysreflexia. Which signs and symptoms occur with this condition? Select all that apply. 1 Involuntary stool 2 Severe drop in BP 3 Sudden onset of severe headache 4 Sweating above the level of the SCI 5 Pallor of the skin above the level of the SCI

34 Autonomic dysreflexia is a condition that can occur in persons with SCI at the level of the sixth thoracic vertebra (T6) or higher. A sensory receptor (as with a distended bladder) is stimulated below the level of injury, and the sympathetic nervous system responds with vasoconstriction. This is not mediated by the parasympathetic nervous system but is caused by the SCI. Thus the patient develops severe hypertension, often with bradycardia. The causative factors also include rectal distension or skin stimulation. The causative factor must be alleviated as soon as possible. The sympathetic stimulation causes flushing of the skin and sweating above the site of the SCI. The rapid rise in BP gives the patient a severe headache. The patient does not have bowel function, so an involuntary bowel movement will not occur. The condition causes severe hypertension, not hypotension.

For the patient with an increased intracranial pressure, who required a tracheostomy to help to maintain adequate ventilation, which postprocedural outcomes indicate an effective intervention? Select all that apply. 1 PaO2 of the patient is 80 mm Hg. 2 PaO2 of the patient is 90 mm Hg. 3 PaO2 of the patient is 110 mm Hg. 4 PaCO2 of the patient is 40 mm Hg. 5 PaCO2 of the patient is 30 mm Hg

34 The goal of maintaining adequate ventilation through tracheostomy is to maintain PaO2 of the patient greater than or equal to 100 mm Hg with PaCO2 in the range of 35 to 45 mm Hg. Therefore the PaO2 value of 110 mm Hg and PaCO2 value of 40 mm Hg indicate effective treatment. A PaO2 of less than 100 and PaCO2 of less than 35 mm Hg indicate ineffective treatment.

Which clinical manifestations would the nurse anticipate identifying in a patient who is comatose? Select all that apply. 1 Patient can cough and swallow. 2 Patient has bowel and bladder control. 3 Patient does not respond to painful stimuli. 4 Patient has incontinence of urine and feces. 5 Patient's corneal and pupillary reflexes are absent.

345 A coma is the deepest state of unconsciousness in which the corneal and pupillary reflexes are absent. A comatose patient is also incontinent of urine and feces and does not respond to painful stimuli. The comatose patient is not able to cough and swallow and does not have any bowel and bladder control.

A patient being discharged from the hospital after a stroke looks at an old photograph and breaks down, crying inconsolably. Which statements by the nurse are appropriate to say to the patient and the family? Select all that apply. 1 "Leave the patient alone for some time." 2 "Try to find out why the patient is crying." 3 "Frustration and depression are common during the first year after stroke." 4 "Do not communicate with the patient on topics that make the patient cry." 5 "Be patient during recovery and do not complain about these involuntary behaviors."

35 Because of the disabilities secondary to stroke, it is common for the patient to get frustrated, and an unpredictable mood is common for stroke patients. Patients who may have previously been emotionally strong may suddenly show a change in behavior after a stroke. Therefore, it is necessary to be patient with them and show them more compassion, care, and encouragement. Leaving the patient alone may make the patient more isolated. Trying to find out the reason for the patient's behavior may make the patient embarrassed and depressed. The family members should not stop communicating with the patient; instead, more opportunities for communication would help the patient to express his or her frustration.

Assessment findings of a patient include a mean arterial pressure (MAP) of 64 mm Hg, intracranial pressure (ICP) of 25 mm Hg, and BP of 180/90 mm Hg. The nurse calculates what cerebral perfusion pressure (CPP)? Record answer as a whole number. _______ mm Hg

39 The CPP is calculated by subtracting the ICP from the MAP; 64 - 25 = 39.Normal CPP is 60 to 100 mm Hg to ensure blood flow to the brain. As CPP decreases, autoregulation fails and cerebral blood flow is decreased.

What type of skull fracture has multiple linear fractures with fragmentation of bone into many pieces? 1 Linear 2 Depressed 3 Compound 4 Comminuted

4 A comminuted skull fracture has multiple linear fractures with fragmentation of bone into many pieces. A depressed fracture is an inward dentation of the skull. A linear fracture is a break in continuity of the bone, and a compound skull fracture involves a depressed skull fracture and scalp lacerations.

After sustaining a head injury, for which clinical manifestation would the nurse monitor potential development in a patient scheduled for a lumbar puncture? 1 Cerebral edema 2 Myelosuppression 3 Total body collapse 4 Cerebral herniation

4 A lumbar puncture involves removal of cerebrospinal fluid from the lumbar region. This can raise the intracranial pressure, resulting in cerebral herniation. Cerebral edema is associated with radiation therapy. Myelosuppression is associated with temozolomide drug therapy. Total body collapse is associated with a ventricular shunt.

After 72 hours of intravenous (IV) fluid therapy for a patient who suffered a diffuse axonal traumatic brain injury (TBI), which rationale supports the nurse seeking an enteral feeding prescription? 1 Administration of free water is avoided in the setting of TBI. 2 Electrolytes and fluids can be managed more efficiently. 3 Enteral feedings assist with avoiding dehydration. 4 Malnutrition promotes continued cerebral edema.

4 A patient with diffuse axonal injury is unconscious and with increased intracranial pressure (ICP). This patient is in a hypermetabolic, hypercatabolic state that increases the need for fuel for healing. Malnutrition promotes continued cerebral edema, and early feeding may improve outcomes when begun within three days after injury. Neither IV fluids nor enteral nutrition is categorized as free water. Electrolytes and fluid volume can be managed with both IV fluid and enteral nutrition administration. Enteral feeding is not a treatment for dehydration; enteral nutrition can actually lead to dehydration due to the high concentration of solute in the feed.

The patient recovering from a stroke who is confined to bed for most of the day is at risk for which condition? 1 Fatigue 2 Malnutrition 3 Dehydration 4 Constipation

4 A patient with poor physical mobility will have problems with constipation due to immobility and weak abdominal muscles. Fatigue is related to participation in physical activity. Malnutrition and dehydration are related to access to food and the ability to feed oneself.

Which interpretation would the nurse associate with a positive Dextrostix test of the clear nasal discharge obtained from the patient who sustained head trauma? 1 The patient has sinusitis. 2 The patient has glaucoma. 3 The patient has allergic rhinitis. 4 The patient has cerebrospinal fluid (CSF) rhinorrhea.

4 A positive Dextrostix test indicates that CSF is leaking from the nose or ear. The fluid from the nose generally leaks due to a cerebrospinal leak and results in CSF rhinorrhea. A Dextrostix test will not give positive results for sinusitis, glaucoma, or allergic rhinitis.

For the patient after a craniotomy, which intracranial pressure (ICP) reading would the nurse report immediately to the health care provider? 1 An ICP of 5 mm Hg 2 An ICP of 10 mm Hg 3 An ICP of 15 mm Hg 4 An ICP of 20 mm Hg

4 A sustained pressure of 20 mm Hg is abnormally high and requires treatment. Normal ICP is 5 to 15 mm Hg, so ICPs of 5 mm Hg, 10 mm Hg, and 15 mm Hg do not require reporting.

The nurse assists with the prehospital care of a patient who experienced a 15-foot fall. Which action by the nurse will limit the damage if a spinal cord injury (SCI) has occurred? 1 Initiating an IV access peripherally 2 Maintaining an open airway using the head tilt method 3 Determining whether the patient is oriented to person, place, and time 4 Applying a rigid cervical collar and using a backboard to transport the patient

4 Application of a rigid neck collar and use of a backboard will immobilize and stabilize the cervical spine to limit immediate injury to the spinal cord. Initiation of IV access is important but is not directly associated with limiting the SCI. Patient orientation will not stabilize a SCI. The airway must be maintained with the jaw thrust technique if SCI is suspected.

*****Which condition presents with a sudden onset of a headache, vomiting, and decreased level of consciousness? 1 Embolic stroke 2 Brain infarction 3 Cerebral edema 4 Hemorrhagic stroke

4 Clinical manifestations of hemorrhagic stroke include a sudden onset of symptoms like headache and vomiting with a change in mental status. Embolic stroke and brain infarction symptoms are related to a change in mental status and functional weakness or disability. Cerebral edema has a gradual onset as the brain swells.******

The RN is teaching a student nurse about the proper way to communicate with a patient who has aphasia due to a stroke. Which statement made by the student nurse indicates a need for further learning? 1 "I will speak in a normal tone with the patient." 2 "I will frame questions in a yes-or-no format." 3 "I will not pretend to understand the patient if I do not." 4 "I will try to force communication with the patient if the patient is upset."

4 Communication should not be forced if the patient is upset because anxiety worsens aphasia. Communication with the patient should be in a normal tone of voice because the patient should not feel as if they are spoken to like a child. Questions should be framed in a yes-or-no format to make communication easier for the patient. The nurse should not pretend to understand the patient. Instead, the patient should be encouraged to use nonverbal modes of communication.

A patient is receiving dexamethasone to prevent cerebral edema caused by a motor vehicle accident. Which nursing intervention will help to prevent complications of the pharmacotherapy? 1 Elevating the head of the bed 30° 2 Performing frequent oral suctioning 3 Requesting a prescription for aluminum hydroxide 4 Requesting a prescription for a proton pump inhibitor

4 Dexamethasone falls under the category of glucocorticoids. Patients taking glucocorticoids are at high risk for gastric erosion and bleeding because the drugs are ulcerogenic; these agents are likely to erode the gastric mucosa during treatment. To prevent this serious complication of therapy, the nurse provides effective preventive care in the form of a proton pump inhibitor. In addition, the nurse would monitor the patient's stool for occult blood and the serum hemoglobin for early detection of gastrointestinal bleeding. Elevating the head of the bed is beneficial for the cerebral edema but is unlikely to help prevent complications of glucocorticoid therapy. Oral suctioning will not reduce the risks associated with use of glucocorticoids. Administering aluminum hydroxide is likely to be ineffective as monotherapy.

Which type of hematoma would the nurse suspect when an older adult patient fell and hit their head on the coffee table two weeks ago? 1 Epidural hematoma 2 Intracerebral hematoma 3 Acute subdural hematoma 4 Chronic subdural hematoma

4 In older adults, due to the presence of a potentially larger subdural space caused by brain atrophy, chronic subdural hematomas are the most commonly seen hematoma. Atrophy increases the tension in the brain; even though supportive structures attach to the brain, tearing of the brain tissues is a potential because of the increased tension. Epidural hematoma, intracerebral hematoma, and acute subdural hematoma are common in all age groups.

Which intervention would the nurse implement to prepare a patient for a prescribed skull x-ray? 1 Encourage oral fluids. 2 Withhold the preceding meal. 3 Instruct the patient to empty the bladder. 4 Explain that the procedure is noninvasive

4 It is important to explain to the patient that a skull x-ray is a noninvasive procedure. This will help to reduce patient anxiety. Nursing preparations such as encouraging fluids, withholding the preceding meal, and emptying the bladder do not apply to a skull x-ray; rather, they apply to procedures such as lumbar puncture, cerebral angiography, and positron emission tomography.

The patient admitted with a closed head injury is awake but lethargic, and the baseline vital signs include a BP of 120/80 mm Hg, pulse of 78 beats/min, and respirations of 20 breaths/min. Which findings indicate deterioration of the patient's condition two hours later? 1 The patient is sleeping but awakens in response to painful stimuli. 2 The patient does not remember what happened during the six hours prior to the injury. 3 BP is 110/80 mm Hg, pulse is 78 beats/min, and respirations are 20 breaths/min. 4 BP is 160/74 mm Hg, pulse is 53 beats/min, and respirations are 10 breaths/min

4 Late signs of increased intracranial pressure include an increased systolic BP and decreasing diastolic BP (widening pulse pressure), bradycardia, and decreased respirations. The patient may also display a decreased level of consciousness, seizures, or both. These symptoms represent the Cushing's triad and require immediate intervention. Not remembering what happened, a sleeping patient who awakens in response to painful stimuli, and a BP of 110/80 mm Hg, pulse of 78 beats/min, and respirations of 20 breaths/min do not necessarily indicate deterioration in the patient's condition.

When providing care for a patient who sustained a traumatic brain injury, which condition indicates the need to maintain closure of the patient's eyes as a nursing intervention? 1 Diplopia 2 Otorrhea 3 Periorbital ecchymosis 4 Loss of the corneal reflex

4 Loss of the corneal reflex may cause corneal abrasions. Taping of the eyes is necessary to protect them. Use an eye patch in patients with diplopia. Use a loose collection pad over the ears for patients with otorrhea. Use cold and warm compresses for patients with periorbital ecchymosis.

Which action would the nurse implement when a patient's assessment reveals an increased intracranial pressure (ICP) and the patient has a lumbar puncture scheduled? 1 Prepare the patient and assist with the lumbar puncture. 2 Reschedule the lumbar puncture for the next business day. 3 Administer IV fluids before the lumbar puncture. 4 Cancel the lumbar puncture and contact the prescribing provider.

4 Lumbar puncture may cause cerebral herniation due to the sudden release of pressure in the skull from the area above the punctured site and is contraindicated in a patient with increased ICP, so cancel the procedure and contact the prescribing provider. Rescheduling the lumbar puncture for the next day may not reduce the risk of cerebral herniation. Performing the lumbar puncture immediately may cause cerebral herniation. Administering IV fluids does not reduce the risk of cerebral herniation.

Which clinical manifestations would the nurse monitor to assess the development of increasing intracranial pressures in a patient who sustained a head injury and has a baseline Glasgow Coma Scale (GCS) score of 14? 1 Increased systolic BP, increased pulse, GCS score of 12 2 Decreased diastolic BP, decreased pulse, and GCS score of 13 3 Increased systolic and diastolic BP, increased pulse, GCS score of 9 4 Increased systolic BP, decreased pulse, widening pulse pressure, GCS score of 4

4 One classic sign of increasing intracranial pressure and neurologic deterioration is an increased systolic BP and decreased diastolic BP (resulting in a widening pulse pressure) accompanied by bradycardia. Cushing's triad includes hypertension (elevated systolic pressure and widening pulse pressure), bradycardia, and bradypnea. Increased systolic BP, increased pulse, and GCS of 12 and decreased diastolic BP, decreased pulse, and GCS of 13 do not indicate deterioration in neurologic status. Increased systolic and diastolic BP, increased pulse, and GCS of 9 indicate that the patient requires continued assessment. Although the BP and pulse may be stable, the GCS has decreased from 14 to 9. A GCS of 15 is the best score, reflecting a fully awake, alert, and oriented patient. Any patient scoring less than 8 on the GCS is comatose.

For the patient with a basilar skull fracture, for which intervention prescribed by the health care provider would the nurse contact the prescriber for clarification? 1 Apply soft cervical collar. 2 Avoid flexion of hip joints. 3 Maintain elevation of the head of bed at 30 degrees. 4 Insert nasogastric (NG) tube and connect to low, intermittent suction.

4 Patients who need gastric decompression following a basilar skull fracture should have an oral gastric tube inserted. The nurse should collaborate with the health care provider about this intervention because of the risk of meningitis. The recommended intervention is an oral feeding, with placement of either an oral tube or NG tube under fluoroscopy. The use of a soft cervical collar to maintain anatomic alignment, avoiding flexion of hip joints, and elevating the head of the bed are all measures to decrease intracranial pressure by promoting venous return.

Which position would the nurse utilize when repositioning a patient who has an increased intracranial pressure (ICP)? 1 Sims' 2 Prone 3 Trendelenburg 4 Semi-Fowler's

4 Position a patient with an increased ICP with his or her head elevated, as in semi-Fowler's position (typically at 30 degrees). Sims' position is side-lying with one leg flexed, which may elevate intracranial pressure. A prone position is flat with the face down, and the Trendelenburg position is supine with the feet higher than the head. The head is not elevated in these positions, which is dangerous for someone with ICP.

After performing an assessment of the oculocephalic reflex, the nurse suspects that the patient has an intracranial lesion. Which patient behavior supports the nurse's assessment findings? 1 When flexing the neck, eye movement is in the upward direction. 2 Movement of the eye is in the opposite direction of the turned head. 3 When extending the neck, eye movement is in the downward direction. 4 Movement of the eye in the sideward direction occurs, with neck extension.

4 Test the oculocephalic reflex by having the patient turn his or her head briskly to the left or right while holding the eyelids open. The eye movement should be in the opposite direction and not in the sideward direction if extending the neck. The sideward eye movement indicates an intracranial lesion. Movement of the eye in the opposite direction to the turning head is a normal response. Movement of eye in the upward direction when flexing the neck is normal and does not indicate any abnormality. When extending the neck, movement of the eye in the downward direction indicates a normal finding.

Which Glasgow Coma Scale score would the nurse assign to the patient who sustained a motor-vehicle crash concussion and who is fully alert upon arrival to the emergency department? 1 3 2 6 3 8 4 15

4 The Glasgow Coma Scale is a quick, practical, and standardized system for assessing the level of consciousness in a patient. According to the Glasgow Coma Scale, the score of a fully alert patient will be 15. This includes 4 for spontaneous response of the patient when approached at the bedside, 5 for appropriate response during verbal questioning, and 6 for obedience of commands. The lowest possible score according to the Glasgow Coma Scale is 3, which indicates severe coma conditions. A score of 6 or 8 indicates coma.

Which statement by the novice nurse demonstrates understanding of the care required for a patient admitted earlier today with a diagnosis of post-head injury concussion? 1 "I can expect the pupils to be unequal in size and sluggish to respond to my pen light." 2 "I will delegate keeping the patient awake for the next eight hours to my unlicensed assistive personnel (UAP)." 3 "To help with post-head injury headaches, I will contact the health care provider about prescribing morphine IV." 4 "I need to assess the patient's level of consciousness frequently because changes are the first indication of complications."

4 The first indication of increased intracranial pressure (ICP) is a change in the patient's level of consciousness. Pupil changes are not an immediate assessment finding following a concussion; in fact, pupil changes are often a late sign of neurologic complications. Keeping the patient awake following a head injury is not necessary. Arousing the patient frequently to assess arousal and level of consciousness is an appropriate plan of care following a head injury. Although headache can be common following a head injury, avoid narcotics for pain management because they can mask the signs of impending complications, particularly alteration in level of consciousness.

Which cranial nerve would the nurse assess when the patient reports, "My taste buds are off. Nothing tastes good anymore"? 1 Trochlear 2 Vagus 3 Hypoglossal 4 Glossopharyngeal

4 The glossopharyngeal nerve connects to the medulla and has both sensory and motor functions. Damage to this nerve may result in altered taste. The trochlear nerve is the only cranial nerve that arises from the back of the brain stem. This nerve controls the superior oblique muscle of the eye. Paralysis of the trochlear nerve results in rotation of the eyeball upward and outward, leading to double vision. The vagus nerve also connects to the medulla and has sensory, motor, and parasympathetic fibers. Damage to this nerve can result in gastroparesis. The hypoglossal nerve connects to the medulla, and the motor nerves connect to the muscles of the tongue. Damage to this nerve can cause paralysis of the tongue

Which diagnosis would the nurse associate with a patient's cerebrospinal fluid (CSF) culture findings of a white blood cell (WBC) count of 1200 cells/ µL, protein 600 mg/dL, and glucose 25 mg/dL? 1 Brain abscess 2 Viral meningitis 3 Viral encephalitis 4 Bacterial meningitis

4 The normal range of WBC count is 0 to 5 cells/µL, the normal range of protein is 15 to 45 mg/dL, and the normal range of glucose is 40 to 70 mg/dL in the CSF. An increased WBC count, increased protein, and decreased glucose are signs of bacterial meningitis. A patient with a brain abscess would have an increased WBC count, normal protein levels, and a decrease or absence of glucose. In viral meningitis, the CSF reflects an increased WBC count and protein level, along with decreased or absent glucose. In viral encephalitis, the CSF reflects an increased WBC count, slightly increased protein level, and normal glucose levels.

Which intervention would the nurse identify as a priority when monitoring a patient recovering from a craniotomy? 1 Monitor the patient for pain. 2 Monitor the patient for an infection. 3 Monitor the patient for excessive bleeding or hemorrhage. 4 Monitor the patient for increased intracranial pressure (ICP).

4 The priority action of the nurse caring for a patient following a craniotomy is to monitor for increased ICP, which can have serious life-threatening implications. Manage the patient's pain, but pain is not an emergency. Monitor the patient for development of an infection, but the infection will not be immediately apparent. A hemorrhage will cause an increase in ICP if it is cerebral.

A nurse is teaching a group of caregivers the warning signs of stroke. Which type of assessment data obtained from the patients would the nurse teach the caregivers to consider an emergency? Select all that apply. 1 The patient is unable to sleep. 2 The patient cannot hear properly. 3 The patient has a loss of appetite. 4 The patient suddenly has blurry vision. 5 The patient suddenly has slurred speech.

45 Blood vessels carry blood throughout the body. When a blood vessel in the brain becomes blocked for a short period of time, the blood flow to that area of the brain slows or stops. This lack of blood (and oxygen) often leads to temporary symptoms such as slurred speech or blurry vision. Insomnia, deafness, and loss of appetite are not associated with stroke.

To determine the amount of cerebral spinal fluid to drain from a patient's ventricle catheter, the nurse calculates the cerebral perfusion pressure (CPP) of an unconscious patient whose BP is 162/58 mm Hg and intracranial pressure (ICP) is 35 mm Hg. Identify the patient's CPP. Record your answer using a whole number. _____ mm Hg

58

When explaining neurological pathophysiology to a group of nursing students, the nurse describes the progression of increased intracranial pressure in which chronological order? 1. Tissue edema 2. Decreased cerebral blood flow 3. Increased intracranial pressure 4. Decreased oxygen and death of brain cells 5. Compression of ventricles and blood vessels 6. Compression of the brainstem and respiratory center

Correct1.Tissue edema Correct2.Increased intracranial pressure Correct3.Compression of ventricles and blood vessels Correct4.Decreased cerebral blood flow Correct5.Decreased oxygen and death of brain cells Correct6.Compression of the brainstem and respiratory center In order, tissue edema occurs and causes reduced blood flow in the cerebellum. The increased cranial pressure leads to decreased oxygen delivery and death of brain cells. The compression of ventricles and blood vessels ultimately causes compression of the brainstem and respiratory center.

Which area of the brain would the nurse associate with a patient's inability to speak after sustaining an intracranial injury?

Damage to Broca's area due to intracranial injury can result in an inability to speak. The part indicated as C in the figure depicts Broca's area, which regulates verbal expression. The part indicated as A in the figure depicts the precentral gyrus, which regulates motor control and movement on the opposite side of the body. The part indicated as B in the figure represents the angular gyrus that helps to process language, numbers, and spatial cognition. The part indicated as D in the figure depicts the postcentral gyrus, which is the receptive area to sense touch.

___________ posture is when all four extremities are in rigid extension with hyperpronation of the forearms and plantar flexion of feet. Decorticate posture is internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers from interruption of voluntary motor tracts in the cerebral cortex. Decorticate response on one side of the body and decerebrate response on the other side of the body may occur depending on the damage to the brain. Opisthotonic posture is decerebrate posture with the neck and back arched posteriorly and is potentially visualized with traumatic brain injury.

Decerebrate

_____________ posture involves internal rotation and adduction of the arms with extension of the elbows, wrists, and fingers, as illustrated in the image. This results from interruption of voluntary motor tracts in the cerebral cortex. The patient may also demonstrate an extension of the legs. A decerebrate posture may indicate more serious damage and results from disruption of motor fibers in the midbrain and brainstem. In this position, the arms are stiffly extended, adducted, and hyperpronated. There is also hyperextension of the legs with plantar extension of the feet. Sinusoidal posturing does not exist. Opisthotonic posturing consists of the head, neck, and spinal column in an arching position.

Decorticate

Which type of stroke is a patient at risk for if atrial fibrillation is untreated? 1 Embolic stroke 2 Thrombotic stroke 3 Intracerebral hemorrhage 4 Subarachnoid hemorrhage

Heart conditions such as atrial fibrillation and infective endocarditis can cause embolic stroke. A thrombotic stroke has clinical manifestations of decreased level of consciousness in the first 24 hours. Intracerebral hemorrhage has clinical manifestations such as decreased level of consciousness and hypertension. Clinical manifestations such as stiff neck and cranial nerve deficits indicate a subarachnoid hemorrhage.

Place the responses from the motor response section of the Glasgow Coma Scale (GCS) in order from best response to worst response. .Obeys simple commands .Withdrawal from pain .Localizing pain .Extension to pain .Flexion to pain .Limbs remain flaccid

In order from best response to worse response for the GCS the patient would (1) obey simple commands, (2) be experiencing only localizing pain, which would then progress to differing responses to pain such as (3) withdrawal from pain, (4) flexion to pain, and (5) extension to pain, with final response as (6) limbs remain flaccid.

_______________ hemorrhage has clinical manifestations such as decreased level of consciousness and hypertension.

Intracerebral

During a lumbar puncture, from which area within the depicted figure would the health care provider obtain cerebrospinal fluid (CSF)?

The part labeled B indicates lumbar vertebrae. A larger subarachnoid space in the third and fourth lumbar vertebrae is used to obtain CSF during lumbar puncture. The part labeled A depicts cervical vertebrae, which provide mobility and stability to the head. The part labeled C indicates the sacrum. The sacrum vertebrae are a fusion of five vertebrae. The part labeled D depicts the coccyx, which serves as an attachment site for muscles, tendons, and ligaments.